***Some details have been altered, changed and fabricated to protect patient identification and maintain HIPAA compliance***
Following an argument with his wife, a patient in his late 40s said he felt like his chest was “fluttering”, but this wasn’t from the uneasy feeling the knowledge that he’d be sleeping on the couch for the night would normally bring. So what did he do? Lay down? Google his symptoms? Call 911? No, he grabbed his stethoscope and auscultated himself.....The patient was an internal medicine MD.
Very soon he was driving to the Emergency Room. When asked what he wanted to be seen for, he told the triage nurse “Well, I’m in A-fib with RVR”. After a quick EKG, the patients self diagnoses was confirmed. Heart rate was irregular and humming along at over 150bpm.
Once he was taken to my room, I obtained an IV, drew labs, set up a crash cart and a defibrillator, placed pacer pads on his chest and administered oxygen. The patient was still in RVR, and although there are multiple treatments, only one has low side effects, a high success rate, and is almost instant...synchronized cardioversion.
The patient was updated on the plan of care, and understandably, a little nervous. Propofol was chosen for sedation and
3ml of was given via IVpush. Almost instantly the patient started to appear sleepy eyed. “How do you feel?” the resident asked. “Hmm pretty good but I’m thinking 3 more cc’s”. We all laughed, and the resident replied, “so I guess you’re just going to direct your own sedation”. The patient grinned, nodded slowly and was out almost immediately after the next 3cc push.
The defibrillator was quickly synced to the heart rate, 200 joules set and once clear, I delivered the shock. His body jolted upward off the stretcher. A pause in his EKG and then relief, he was successfully converted. Normal sinus rhythm in the 80s.
Less than 10 minutes later, he woke. The first slurred words out of his mouth… “I feel like I need 3cc more, I’m waking up”. “it’s done” I replied, “we converted you”. “No $hit, really??? I don’t remember... God I am sore but I think after 20 years of marriage I finally won an argument with my wife!”
Just 30 minutes later, he was sitting up on his laptop placing orders for HIS patients. As I handed him his discharge orders, he said to me “you guys really do this every day!?”, I just smiled, “maybe not every day but it’s definitely something we’re used to”. I had to just think to myself how incredible it was that a man who just had 200 joules of energy shot through his heart was walking away from the ER
My job is awesome!!!
A little about A-fib RVR for my non medical folks! The full name is actually Atrial fibrillation with rapid ventricular response, and its basically fancy terminology for 'fast and irregular heartbeat'. Sometimes, if your hearts electrical signals are not firing correctly, it can lead to a heartbeat that is either too fast or too slow! In most patients, this incorrect signaling affects the heart's two upper chambers, the atria, causing them to slightly quiver ie. Atrial Fibrillation. But in some cases. the misfiring signals can also effect heart’s two bottom chambers, known as the ventricles. Thus when both the atria and the ventricles are beating rapidly and irregularly, we call it atrial fibrillation with rapid ventricular response(Afib with RVR).
Complications from not treating the condition can include stroke, heart disease, heart failure, and cardiac arrest. I touched on the treatments above, but many times, in patients with a known etiology (cause), medications such as anti-arrhythmic, beta-blockers, blood thinners and digoxin will be used. Because it is an electrical problem, catheter ablation is the definitive treatment, especially in those like this patient who is young and healthy. Ablation is the freezing/cauterizing the faulty electrical nodes within the heart!
***Some details have been altered, changed and fabricated to protect patient identifiers and maintain HIPAA compliance***