Reversals

The call is at a nursing home for groin pain. We find a seventy year old man holding his groin and writhing on the bed. He has dementia so it is hard to have any kind of conversation. The daughter looks familiar and she says I brought her father in to the hospital last week. I ask what for. She says for low blood pressure. It doesn’t ring a bell. “I do so many calls,” I say, “but you look familiar.”

The daughter says she thinks her father has a fever. His forehead feels warm and dry, but his core is definitely hot. The daughter says they took a catheter out a couple days ago. I ask what was the outcome of his hospital stay and she says they couldn’t figure it out – they think it may have been related to his constipation – straining to go to the bathroom had made him hypotensive.

We load him on the stretcher and I tell my partner – a new EMT -- to head for the hospital on a non-priority. On the way I have a hard time getting a blood pressure because the patient keeps tightening his arm. I finally hear it at about 70. I put him on the monitor. The rhythm catches my attention:

F-Me I think. He's in V-Tack.



Here I am bumping down the highway. I have a writhing feverish patient, no IV, haven’t done a 12 lead and he is in what looks like V-Tach. What an idiot I am going to look like at the hospital. But how can he be in VT?

The only thing going for me is that he doesn’t look like he is about to die. I did not expect to see a rhythm like this. I look at it closer. Odd looking. It looks on first impression like VT, but now that my heart has stilled, I look at it more critically, and I also quickly apply the 12-lead and hope that it will analyze on the move. It surprisingly does.

Suspect Arm reversal the ECG reads:

Opps.

I have the left and the right arms mixed up. That'll do it.

I switch the arm leads and it looks a little different. Much better.



I read his W10. He has a history of afib and hypotension. I remember him now. I got a manual blood pressure last week of 90/50, but when the hospital put him on their machine at triage it came out 60/40 and he was sent to a medical alert room, where I suddenly found myself having to give a report to a room full of doctors and nurses. "I got 90, your machine got 60. I did a manual…”

“Do a manual,” the doctor said to a nurse.

When I came back with the completed paperwork there was only a nurse in the room – all the doctors were back at their stations. People in afib shouldn’t have their BPs taken with automatic cuffs because missed beats will cause the pressure to read lower. Even when you take it manually, you have to lower the pressure very slowly.

I pop in an IV as we pull into the ER – not much a 22 in the hand, but it is all I can access because of his thrashing. I pretty much think I have it figured out now. He has a fever and an infection possibly from the catheter he had in, and that’s what’s causing the groin pain, with the fever also causing the rigors.

At the hospital, their machine shows a pressure of 110/62. In a reversal from last week, he goes to a regular room this time – even though I admit the only pressure I could hear was 70 -- not that it was right. The hospital machine is like an all-knowing Aztec god. We bow before it – always right, always accurate, always saving providers from having to get off their butts and take a manual pressure.

Turns out he has a fever of 103.5. That'll do it.