Oh It's Gonna Be a Bad Day

My shift starts at 0700. At 0703 I get my first patient, a 4o year old female with no medical history who has a 1 day history of epigastric pain, nausea and vomiting. The triage nurse was sharp and noticed that the lady was also pale and sweaty, could be possibly from gastroenteritis but she brought her straight back to the cardiac room anyway where we immediately did an EKG.

The EKG didn't show any acute ST elevation but she did have some ST depression in her inferior and septal leads. The doctor orders cardiac labs, aspirin and nitro.

It is now 0710 (when it comes to cardiac-we are a well oiled machine) I give her 4 baby aspirin to chew while a colleague establishes an IV with saline running TKO. At 0711 I give her one nitro under her tongue after educating her on the medication and why we are giving it. At 0712 she says those words that strikes fear into every nurses heart:

"Oh.....I don't feel very well." At the same moment the red alert alarm goes off on the cardiac monitor - the other nurse and I look up and instead of a row of cardiac complexes marching across the screen we see 2. Two complexes equals a heart rate of about 18. Not really compatible with life, which was evidenced by my patients eyes rolling back in her head as she starts seizing from lack of oxygen to the brain.

My friends, this is an 'OH SHIT' moment.

Then adrenalin hits, the other nurse pops open the crash cart drawer and starts pulling out the pacer/defibrillator pads to apply to the patient. I yell out the door for help as I am pulling out the ambu bag to ventilate the patient. I can hear the central monitor alarms ringing out at the desk.

Bag the patient, start CPR, give epi, intubate, give atropine and continue CPR, open up the saline and put it on a pressure bag - now we have a pulse but the rate is still slow, hang a vasopressor to bring up the heart rate and blood pressure. Call the cardiologist and the cath lab, now the blood pressure is coming up - 78/40, still critically low but better than 0. Heart rate is now 48 and rising.

0723 and the cardiologist arrives. The blood pressure is 88/53 and the heart rate is up to 57. we transport the patient to the cath lab.

0740 I arrive back in the ER with an empty stretcher, pulse still pounding from the adrenalin rush. In the last 40 minutes all my rooms have been filled and as I am coming down the hall I see several nurses and the doc in one of them intubating another patient.

Oh boy. It's gonna be a bad day!

And the patient had a 100% occlusion of the RCA artery which was stented successfully, she was extubated after the procedure and went home the next day with no permanent cardiac damage. This is just the kind of patient that would have been misdiagnosed a few years ago, middle-aged female with no significant medical history, non-smoker and vague GI symptoms. Her only real risk was family - her dad and uncle both died young from MI's.