Monday, February 4, 2008

Momentary Complexity

I recognized the rhythm as soon as the monitor started displaying it, and smiled to myself in anticipation of a job well done. This was rapid atrial fibrillation and I knew exactly how to handle it. The algorithm was clear in my memory, it's dosages and considerations familiar to me as if I had handled a case like this yesterday.

...I hadn't though. This was the first time I've seen it in "real life," and though all of my academic confidence there remained just a twinge of unease.

As a whole, the woman was stable. Her blood pressure was in the low 100's, her mental status at baseline. She complained of chest pains and said that she has been feeling "weak" and "uneasy" since earlier this morning. When I started asking her about her medical history, she mentioned the a-fib and a recent ablation surgery to rid herself of it. She was on daily Coumadin and a beta blocker. It was pretty clear-cut.

My partner and I did the basics. We put the woman on some oxygen, started an IV, and obtained a 12 lead ECG. There was no evidence of WPW. I ran through assessment techniques that I had performed hundreds of times before, and we spoke in easy tones with our nervous patient, easing and relaxing the situation until her stress was gone.

Zero point two five milligrams per kilogram was the dose for Cardizem, I remembered it clearly. I got the patient's weight, converted to kilograms, calculated the dose, drew up the proper amount, and slowly pushed the medication through the IV line. My first time with Cardizem, but the mechanics of the task were routine and I knew enough to say that I had been there before. No problem. Together the patient and I watched the monitor for changes, and like magic:

There it was. Still a-fib, but a much more satisfactory rate. Beautiful.

I remembered the next line in the algorhythm too: start a maintenance infusion. The dose was 10-15 milligrams per hour, a slow drip as prophylaxis against the rhythm returning. My paramedic instructor had always made a big deal about dysrhythmic maintenance infusions, drilling the point home on exams and quizzes so that we would never forget. It was an important step, often neglected in the ambulance but not this time: I was going to do it.

The math, though, oh the math. I was lost. Between talking with the patient, monitoring my equipment, and obtaining reassessment information, I found it impossible to calculate the proper drip-rate with the supplies that I had on board. The smallest saline bag I had on hand was 500mL, and there was only 25 milligrams of Cardizem left for the infusion. I shot the medication into the bag, and sat there on the bench with a faraway look in my eyes as I mixed it. I was good at these in medic school with pen, paper, and calculator. ...But now, sitting in the back of the moving ambulance with a patient and a bag in my hand, my brain froze over and slowed to a crawl. I tried the math a few times on my notepad and failed, cursing quietly under my breath.

I knew approximately what it was that needed to get done. The patient needed about half of what was in the bag over an hour's time: 12.5 milligrams per hour. I hung the assembly and piggybacked the line, setting a drip rate at "about" what I thought would drain within that time. I watched it carefully as we drove to the hospital, adjusting it slightly after 50cc's had flowed. Practically, the rate was just about correct. Academically, though, I had no idea what exact drip-rate the patient was getting. It made me extremely nervous. I imagined showing up to the hospital and being questioned on my assembly, the concentration and what infusion rate I had chosen. I could recite "about" what it was, but remained terrified that the ED staff would question the specifics. What do you mean you started a medication infusion and you don't know what the drip-rate is? I imagined I would stammer and sweat, standing there in the harsh ED lights looking not only ridiculous, but incompetent.

I tried over and over with the math, but with the distractions and the increasing stress as we approached the hospital, I just could not do it. I had no calculator, and the numbers were starting to blur into meaninglessness. We arrived at the hospital before I was ready, and without anything else to do, I decided to just lock the IV line and head in to the ED.

The ED staff didn't seem to care much at all about my drip. The pulled the piggybacked bag off of my main IV line and tossed it to the side. They assessed the patient on their own, barely listening to my report and only glancing at my ECG strips. Never once did they ask me at all what infusion rate I had administered my patient. Hearing the story, the doctor smiled at me and told me I "fixed her," patting me on the back. I nodded and backed slowly out of the room.

The drip rate calculation took me less than 30 seconds as I sat at a desk writing my report. I immediately recognized the mistake I was making earlier, and shook my head in wonder of how I could have messed it all up. Simple. It really was simple.

I made simple, rookie mistake because I was flustered with a new situation and new procedure. With all of the routine ALS that I have been doing lately, satisfaction with my performance of the familiar was beginning to inspire an unearned confidence. The experience was a sobering one, bringing me back to the ground after so many months of remaining largely unchallenged. No matter how much I think I've learned, experiences like this have been reminding me that this job has the potential to surprise at any moment. ...Without warning exposing a weakness in harsh, bright light.

Baby Medic, you'd better stay sharp.


Terry at Counting Sheep said...

Strong work! Congrats. You'll build on it, for sure.

Katie said...

Why do some of the QRS complexes appear upside down in the last image?

anthonym83 said...

Good post.

Could you explain the differences in the before and after EKGs of AFib? I'm still learning EKGs, so they both looked pretty similar to me and don't think I could've told the difference in the field.

-Anthony, EMT

AttorneyMedic said...

im just a lowly B, but looks like the QRST complexes on the first line are more spread out after drug intervention.

fiznat said...

attourneymedic hit it on the head. While both strips show a-fib, the difference between the two is the rate. The first strip averages out to about 160 beats per minute, while the second is at about half that. In an older patient such as this with pre-existing heart conditions, slowing the rate can translate into a meaningful (and sometimes critical) difference in cardiac work and oxygen demand.

Nurse Carolyn said...

Great post --EKG strips and all!


I often think that same thing...
classroom vs. reality. We ought to have an exam where the teacher tosses us a calculation and then stands over us with a timer.

Anonymous said...

Out of curiosity, what was the drip rate you figured out?

Howdy said...

My protocol shows a beta blocker as a contraindication for Cardizem.

fiznat said...


Beta blockers are a relative contraindication, not an absolute one. The worry is inducing bradycardia or hypotension (or both) with the concurrent meds, but I felt that this patient was tachy enough that something needed to be done about it right away rather than wait. In addition, Cardizem had worked for this patient in the past, so I was fairly confident that it would be a relatively safe choice this time as well. We have protocols to give Calcium Chloride/Atropine/Dopamine/Glucagon if the Cardizem slows the rhythm too much, not to mention pacing, so I had "outs" if things went wrong.

You're right though, the beta blocker prescription is definitely something to consider. Thanks for the comment.