Pacemaker + Fail = Pump and Blow, Load and Go!

The call is for "trouble breathing" but by the time we get there, it's something else. A community swimming pool and it's a guy in his late 60s. He started having trouble catching his breath in the pool.

The BLS (Basic Life Support) crew is strapping him to their cot. I have the luxury of doing nothing but looking at him (many hands).

"Um...I don't see breathing." I feel like the kid who said the emperor has no clothes. My words galvanize a group of people into action.

BVM, Cot to the medic unit, IV, EKG. Go go go go.

Nope, he's not breathing and his pulse is fading fast. I'm on his chest so I look to my right and say to the medic I just met 3 hours before, "You've got airway and breathing. Get me a good tube. you're second line for ACLS drugs. Got it?"

I'm the new guy but she nods at me as if I was there every day for 20 years.

I look to my left where CC-Rider, my new pal and best friend, has already pulled out the combi-pads (sticky things that allow us to shock someone's heart) and EKG leads (more sticky things that allow us to analyze what the heart is doing).

"IV and meds, Please."

That earns me a wink and a nod.

I dial up the EKG and see that this guy is in a ventricular escape rhythm (the lower 2/3 of his heart is trying to beat) but it's way too fast (about 70/minute). CC-Rider and I realize that we can't put the combi-pads in the usual place because he's got a big, metal square under his skin just inside his left shoulder.

Can you say "Pacemaker?"

I can...and i did.

OOOKay. Well. pacemaker or not we treat this patient. I see no pacemaker "spikes" on the monitor.

Can you say, "Pacemaker FAIL?"

I can and do.

MedicToMyRight drops a perfect tube and we get a capnography wave that is good but the CO2 level does not get above 17 mm of Hg and is dropping (this tells us how much air is getting through the lungs into the blood by measuring the return Carbon Dioxide). I'm looking for a nice wave and a level above 28.

That's when I see pink foam surging up the airway tube on every exhale.

Pulmonary edema.

Deep suction takes out a LOT of the "juice" and we get a capnography reading of 30. Lovely!

I'm doing chest compressions by this point because there is no pulse that any of us can feel anywhere.

IV is in.

Pump and blow

Epinepherine, 1mg. BAM!

Pump and blow.

Check the monitor:

Asystole. (flatline) No heart activity.

I'm not giving up!

Pump and blow.

Capnography says 15mm of Hg and dropping.

Crap! Suction again!! It climbs to 25. Good enough!

Atropine: 1mg

Pump and blow.

Epinepherine: 1mg

Pump and blow

EKG is a flat line with occasional, weak attempts by the heart to do something.

Diesel Thereapy!! (Drive fast!)

Perhaps a bit too fast. The firefighter who jumped in the driver's seat of our Medic unit made a traffic decision that lead us onto a Hella-bumpy road.

Only my experience in the Coast Guard on small boats in high seas keeps me upright. CC-Rider and MedicToMyRight are both on their butts on the floor.

We arrive at the hospital a bit frazzled but with a completely worked patient. I'm standing on the carriage of the cot so I can continue chest compressions without having to walk. All the while, I'm directing the 3rd round of ACLS drugs and getting the BLS provider to work with MedicToMyRight to check that we haven't lost the tube and we're still suctioning the HUGE amount of fluid infiltrating this guy's lungs.

Like usual, we seamlessly merge with the resuscitation team and I find myself moving to airway with bagging and then drawing up more drugs.

By the time I have a chance to step back and wash my hands. It's over.

The doctor declares this one dead. Ah, fooey.

Not that we didn't see that one coming. This guy had a pacemaker that kept his heart beating well. He also was doing all he could to keep that working right. According to the staff at the fitness center, he was a regular. Swam a mile every day.

Unfortunately, his pacemaker failed. It failed while he was in the middle of his swim. As a result, his heart was not able to crank out enough pressure to his body and then the pressure in the blood going to his lungs began to rise. It got to the point where the pressure of the blood going to his lungs started to push the water in his blood into the breathing space of his lungs.

Pulmonary edema.

Acute congestive heart failure.

CC-Rider, MedicToMyRight and I were cleaning up and getting ready to talk about the call. In my head, I'm thinking about what went well, what went wrong and what I could have done better.

We all agree that by the time we got to the patient, there was not much more we could do. His heart had stopped working properly and he had stopped breathing. We did what we were trained to do and, we did it exeedingly well. We all worked together as if we were the same person.

As this was the first time I worked with CC-Rider and MedicToMyRight (the first call, in fact), I asked how I did.

"Maddog, You're in charge!"

"That was awesome. You knew exactly what to do and you told us when to do it."

"You 'da man!"

Golly! *cue maddog blushing*

But wait! We did this again and again!!!

...more to come...

--maddog

Scared?

I got "pinged" by a reader. She's a regular and she hadn't seen me post in a while. So she sent me an email asking how I was doing.

Somehow, coming from a stranger, that meant a lot to me.

I've been busy with family death and my own non-blogging obligations. Yet, there's more than that.

You see, I'm a fundamentally broken man. I feel that I don't fit into where I am. There are parts of me that don't fit into how the rest of the world lives. I'm working really hard to make myself fit but I see the reminders of how I don't and it's a powerful thing. I'm reminded all the time of what an outsider I am.

I try and I try but, really, I'm not like anyone around me. We all live as if we will never die, or, if we do, it'll be a thing we're all ready for. We will all die. Many of us will do so unexpectedly.

That sucks. Big Time.

I'm aware of that all the time.

(Here's the really scary part:)

I know my father will die. I'll likely be there

I know my mother will die, I hope I will be there.

I know Herself will surely die and I will surely be there.

EVERYONE will die (even me!!!).

But many of us live comfortably because the frailty of life is not in our face. We assume that so-and-so will be there tomorrow. We operate under the assumption that we will all have friends and family around us tomorrow as we did today.

Am I the only one who feels in his guts that this is SO not true?

I'm scared all the time.

Am I allowed to be scared?

--maddog