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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

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.

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.

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.

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?

Here is an article that talks about how scientists have discovered where the oil from the BP spill went. It is highly misleading, and I will show you why:

the scientists mapped a huge plume in late June when the well was still leaking. The components of oil were detected in a flow that measured more than a mile wide and more than 650 feet from top to bottom.

 A volume of water 22 miles long, a mile wide, and 650 feet tall encompasses 398 billion cubic feet. That volume contains about 3 trillion gallons of liquid. The report goes on to say:

Now federal officials say as much as 42 million gallons of oil may be lurking below the surface in amounts that are much smaller than the width of a human hair.

So even if the entire 42 million gallons is located within the 22 mile long area tested, That gives us a concentration of 1 part per 71,000, or 14 mg per liter (to use the SI standard).  The EPA allows 10 mg/l of Xylenes to be present in drinking water. In fact, 14 mg per liter is equivalent to 3 shot glasses poured into your average swimming pool.

The article then says:

The study conclusively shows that a plume exists, that it came from the BP well and that it probably never got close to the surface of the Gulf of Mexico, Camilli said. It is probably even larger than 22 miles long, but scientists had to stop measuring because of Hurricane Alex.

Which means that the Gulf of Mexico, at least as far as oil is concerned, is cleaner than the water from your tap.

It all started when my wife said that hunting was evil, that no one should kill a living animal. I pointed out to her that the cow providing that Outback steak dinner that she loves did not become despondent and leap off of a building, thus making her position just a little hypocritical. She responded that she chooses to believe that the animals on her plate died of natural causes. I explained to her that it was illegal to butcher an animal that dies of disease or illness. We came to a truce of sorts whereupon I promised not to hunt, and we continued our normal dietary lives. (This excludes pork- she says pigs are nasty and won’t eat pork. I still eat bacon, but that is cool with her, as she doesn’t eat anything for breakfast except the occasional bowl of cereal or pancake)

Until today.

We were at the store, shopping for this week’s menu, when she made the announcement that as soon as the supply of meat in the freezer is gone, she is becoming a vegetarian. I could almost live with this, except for two things:

1 She won’t eat vegetables. She hates them. The only vegetables I can get her to eat are corn, peas, and tomato sauce.

2 She still says we will have a real issue if I decide to hunt. In other words, we are at an impasse. Not only am I prohibited from hunting, but I fear that the time will come when she attempts to control my meat eating habits.

Her diet will consist of pasta, cheese, seafood, and candy. I am a carnivore, and while I don’t mind eating that stuff, the diet she is embarking on is most unhealthy, and is a road that I simply cannot follow. I recently had to crack down on her, as she was eating 2200 calories a day of life savers. (That is not an exaggeration- she was eating candy all day, and that is it.)

I really fear for her health, and for the health of a 6 year relationship that is taking a decidedly bad turn.

OK, vent complete.