Irregular Rhythms

So, I just finished my 2nd day shift at my new rotation of BGH.  There's been sort of a common theme over the last 2 days:  chest pain and heart irregularities.  Of course, I also have the abdominal pains, the SOB's (shortness of breath, remember?), the back pains, etc.  It seems like I see a lot more real medicine patients here.  So much so that this morning I was convinced I was working a primary care clinic.

But onto the good stuff:

Chest pain central:  we've have several STEMI's (ST elevation myocardial infarctions) = think major heart attack you're going to die unless we open up that clogged artery.  The hospital is known as a chest pain center, so we get admissions from all over the surrounding area.  Some patients get stabilized at their closest E.D. and then sent to us.  Some come in the door "hot" meaning they're in the midst of a massive M.I.  Our "door to balloon" time is about less than 45 minutes.  We had a 38 minute run yesterday.  Balloon means angioplasty means opening clogged artery with a balloon and then usually stent placement.  Very exciting stuff.

We've also had a rash of NSTEMI's (non-STEMI's) which is chest pain not currently showing signs of having a heart attack but at risk for a heart attack.  They go to our chest pain center where they're observed for a day or so, given a stress test and then discharged.  I've actually admitted about 5 patients to our observation unit.  We're filling up the beds.

The one exciting patient we had came in with heart rate of 15.  That's right: 15.  AND she was awake and talking to us.  We couldn't even measure a blood pressure on her because you need a certain heart beat to be able to maintain an adequate blood pressure.  Again, she was awake and talking to us.  Very impressive, and very scary to have to work-up.  We finally got her heart rate up to about 50 and some semblance of a blood pressure.  At one point we had external pacemaker pads on her just in case we were going to need to pace her from the outside.  Just an FYI - getting "mini" shocks to keep her heart going would not be fun... for anyone.

And, speaking of shocks, my last patient today had an AICD (Automatic Internal Cardiac Defibrillator) placed yesterday.  If his heart goes into a lethal rhythm, the defibrillator will go off and give him a shock.

Unfortunately, as he was making his way to his car having been discharged from the hospital, his AICD fired off.  He described the sensation as "being hit in the chest with a sledgehammer," and it happened five times.  He's been admitted to have his AICD evaluated.  They can actually put a monitor over it and read out why it fired off and run diagnostics on it.  Cool stuff.

Some other random, non-cardiac (heart) thoughts:

- the emergency department does not work like a drive thru;  you can't just come in, expect to be seen immediately, have your tests completed in under an hour and go home.  Don't come to the E.D. if you "have plans."  It's not like going to the doctor's office.  They see one patient at a time, I see 5-6 (so far, I'll get better).  Your two weeks of leg pain that has to be seen and evaluated right now falls below my other 4 patients with the chest pains, breathing problems and abdominal pains needing surgery.  So, it's gonna take a while.  You waited two weeks, what's another 2 hours.  Go out and smoke while you're waiting.  It'll help pass the time and clog up what's left of your leg's blood supply which is probably the reason you have the leg pain now.

- drug seekers come in all shapes and sizes.  Even "sweet little old ladies" become raging, um, monsters when they're jonesing for another vicodin/percocet/lortab/etc.

- did I mention I'm getting really good at rectals?  Don't ask....  

Tags: chest pain, nstemi, stemi, angioplasty