Monday, June 25, 2007

A Potent Lesson

The man looks up at me from his bed, surrounded with the trappings of his daily life. Within reach are carefully arranged remote controls, for his bed, tv, stereo, and nurse. His pillows are arranged just-so, tucked under his legs and back in an assembly that surely took weeks of trial-and-error to get just right. Photographs of family and friends surround the bed, adorned with gifts and trinkets, flowers and balloons. He is 82 years old, relegated to bed by age and disease, chosen to stay there through consent forms clearly indicating his wishes: Do Not Recesustate, Do Not Intubate, Do Not Hospitalize.

He looks at me, sweating. I dont even get to ask what is wrong before the problem presents itself, making it's own introduction. The man's muscles flex and bend inward, all 4 extremities tightening and releasing quickly as electricity claims control for the millisecond. A shock from his implanted AICD. The man's face portrays equal amounts of annoyance and pain. "It's been happening all day," he says. "Just go ahead and get me to the hospital so they can turn this damn thing off."

Aware of the man's advance directives, I ask what it is that he would like us to do on the way. We have drugs that may help stop the shocks, I would like to give them a try if it is okay with him. Exasperated with the painful shocks, he reluctantly agrees. I explain what I would like to do, and the man waves his hand- "Do what you have to do, just make this stop."

On go the white, black, red and green wires:

Except for the jolt of electricity every 60 seconds, the man is without complaint. I ask all of the pertinent questions, perform my exam and search for more, but there doesnt seem to be much other than what is printed on the EKG paper, and the occasional flexing and arching of electricity. The blood pressure is 130/80, SPO2 99% on room air, the man is without pain or shortness of breath.

I leave the monitor on print, capturing the various outrages of the man's irritable heart:

I watched the rhythm widen and become narrow again, it's irregularity and rate alternating unpredictably, punctuated by discharges from the man's AICD and perhaps his pacemaker as well. I recognize a-fib underneath, but waver at a clear interpretation of the faster, shockable rhythm. The man sweats uncomfortably, bracing as he awaits his next scheduled shock. He asks me if we can get a move on. I call the faster rhythm a "wide complex tachycardia of unknown origin." Even though I see the rhythm narrow in places, I am nagged by occasional width, and spurred onward by the man's prodding. I am eager to provide relief, and ready to make a decision about the EKG.

I should have slowed down.

I get the man on some oxygen, and start an IV. Acutely aware of the rhythm changes, I make a decision to administer Amiodorone: 150 milligrams over 10 minutes, diluted in 100cc of normal saline. I am an expert at the tasks by this point, and the work goes quickly. It was a difficult IV, but I got it. Our buritrol was broken, but I managed. I mixed up the drug, piggybacked a line, and accurately calculated the drip rate. Like a machine.

We drip the drug in on the way to the hospital, a 10 minute trip. It is at this point that I remember the 12 lead cables. I see them in the back of the monitor as I am looking for something else, bunched up where I put them last and conspicuously unused. I recognize immediately that I should have used them earlier. I look up at the medication bag, and it is halfway gone.

On go the six black wires:

The rate is still fast, but nothing else is the same. It was as if I had wiped away a dirty window and looked again, amazed with a new vision- unobstructed and clear as day. This rhythm is not wide at all. It is narrow, irregular, fast. It is a-fib. Any day of the week, a-fib.

I stare at the strip, drained. The Amiodorone is almost all of the way in now, and while the drug is far from the wrong one (it may still help), it should not have been my first choice. A-fib like this gets calcium channel blockers, not general antidysrhythmics. Mine was an appropriate treatment still, but a less effective one - and something that I will have to explain to the doctor who will surely ask why I made such a decision.

The patient, unaware, rests comfortably. I look up from the EKG paper as he touches my knee. "Thank you," he says. "This is much better." His heart rate has come down slightly, to about 150, and the AICD has stopped shocking. The diaphoresis is gone. I tell him he is welcome, grateful for his relief.

In the ED the doctor does ask me why I chose Amiodorone. He looks over the strips quickly as he moves between charts. "That looks like a-fib or flutter. Pretty fast, too." I offer a weak explanation that the rhythm appeared wide at times, and that I felt that this drug was a safe call considering the varied morphologies. He shrugs, and says okay. At least he's not getting shocked anymore. I shrink back away and try to disappear.

