50-year-old woman recent heart surgery to replace a valve. Visiting nurse says the patient is bradycardic. The officer tells me the patient doesn't look very good. I find the woman laying on the couch with a nonrebreather on. She says she doesn't have any pain, but doesn't feel well, and vomited a couple hours ago. Her skin is dry, but her complexion is grey. I get her in a hospital gown and on the monitor. She's in a third degree block at 30. Still her BP is okay 112/60. And she is satting at 100% so I switch her down to a cannula.
Out in the ambulance, I put a 16 gauge in her right AC, toss her some Aspirin and give her 4 of Zofran for the nausea. And we head in to the hospital. Nonlights and sirens. She is stable, maintaining her rate at 30. Her BP remains constant.
I think about putting her on the pacer pads, but don't want to alarm her. I explain what is going on, and how she is going a little too slow, but that she is stable now. I assure her if anything happens I have the ability to keep her heart going at a steady rate.
I have had many patients with third degree heart block, but they have all been largely stable and asymptomatic. It costs $80 to open up the pacer pads. If anything happens, I can just rip the package open and slap them on and start zapping away.
At the hospital the ED doctor takes a report from me and then asks if I applied the pacer pads. No, I say, she's been pretty stable.
And the ED gets a good set of vitals too, except of course for the 30 pulse. The doctor explains to a med student that even though the patient is in 3rd Degree Block, she is stable. He has called the patient's heart doctor who is in the building. If the student wants to go to lunch that will be okay.
The nurse asks me then if the patient has any allergies. I say Penicillin. The patient's sister who is now in the room pipes in that she is allergic to amoxicillin. The nurse who has just left the room for a moment comes back in and I add that the patient is allergic to amoxicillin. That's the same as penicillin, the nurse says. Really, I say, why you learn something to new everyday. See, the doctor says, even an experienced paramedic can learn new things. True, I say.
I leave to go write my run form, and while I am writing it, I think about writing "Had pacer pads out on standby," but then I don't because I don't think I can really write that unless I actually put the pads on. No big deal, I think. I saved $80, plus since I do the ordering, I won't have to put in a new order yet. We have been getting a little low on our combi/defib/pacer pads.
I finish writing the form and I come back and there is quite the crowd in the patient's room. I go in to drop off my form and see her jerking. She is really jerking and I can see now she is being paced. She is trying to talk, but her whole body is jerking. I have paced people before, but never seen anyone twitching so violently. There is a tall man in scrubs in the room and he is talking on a cell phone. I need to get the cath lab open, I need those bodies off the table. This lady is dying down here.
Wow, I think.
The doctor turns to the lady and says, "Its going to be okay. You need a pacemaker. We're going to take care of you," then a moment later he is back on the phone shouting, "She's going to die if we don't get her on the table."
It seems while I was out of the room, the patient suddenly went asystole. She is now being paced at almost full power, and even at that they are barely maintaining capture. I watch as they sedate and then intubate her, and then finally rush her upstairs.
That was sudden, I say to the ED doc after the room has cleared.
She just went asystole, he says. Good thing we were still in the room.
I didn't put the pads on because I thought she was stable, I say.
I always put the pads on, he says. You never know.
I hear you, I say.
Hey, I'm always open to learning.
Just then the medical student appears.
Did I miss something? she asks.
***
Post script: At last report, the patient is doing very well. They put in a temporary pacer in the cath lab without problem.
