Wednesday, February 06, 2008

The Wonder Of...

Happy post to start.

I firmly believe life is more enjoyable (or bearable) if one can take pleasure in the small things. Simple things, for simple minds, maybe, but I get excited by the simplest things. Some people take great joy from the first blossom of Spring, or puppies, or whatever. For me it's not usually quite so 'traditional', but the principle is the same. Little things make me smile and brighten my day.

Medicine is replete with opportunites for this. There are many things we, as health professionals, can do that have an instant effect. (ideally making the patient feel better.) Treating patients is great. What I mean is perhaps typified by the treatment of SVT. Supraventricular tachycardia. The patient's heart beats fast, caught in a feedback loop in its electrical 'circuitry'. A number of tricks will restore normal rhythm - squatting, blowing out a syringe, ice cold water on the face. Mostly we use drugs.

The first time I saw one treated was as a medical student. I was doing a surgical attachment in North Devon, and one of our patients had flipped into SVT on the ward. My Houseman and I moved the patient to a telemetry bed; she filled a syringe, and then turned to me - 'Watch this', she says. One quick flush, and the too rapid trace on the monitor was replaced by a nice normal one. 'Isn't that amazing?', she said. I know it sounds twee, but it was. It is. The drug in question was adenosine. There's others we can use, and I know most of you will be thinking what a sap I am; I don't care. This is what I mean about the small things. Nice, simple and instant. Hugely pleasing.

(As an aside, looking back it now also seems amazing that we, as junior surgeons, treated this all by ourselves...)

Now, when it comes to being amazed by things medical, much of what a person will be amazed by depends on your frame of reference; the more you see something, the less amazing it becomes, and the more commonplace. Unless you're a simpleton like me, continually surprised by the rising of the sun. For example, several years ago, I was treating a fella with a bad nosebleed. I tried cautery, but the bleed was too posterior, so I packed the nose and waited.

Evidently the packing didn't work, and he began bleeding from the corners of his eyes. It's basically the same trick as people blowing bubbles out their eyes, or laughing milk out their noses (well, sort of...). The blood, denied the usual route of egress found a way out through the naso-lacrimal duct. The blood leaked out of his eyes. I thought this was amazing, and I bresathlessly phoined the ENT doc.

'You gotta take this guy', I yammered down the phone, 'his nosebleed is coming out of his eyes!'.

'Yeah, whatever', he drawled, barely stifling a yawn. 'Send him up, I'll see him on the ward'.

I couldn't believe he could be so blase. It later dawned on me that, as a guy who spends the bulk of his life fiddling with noses (or whatever the ENT wizards do) he must have seen loads of eye-bleeders. So, it was old hat for him.

This might explain my reaction during the following tale. I was almost literally awestruck by the events I am about to recount. The other protagonist in this vignette was decidedly non-plussed, as may you be. But it made my day, and is easily the best thing I've sen this year.

The story begins with a chap sent up by his GP with transient bradycardia. His heart keeps slowing down, slow enough to make him ill. The ambos reported rates as slow as 20. If any non-medics are wondering, unless you are Miguel Indurain, a heart rate of 20 just isn't going to cut it. In fact it's even a bit slow for our Miguel. Anyway, his heart as ticking over at a happy and healthy 80-odd when he got to us.

For a bit.

He quite promptly dropped to the low 40s, and turned a whiter shade of pale. He was hustled into Resus, and hooked up to the machine that goes 'beep', and the machines that go 'buzz'. All the machines, in fact.

By then of course, his rate was back to normal. We called the Cardiologist down, and he came with a minimal of fuss. No choir of angels, no cherabim or seraphim. In fact, he was a bit grumpy, because we had failed to catch the slow heart rate on paper. No print out, no proof. It drives this particular cardiologist mad that we have such a low strike rate.

I can see his point.

Little did we know the moment of triumph was nearly upon us.

While writing up the notes, the patient began to drop his rate. He revisited Procul Harem as we gathered around the monitor, breathless, atropine in hand watchin the sacred print out. His rate dropped to 40, 30, 20... it reminded me of excitable Gridiron commentators, when someone breaks into the open: 'He's at the 40 yard line! Still going! 35, 30, 25, 20, 10 and touchdown!'

Except this ended with asystole. Just a pause? No. When three seconds elapsed with no sign of electrical activity, and the patient fading, as I was just about to fill him with atropine, my new hero thumped him square on the chest. The monitor registwered a beat. Another thump, another beat, and another, and another... at that point his heart fired up again. But I had witnessed percussion pacing. A technique I have never seen work. That I thought was pure bunkum; a tale to tell of the old days. Like ether as an anaesthetic.

I was completely goggle eyed. So simple. Percussion pacing, wherein the operator uses his fist to impart a low energy 'shock' to the patient's heart, causing it to contract. The most primitive form of defibrillation.

Cardiology, however, was very matter of fact about it. This is of, course, because he is cardiology, and his field is electrophysiology. Percussion pacing is his bread ad butter.

But I don't care. I think it was awesome, and my day was brighter because of it.


MonkeyGirl said...

Yup. I've only seen it done once, and I told every single living soul I came in contact with all about it for at least a week afterwards. (Not that any of them were nearly as impressed as I was.)

That right there is cooler'n shit.

DrShroom said...

I'm glad it ain't just me. Everybody looked at me like a dog that's just been shown a card trick when I waxed lyrical about it

Kate said...

I'm with you-- SVT, nursemaid's elbows, things with instant gratification.

Faith Walker said...

Haha- i would have been amazed as well.

I wish i'd had my crazy svt/tachycardia whatever it is with you around- it would have been far more interesting than whats happened to me so far eg. Just sitting there for 2 hours and waiting for it to go.

missjillycool said...

Scuse my lack of knowledge but is that the the precordial thump?
Love reading your blog!

DrShroom said...

Sort of, in that you are thumpin the precordium... but whereas precordial thump is a once only blow, delivered in a witnessed, monitored VF/pulseless VT, this i slightly less energy, in someone who is very bradycardic/pwave asystolic etc...