Paramedic friends of mine say that I'm too hard on myself. I should have done a 12 lead first - especially on a stable patient like this one - but they pat me on the back and tell me I still did well. It's hard, they all say, to make these determinations quickly, in the back of the ambulance surrounded by the chaos of a patient in pain and buried under a mountain of other tasks that must be done at the same time. "Dont overthink these things," one medic tells me. "Just next time make sure you get that 12 and you'll be right on."

Still though, I'm angry with myself. I was eager to get to the treatment, moving too quickly for a necessary second glance at the rhythm. It was embarrassing to come into the emergency department, to give reports to doctors that I respect, fully knowing that I didnt quite do the right thing and, worse, that the cause of the problem was an omitted step. These kinds of mistakes can turn out well, like they did this time, or they can be deadly. It is a scary thing, and I really need to be more careful. This was no benign error.

This is something I will not soon forget. I feel strongly that the resilience of this kind of lesson is equal in proportion to the amount of danger the inciting mistake imposes. This was a small omission which could have posed a significant danger to a different patient. The importance of such an opportunity to learn consequence-free is not lost on me, and I will make great efforts to make sure that the memory sticks. I will squeeze this for what it is worth.

I overheard a new medic the other day, worried about his upcoming ride-time as a new preceptee. He was nervous, explaining that he hoped he didnt "make too many mistakes." To the contrary, I think. May he make lots of mistakes. Let them pile up underneath him, build up his experience and stick with his memory. May his errors remain free from serious consequence, but packed full of value, so that next time the choices will be clear and ready.

I am new. I will continue to make mistakes. I cannot hope that they will not happen, only that when they do I am able to claim from them the fruit of experience, and pass the benefit to my next patient.

I will be better next time.


Rory said...

"Amiodarone shows beta blocker-like and calcium channel blocker-like actions on the SA and AV nodes, increases the refractory period via sodium- and potassium-channel effects, and slows intra-cardiac conduction of the cardiac action potential, via sodium-channel effects."

amiodarone is never wrong for tachycardias, save for torsaddes since it can prolong QT.

Ambulance Driver said...

Cheer up, Baby Medic. You did indeed use the right drug. Amiodarone is an excellent choice for wide complex tachycardia with varying morphology. It's even commonly used for atrial fib, although more often for rhythm conversion than simple rate control.

Amidoarone works well on both wide and narrow complex tachycardias. It possesses characteristics of most of the Vaughn Williams classes of antiarrhtyhmics - sodium channel blockade, potassium channel blockade and calcium channel blockade. It's a pretty good jack-of-all-trades antiarrhythmic.

And if you HAD used a calcium channel blocker and the patient's rhythm did indeed turn out to be VT or WPW (atrial fib with WPW looks a lot like VT), you could have killed your patient.

You done good.

Blue Ridge Medic said...

"The Great Sage and Immenant Medic" better known as Ambulance Driver, once told me, "Good judgement comes from experience and experience comes from bad judgement".

Once I was very hard on myself for any mistake I made, down to the smallest thing. Now, like you, I still get angry with myself, but I realize that I will make mistakes and but I will learn from them. I'm new too, so I don't really have room to say, but I think you did ok. Keep your head up.


Shane said...

The most impressive thing about this whole experience is your attitude about what you can take from the call. That attitude will take you far in medicine, weather as a doctor or continuing life as a paramedic. You're always willing to take something from an experience and assume the responsibility for your actions. That goes a long way in itself. You are smart and will do just fine on your own. I have no doube about that.

As for the call itself, you and I have already talked about it. Not a bad job, and a lesson learned. What more can you ask for?

Brett said...

I agree with your mode of tx, cardizem might have been better.. but thats a MIGHT, even if you were on the fence about a-fib/v-tach amio is a catch all. maybe cardizem would have worked, but i dont think that you made the wrong choice at all

Medic Kevorkian said...

If you aren't hard on yourself, I'd think there was something wrong with you. All of us in this business are perfectionists. Over time and experience you will learn from your mistakes, grow from your mistakes, and share those experiences with others. That's what will make you a great medic.

I have the utmost confidence that you will do well. Believe it or not, even as your preceptor, I learned a great deal. Kick some ass!