Wide complex Tachycardias

I want to take a couple of minutes to follow up on my tachycardia post from the other day. I left off on wide complex tachycardias, and I feel like this is a follow up that needs to be done.

As I said in the other post, we assume that all wide complex tachycardias are VT unless proven otherwise. The first question that we need to know is: does this wide complex tachycardia have a pulse? If the answer is no, then we work the patient as if it was a VF/VT code. If there is anything that a person with an ACLS card in his pocket should know how to do, it is work a VF/VT code. For crying out loud, they train cashiers at WalMart how to do most of this, and if you can’t, then maybe you should turn in that ACLS card and throw in an application to WalMart.

Anyway, if the patient has a pulse with this tachycardia, the next question we should ask ourselves is whether or not this patient is critically unstable as a result. There is only one thing that counts: Are we perfusing the brain? There are two fairly reliable indicators that we can use to determine this: mental status and blood pressure.

If the patient has altered mental status, or has a systolic blood pressure of less than 90mm Hg, then this patient is critically unstable and needs immediate intervention. Synchronized cardioversion is the way to go here. Time is tissue. Going with drugs at this point is costing you brain tissue: time to get the IV, time to drip amiodarone over 10 minutes, or time to push the lidocaine is going to cost the patient brain tissue.

If the patient is not critically unstable, then we have time to find out what we are dealing with: Is this VT or is it SVT with an aberrancy? We can tell by running a 12 lead. Run a 12 lead EKG, and if leads aVF and I are both showing negative deflection, then your QRS axis is in the upper left quadrant, meaning XAD or Indeterminate axis. This is an indicator that your patients heart is experiencing retrograde conduction. The foci, or pacemaker, in this heart is in the ventricles, and you are dealing with VT. Otherwise, it is SVT with an aberrant conduction.

Hope this helps. Good luck out there!

Trials of being a parent

I have two children. I divorced my wife when they were young. My son was eight years old, and my daughter was six. I know it was hard on them, and I always regretted that. When my ex wife and I divorced, both of the kids took it pretty hard.

I paid my court ordered child support, which in Florida is a punishing amount (payroll deducted). My child support was $1400 a month, and that left me only $800 a month after taxes. I was always broke.

The actions of my ex wife didn’t make things any easier. When I would go to pick the kids up for visitation, the ex-wife would refuse to let them see me unless I gave her more money, and when I refused, she would tell the kids that I didn’t take them with me because I didn’t love them. My son wouldn’t believe it, and would tell his mother to stop badmouthing me.

When the kids were allowed to come over, they always came without clothes, and the ones they were wearing were so worn as to be unsuitable for going anywhere. When I would ask about that, she told me that if I wanted to take them anywhere, I had to buy them clothes.

The kids would come to me and tell me that their class was going on a field trip, or they needed supplies for school, or some other event that required money, and their mother told them if I didn’t pay, they would do without. Of course I paid.

Once, the mother’s new boyfriend called me at home and told me, “Your daughter just called me daddy. Just thought you should know,” then laughed and hung up. That incident alone shows how restrained and in control I am, since I did not go down there and… well.

Just before my son turned 15 and he started costing more to raise, his mother threw him out- she said he was too hard to control. He came to live with me, got straight A’s, and graduated high school two years early, at the age of 16. He graduated college and the fire academy, all before he turned 20.

When my daughter turned 15, her mother caught her hanging around with a ne’er do well boyfriend with an arrest record, doing drugs, and skipping school. She sent my daughter to live with me. It was three years of fighting. Three years of school skipping, catching her with drugs, her being brought home by the police, her getting arrested, and me being threatened with violence by her boyfriend for interfering. The cops were not help, and neither were the courts. Three years of being told that she couldn’t wait to move out and be rid of my “bullshit rules” so she could live with her “soul mate.”

On her eighteenth birthday, she left and went to live with her boyfriend and his parents. A few months after she left, I was at her high school graduation. That was the last time I saw her until Christmas, when she came by to ask if I had bought her a present. She had broken up with her “soul mate” and he stalked her for six months or so, until she got a restraining order.

That was over two years ago. My daughter now lives in an apartment with 8 roommates, and has another skeezy boyfriend who uses all sorts of mind expanding chemicals. They both wait tables for a living. Still, I try not to express my displeasure, after all, I remember what it was like to be 20. We have been speaking, off and on for about the last year.

