Standstill

Last post we talked about how the methodology for ambulance dispatch. I also mentioned that things don’t always go according to plan.

We received the page after lunch: 80 year old female, seizure, post ictal, breathing normally. Normally, these jobs would be an emergency case; a priority 1 with lights and sirens.

But the pager said that it wasn’t. We double checked with comms that we were only meant to be driving out on a 2. It was odd. But we drove off enjoying the views as we pulled into the seaside hamlet.

As we pulled into the driveway, an ominous call came through from dispatch “what’s your ETA? We’ve just heard from the family that the patient still hasn’t recovered”.

Considering that it had taken us more than 20 minutes to get to the scene this wasn’t a great sign. So with a little more intentionality we headed inside.

Our patient was lying semi-recumbent in a recliner. Around her were her husband, daughters, granddaughters and partners. She was pale, nauseas, and more than a little dopey.

I don’t know why, but something was just concerning me about this patient. We discovered that these ‘seizures’ were becoming more and more regular.

We also learned that she had a 3cm AAA, significant cardiac history and due to a fear of hospitals and doctors did not receive medical assessment or treatment regularly.

As my partner and I discussed differential diagnosis, I cast my eye over the monitor. We’d printed multiple strips and seen no signs of ischemic changes.

But the heart rate started to slow. 80, 75, 60, 52…. No sooner had I said the words “mate, you might wanna have a look at this” than the patient went into asystole. Runs of VT dashed across the screen. Our patient’s eyes rolled back in her head. Her body slumped heavily into the chair.

In the space of 10 seconds, our patient had progressed from sinus rhythm, into third degree heart block, through to ventricular standstill.

My partner and I paused. Almost as if in a comedy, we blankly looked at our patient, to each other, and then back to our patient again.

And then our brains started working again. My partner gave a sternal rub, trying to get a response. I clambered over the ECG, blood pressure and oxygen lines, forcing myself to walk out to the truck to call in to comms for backup.

In the most steady voice I could muster “good afternoon, can we please get ICP backup, patient in asystole, with runs of VT.

Leaping up the stairs on the way in, I expected to see the patient on the floor with family members doing CPR whilst my partner was ventilating….

But she wasn’t. Our patient had output again. She had been down for at least 15 seconds.

But she was conscious…. for now. So we got moving.

Pads (or as we say in front of patients, the ‘big sensitive dots’) went on. The 12 lead was wired up and another ECG was taken. An IV line was put in and a bag of fluid hung TKVO. All the while with me praying that she wouldn’t arrest until we got to hospital.

Oddly (and thankfully) enough, nothing else exciting did happen, even after we got to hospital. Our backup arrived, we moved the patient into the car, and transported uneventfully.

We took her into the resus bay, where in all the busyness we expected her to deteriorate. But she didn’t. As we poked our heads in 30 minutes later after writing our report, the condition of Ventricular Standstill was being explained to the patient and her family. She was going to be fine.

Things like this are the reason we never trust our pagers. We nearly stopped by the bakery for coffee on the way to this patient. We almost took the scenic (and considerably longer) route along the coast.

We almost had to perform a full resus for a  witnessed cardiac arrest.

Valuable lessons were learned that day. Don’t stuff about on your way to jobs, even if they seem benign. Don’t leave your patient or a monitor unattended. Don’t be lazy in your assessment because everything seems fine.

Because I also learned ventricular standstill kills a lot patients because clinicians walk away and leave the patient by themselves or send them home too early.

As with so many things in life, its the things you can’t see that you need worry about.

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