Early in the morning yesterday, my unit was dispatched with a BLS fire engine to an affluent neighborhood for reports of a “40 year old man, not feeling well.” I have driven by this neighborhood several times, but had yet to actually cross into the well-groomed lawns behind the fortress-looking gate house.
Since “not feeling well” could mean virtually anything from a stomach bug to a knife impaled in a stomach, I was prepared for something odd.
We were met by the very kind woman of the house, who informed us that the man of the house woke up this morning feeling ill, and was simply unable to get off the toilet. If this isn’t a good way to start a long shift, I don’t know what is.
We located the aforementioned gentleman, sure enough, sitting on his toilet, which contained a bowel movement roughly a type 5 on the Bristol Stool Chart. For lack of a better term, this gentleman looked like death eating a cracker.* He was pale, even more so than a twenty-something that rarely ventures out of his mother’s basement, and he was drenched in sweat, despite the very cool temperature in his palatial house.
He complained of dizziness, shakiness, nausea, and general malaise. The rest of the exam, performed by my capable and trusty partner, Slimm, was unremarkable. His pulse was bounding and regular, and his 12-lead didn’t show any elevations or depressions in his ST-segments. The tracing was not of the best quality, as he was having a very hard time “holding still” as directed by the somnolent fire crew. His blood glucose and blood pressure levels were close enough to normal, albeit mildly hypertensive.
No big deal here. Grab a stair chair, move him off the toilet, and down to the stretcher. A little bit of O2, and an IV to the hand, and off to the hospital we go.
Being the anal-retentive ECG reader that my colleagues insist I am, I set off to obtain a cleaner tracing, which was still somewhat difficult.
What I did notice, and not on the tracing, or printouts, but on the monitor itself, was the patient’s steady rate. It never changed. 75 beats per minute, not slowing or increasing for anything, even when Slimm poked that 18 gauge catheter into the back of his hand.
Having some extra time on my hands, (what neighborhood full of million-dollar homes is 5 minutes from a major hospital?) and with the interestingly steady rate, I opted to check out the Lewis lead.
Bam! As Emeril Lagasse would say. Atrial flutter! 4 to 1 conduction!
Fast-forward to the hand-off of this patient to the nurse, who is preparing to go home after what was, apparently, a very adventurous night in the Emergency Room.
“Good morning. This is Mr. Smith. He woke up feeling cruddy, and had a loose stool. He is nauseous, but hasn’t vomited yet. His vitals are pretty normal. He has an 18 in his left hand for you. Here’s his 12-lead, and here’s a print out of Lewis lead. He looks like he’s in a-flutter.”
“But the 12-lead says ‘Normal Sinus Rhythm.’”
“Well, those have never been wrong, have they?”
“This is classic vertigo. SIR, ARE YOU DIZZY?”
A very shaky “Yyyy-eeee-sssss.” is the reply from behind the curtain.
“Yeah, this is vertigo.”
“These are pretty clear flutter waves here on this prin-”
“You need me to sign something for you so you can go?”
2 hours later, after shift change, we are dropping off in the room next door to Mr. Smith. I decide to check in on Mr. Smith, to see how the Antivert did for him. His absence was conspicuous.
“Hey, where is Mr. Smith?” I ask the nurse assigned to him.
“Him? Oh, he went up to the cath lab. He was in a-flutter, so cardiology wanted to do an ablation.”
*My father’s term. I like it, and try to use it when applicable.
No related posts.
Somebody needs to have her ACLS revoked. Maybe more. I hope you keep copies of this stuff in case he dies in the ER while being ignored for vertigo in Level 2.
This is one of those cases where if I could manage to “run across” the ER doc, I’d say, “Hey doc, you should see this AFlutter on a Lewis Lead that I took.” And after he remarked on it, I’d just throw off, “Yeah, the nurse thinks his only problem is vertigo but I left her the printout so I figured you guys would catch it.”
In the nurse’s defense, I don’t remember learning too much about Lewis Lead in ACLS.
Some of the doctors are better than others, you know.
“Hey, doc, check out this a-flutter on my Lewis Lead.”
“I don’t think that’s flutter; there is a p-wave right there in lead II.”
“That’s not a real lead II, since the RA electrode is moved and everything.”
“I gotta go take this phone call.”
So who’s the most qualified person in the room, then? Just sayin’.
But I agree, in my case, with my old friend and mentor, with EKG’s and cardiology, arguably, it was always him, just about no matter who was in the room.
Cardiologist to paramedic: “Come look at this EKG and tell us what you think. We’re not sure about this.” I was there when that happened.
Maybe I’m missing something. I don’t see a relationship between his flutter and his illness. I didn’t see a reference to his age or any PMH, but you did note that he was hypertensive. His problem is not vertigo, since that’s a symptom, not a diagnosis.
While he might need a visit to the EP lab at some point, I’d think the hospital would want to stabilize him before. that.
I didn’t see a relationship between the two, either. He may or may not have had vertigo, but he certainly was in a-flutter. I never got to talk with him, so I’m not sure if the Antivert worked or not.
Dizzy does not = vertigo anyway, completely different than dizziness. Glad that nurse was able to diagnose it without even doing a Dix-Hallpike.
Good catch on the arrhythmia.
” ‘Him? Oh, he went up to the cath lab. He was in a-flutter, so cardiology wanted to do an ablation.’ ”
Of course cardiology wanted to do an ablation. The question was did the patient NEED and ablation?
Don’t know how I missed this post in my RSS Reader! Well done sir. Would love to see the tracings