Until this morning. She had friended my brother and my nephew on a social networking site, and it seemed like family relations were improving. Then, my daughter began posting pictures of her illegal substance use, pictures of partial nudity of her and her friends partying, and other mature themes. My brother asked her to tone it down, as her 9 year old nephew could see it. She replied that she would not censor herself for anyone.

I jumped in and asked her to keep in mind that what goes on the internet can hurt you later in life, and also reminded her of the importance of family. She promptly told all of us to f- off.

They joys of parenthood. Why am I expected to endure behavior from relatives that I would never tolerate from strangers?

BATFE ice wine ruling

Bureau of Alcohol, Tobacco, Firearms and Explosives (BATFE) has a great many responsibilities, one of which is determining how wine is labeled and sold. BATFE ruling 27 CFR 4.39(a)(1)states that a wine made with grapes that are frozen after harvest may not be labeled “ice wine”. True ice wine is made from grapes that are frozen on the vine, according to ATF Ruling 78-4, 1978 C.B. 61. This ruling was made because this is misleading the public and true ice wine has particular property and characteristics that are not achievable by freezing the grapes after picking.

I wonder if BATFE conducts raids on wineries like they do gun stores and gun owners? Torching wine casks open, stomping on kittens, confiscating wine. Remember the good old days, when BATFE ruled on things like declaring a shoestring to be a machine gun?

 

Call of the week- is it SVT or do you need a refresher?

54 year old golfer who was struck by lightning 3 years ago and now lives in a local nursing home. We get called to the establishment for a report of rapid heart rate. Nevermind that he had been convulsing for over 45 minutes, they were worried about his heart rate of 160. The fact that the seizure was causing the poor, bedridden man to run a marathon never crossed her mind. She was locked on to the fact that his heart was racing.

At that point the RN was trying to explain to me that a HR over 140 is SVT. For all of you who are rhythm challenged, we will have a quick ACLS review here:

SVT means Supraventricular Tachycardia, or literally “a tachycardia occurring above the ventricles.” Theoretically, it means any tachycardia that is not ventricular in nature, and this would include a Sinus Tachycardia that is a part of the body’s normal response to physiological demands.

In reality, when people talk about SVT, what they are really referring to is a tachycardia that is caused by an electrical problem within the heart. This can include Multifocal Atrial Tachycardia (MAT), Atrial Fibrillation (Afib), Atrial Flutter (Aflutter), Atrioventricular Nodal Reentrant Tachycardia (AVNRT), and a few others.

 How do we tell the difference? Assessment is the key to medicine. If the patient is exerting himself and placing major metabolic demands on his body, the problem is not in the heart. Seizures, heavy physical activity, trauma, as well as other metabolic and neurological conditions will cause the heart to beat rapidly. A man watching TV who experiences sudden tachycardia is not responding to metabolic demands.

Don’t let anyone tell you that a HR over 140 is automatically SVT, and below that is not. A good example of why the “140 rule” is a bad one is Aflutter with an atrial rate of 330 and 3:1 conduction. That will give a heart rate of only 110, yet such a patient is in SVT.

In the call we are talking about at the beginning of this post, the man has a heart rate of 160 because of the heavy metabolic demands that the 45 minutes of seizure activity is placing on his normally sedentary body, not because he has a heart problem.

We treat a sinus tachycardia that is caused by metabolic demands in a simple way: we correct the metabolic problem. In this case 10mg of diazepam by IVP stopped the convulsions, and within 15 minutes his heart rate was back to normal.

But how do we treat PSVT? This is an abnormal condition, and should be treated as a cardiac rhythm disturbance per the ACLS tachycardia card. We can consider synchronized cardioversion, and if we don’t know the origin, just start at 100 joules.

If we don’t go with electrical therapy, the problem gets a bit stickier. Narrow complex tachycardias are usually AVNRT, and we can just try Adenosine (6mg initial dose, followed by 12mg and 12mg more if unsuccessful) to see if that corrects it. Be sure to run a strip while you are giving the drug, so you can perhaps see if the rhythm is actually Afib or Aflutter.

If that narrow tachycardia turns out to be Afib or Aflutter, then you can try a calcium channel blocker like Diltiazem. I would not go with a calcium channel blocker in AVNRT though, because that rhythm is caused by an accessory pathway, and giving these drugs to a patient with AVNRT will shut down the calcium driven  AV node, and make the sodium driven accessory pathway the king of the highway. Now you have converted a patient from Aflutter with 3:1 or 2:1 conduction into a patient with 1:1 conduction, and a HR of 300!

