Wednesday, October 07, 2009


Memory is a curious thing. It is almost infinitely plastic, and malleable. We can play with our memories, and over time convince ourselves our version of the truth is more real than someone else's. Even with insight we spin and play events, trying them out for size.

History is written by the victor, and memory is constantly re-written by our subconscious, seeking the most palatable version.

Earlier this week, a patient was brought to us from a hostel; he had been staying there for some sort of reunion. He had collapsed, perhaps losing consciousness briefly. All he could say was that he felt unwell.

He looked bloody awful. Pale, clammy, breathing fast and shallow, pulse strong, but fast. The sternotomy scar announcing his membership of the cardiac club. His sats were low, but not catastrophically so, and his pressure good. His lungs sounded clear, and his ECG looked clean.

Interestingly, the 12 lead done by the Ambos showed a Right bundle, conspicuously absent now.

While rummaging around his radial artery, trying for an ABG, his pulse volume seemed to waver and fade. I glance up at him, trying to use my patented diagnostic eyes; he still looked pale and ill, but no more so. Maybe...

"Just check his pressure again for me, please..?"

A minute later, he declared himself. I just decided I wasn't going to get an ABG on this side, when he announced his intention to be sick. This always makes me anxious, because it's often a side effect of a piss poor BP. A quick glance at the monitor showed long pauses punctuated by ugly, broad ventricular escape complexes. Instead of vomiting, the patient slumped back on the trolley, his head lolling, his tongue protruding from his pallid lips.

A few quick shakes of the shoulder and calls to attention, produced no response. The monitor still showed a rate in the 20s.

I punched him in the chest.

The correct term is probably pre-cordial thump.

The effect, dramatic. It was accompanied by a beat on the monitor, and the patient opened his eyes, wide, surprised. I suspect his look was mirrored, not only on my face, but on those of the nurses working with me. The pause was long enough, and his heart beat no more, and I lost my nerve.

A minute of frantic CPR, and he was reaching up to pull out his OPA, the monitor bright and alive with joyful activity.

What had I hoped to,achieve? A precordial thump is intended for use in a witnessed, monitored, shockable cardiac arrest. I think it had been in my mind to percussion pace him. I'd been talking about that earlier in the day. If that was the case, I didn't do it right, I lost my nerve after the initial thump.

Maybe I just panicked?

My memory rejects that version; I'll let it, for now. The patient is alive, and, at the end of the day, that's what counts.

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