Case Study: Halloween Tricks and Treats

[Asysin2leads]

I'm starting to feel like I'm reviewing the film from last night's game with these, but here we go again. A while ago we had a really great discussion based on a call I did about differentiating ventricular tachycardia from an SVT with a variancy, looking at related signs and symptoms. We discussed whether someone could be in ventricular tachycardia and still maintain a pulse, be AOX3, and look generally okay, or if we could take someone who showed something that looked like V-tach on the monitor but presented normally as having an SVT with a variancy. Basically, I've had two calls where someone had an EKG that looked exactly like V-tach, but later turned out to be funky SVT's. Okay, now, hit the lights, and lets go to the tape.

Halloween night, 1535hrs, recieved call for difficulty breathing, job text states "male at location difficulty breathing...possible stroke". Arrived to find 76 year old man AOx3 sitting comfortably with firefighters on oxygen on chair on sidewalk, sts he had a few drinks with friends today and then passed out while in a store. States he feels fine now and doesn't want a hassle, asks if he could just get on the bus and go home. Convinced by crew and friends to be assesssed.

As stated above, pt. sts he suffered brief period of syncope lasting approximately 30 seconds while in a store, negative chest pain, negative SOB, negative dizziness, negative nausea/vomiting, negative seizure activity reported. PMH: Stent placement surgery. Meds:Plavix. Allergies: NKA.

VS: BP 80/P, HR 150, RR 20, GCS 15, SPO2 98%

PE: PERRL, skin cool, dry, negative cyanosis, negative JVD, trachea midline, negative accessory muscle use, equal chest expansion, lungs clear bilaterally, abdomen soft, non-tender, positive fecal incontinence, PMS present x 4 in extremities, negative edema.

EKG: Wide complex tachycardia, looks very much like v-tach.

Okay, so now I'm ready for this one. The guy who presents with mild complaints but shows something that looks like v-tach on the monitor, right? Not only that, we now have amiodarone, which will work on either an SVT or a ventricular rhythm, so I am ready to treat the crap out of this rhythm. I have my partner start setting up the amiodarone drip while I get IV access, as I expound on my knowledge of SVT's with variancies. Patient then states "Hey, its getting really bright in here," slumps to the side, becomes unresponsive, loses pulse and becomes apneic, with no change in the rhythm. I Immediately apply defib pads and defibrillate at 360 joules (recent protocol change, no more stacked shocks in pulseless v-tach/v-fib, hit them right off with 360, and yeah, one of these days when the patient suddenly arrests on me I'll have the presence of mind to try the precordial thump, but until then they'll get defibbed and like it), patient immediately converts to RSR, regains consciousness and seems remarkably non-chalant for being dead a few seconds ago. This is pretty much how the conversation went:

Me: Ummmmm.... how you feeling?

Pt: Fine, why?

Me: Uh, does your chest hurt at all?

Pt: No, should it?

Me: (under breath) Well, I did just put 360 joules through you... Are you sure you feel okay?

Pt: Yes, I feel great... Though I feel awful about making in my pants before, though, how embarrassing, you know. Why, what's up?

Me: Well...uh... your heart just kinda stopped there for a minute, I had to shock you to restart it... you don't remember any of that?

Pt: No... You're kidding me, right?

Me: No, no I'm not.

Pt: So are you sure I gotta go to the hospital?

Me: Yeah, I'm sure.

Administered Amiodarone drip 150mg in 100 cc's D5W, transported without incident. Patient presented with no complaints in ER, remained AOX3 at all times, transferred to MICU for observation. I did learn first hand an important answer to the question I had posed in my previous post, and that is yes, a patient can walk, talk, sing and dance and still be in v-tach and about to arrest. So the Halloween trick was that after my experiences with SVT with variancies, I was given someone who really was in V-tach, and ha ha ha, someone somewhere is having a laugh about this, because I swear to God this crap only happens to me. But then, the Halloween treat was that he introduced me to his waiting family as "the guy who saved my life", and yeah, that still feels really good now and then.

[mediccjh]

That's a save! Now you can frame the paper on the wall.

[Dustdevil]

LMAO!

I'm going to try that convo with a patient on April Fools and see if they believe it.

[BushyFromOz]

Dust you evil bloke

[paramedicmike]

...sitting comfortably with firefighters on oxygen on chair on sidewalk...

Uh...so why were the firefighters on oxygen?

Seriously, though. Nice save!

And yes. This must only happen to you. I've been a $hit magnet lately. But nothing like this.

-be safe.

[zzyzx]

Nice save! And what a great Halloween story!

[Ridryder 911]

Atta..boy !

R/r 911

[Medic_Kidd]

That's awesome! high^5 and a triple backflip mctwist to you!!! :hello1:

i had a pretty cool one the other day, but mine's nothing compared to yours! rock on!

:-)