You can also try cordarone, which is pretty effective on wide and narrow tachycardias, just watch out for cordarone’s most common side effect: hypotension.

Speaking of wide complex tachycardias, they are a bit different. First, determine if that tachycardia comes with a pulse. If not, it is VT. If it does have a pulse, we consider synchronized cardioversion, and if we don’t go that way, we need to consider drugs. All wide complex tachycardias are to be treated as ventricular tachycardia until proven otherwise. More on determining that in a later post. For now, we can just try antiarrhythmics like cordarone or lidocaine for treating wide complex tachycardia. (Important caution: corddarone and lidocaine should not both be given to the same patient. Since cordarone lengthens the refractory period by blocking potassium channels, and lidocaine blocks fast sodium channels resulting in a slower conduction velocity, the two together can cause asystole.)

This post is long enough for now, so good luck.

Edited to add: Here is the wide complex post

Tight schedule

Excuse the lack of posting lately. I work two jobs, and I am taking 22 credit hours of college this semester. I am trying to get in to school to get a Master’s degree, so the prerequisites are eating up my time. More details on that later.

Last week’s schedule was 48 hours at my fire department job, 12 hours teaching classes, and my time in school TAKING classes.

This week I work 64 hours at my fire department job, and 10 hours teaching, as well as classes.

On top of that, I have to mow the lawn each week. No time left for posting.

I ain’t skeered

TOTWTYTR replied to my recent post concerning the need for cops to wear cameras while on duty. I was originally going to respond in the comments section, but thought that my thoughts on this would require more room than I had, so I figure I can get a post out of it.

Be careful what you ask for because it’s not a stretch for someone to say “Paramedics need cameras” too. Like the ones that some systems have in their ambulances to track your driving skills. 

My department installed cameras in the patient compartment of all of the rigs a few years ago, and the original plan was to record all of the action. I was one of the most vocal opponents of this plan, and I pointed out that personal injury attorneys would analyze every frame of video to score a “gotcha” moment and use it against you. I also noted that HIPPA compliance would be a real issue with these recordings. I used to think that there is no way that I would want to be recorded. I have since changed that view.

I have a few thoughts on this that I want to share:

First, it would be hypocritical of me to expect a cop to wear a camera and not be willing to do the same. I am being paid by the public, and the public has every right to know what and how I am doing things on their behalf and on their dime. I have no problem with being recorded while on the job, as long as those recordings protect the modesty and privacy of my patients, who do have a right to expect their privacy is secure. If the patient were blurred out, or if the recordings were only released to the patient, then the patient’s right to privacy is secure, and I am just fine with it.

Second, if I am doing my job, and treating the patient they way that they are supposed to be treated, I have nothing to worry about. I do my job, and I do it well. The worst thing that anyone will see on video is that I occasionally miss an IV or a tube. So what? I will get an IO or a King tube, and that is the end of it. In order for this to create a liability, the lawyer needs to prove three things:

1 That there was a duty to act, and
2 That the paramedic failed to act, or acted in a way that a reasonable paramedic with his experience and training would not have acted, and
3 this failure resulted in a negative outcome or harm for the patient.

Even if there is no video, if you are doing things that are not in the best interests of your patients, you are going to get sued, and rightly so. To a good medic, a video can help more than hurt. A video is poison to a bad medic.

The only official complaint that I have ever had filed against me was one where a Doctor accused me of failing in a treatment, and the thing that saved me was a memory dump of my LifePack. If it wasn’t for the telemetry information that was contained in the monitor, I would be a greeter at Wal-Mart. A video would have done wonders for my case.

The third thought on this matter: I know a lot of crappy medics. They make up vitals, they do as little as possible, and do everything they can get away with to complete the run and go sit down somewhere. They have been known to bring in patients with agonal respirations with only a nonrebreather. They bring codes in to the ER with only BLS in progress. These are the medics who make the good medics look bad. Those of you who want to improve EMS, and who want paramedicine to excel, remember that the crappy medics who are getting away with that sort of thing are the ones who are making us all look bad.

Maybe it is time that they leave us.

Cops need cameras

Story after story is in the news, where cops abuse citizens, citizens claim that cops framed them, cops murder citizens, cops refuse to be filmed, yet desire to film everyone else.

I think that since the technology is there, every cop should, for the duration of the time he is on duty, wear a recorder that they cannot shut off, and the recording of the officer’s shift should be downloaded and stored for one year, unless a subpoena or court orders that the recording be kept longer. Such recordings would be public record, except those who identify minors, victims of sex crimes, or witnesses who are deemed to be at risk.

Any recording that is discovered to be damaged, missing, or unavailable for any reason (including the famous “technical difficulty” that causes so many police recordings to disappear) shall cause the court case to be decided against the cop. If you don’t have anything to hide, you don’t have anything to worry about, skippy.

How to simulate Paramedic life

Do you have a friend or family member who works in EMS? Do you want to work in EMS? Have you always wondered what it is like to be a paramedic? Well, wonder no more, I have come up with a way to simulate the life of a paramedic:

– Write down every task that you need to perform in the house and how it is to be done, such as lawn mowing, painting, sweeping the floor, etc. Place all of the sheets in a notebook titled “Protocols.” Memorize the entire book. Change the protocols at least once a month, and take a test to ensure that you have the new way memorized.

– Have your neighbors call you at random times throughout the day and night, so you can go to their homes and perform tasks. Your neighbor gets bonus points if the task needed isn’t in the protocol book, or if the task is gross, disgusting, or a complete waste of time. A good example would be calling you to come change the thermostat for the air conditioning, or rub cream on his hemorrhoids.

– If a task to be performed isn’t in the protocol book, you must call your father in law on the phone, describe the situation, and ask him what to do.

– Stay dressed all day so that you can make it to the car in less than 30 seconds. To test this, have a neighbor run through your house several times a day with a megaphone yelling “Copy code three” whereupon you jump up and run to your car. Every fourth time, after you have gotten in the car, have the neighbor tell you that you are canceled, and you can return to what you were doing. Bonus points if you were in the shower, cooking or eating dinner, or sitting on the toilet.

–  Every day, write down the contents of your medicine cabinet and pantry. Then check the car out, paying close attention to fuel and oil levels, and the condition of the tires. Also, confirm that the headlights and horn work. Write this all down and stuff the papers in a drawer where no one will ever see them again.

– If you need something to replace missing items needed to carry out your protocols, send an email to a relative, who will go to the store and shop for you. Make sure they either buy the wrong thing, or get too much or too little of whatever it was.

–  To simulate your coworkers, when you perform a task, have another person stand behind you and comment on the way you did it, either telling you that you aren’t following protocol, or pointing out that they would have done it differently.

– Every time you perform a task, write down everything you did in the form of a report. Have someone randomly pick out every fourth report from a week ago and point out that you misspelled a word, got the zip code of the grocery store wrong, or that you missed a step in the protocol for whatever task you performed. This will force you to rewrite the entire report.

– For at least 4 hours a week, you should watch training films that you have seen at least a dozen times. Then you should write a detailed report about what you learned.

– For another 2 hours a week, have someone “teach” you how to do something that you already do on a daily basis by reading an article from a two year old copy of JEMS, Good Housekeeping, or some other magazine out loud. It helps if they do this by reading the article verbatim from a power point that you could easily read for yourself.

-Get four friends to stay at your house as company. They can even call themselves your “squad” or “truck company.” Have them watch you do all of these tasks and make fun of you while they take turns alternatively napping and eating ice cream. Then have them point out to you that you need to clean the toilets.

– Make sure that there is no toilet paper in the bathroom, and at least once a day have your neighbor call you to come to his house while you are on the toilet.

– When preparing dinner, have that neighbor call you to come over while it is cooking. This will force you to either recook the food, forget to turn the food off and burn it, or just say forget it and get something to go from McDonalds.

– Have your mother-in-law write down everything she’s going to do for the day, then have her make you stand in the back yard at 7am and read it to you.

– Sleep in your car while it is parked in the driveway. Have someone else sleep in the car with you, or better yet, have them watch a movie while laughing maniacally every 5 minutes. Make sure that whoever is in the car with you farts at least twice an hour. They get bonus points if they ate relish and boiled cabbage for dinner.

-To simulate move ups, have someone call you on the cell phone at least twice between midnight at five am, to instruct you to dive 5 miles to sit a nearby, random parking lot. Fifteen minutes after you get there, have them call you again to drive home and sleep in your driveway again.

– Wash the car every morning with a scrub brush and brillo pad, then have your wife come out and complain that you missed a spot.

Did I miss any?