cardiac

Deserted but not Alone.

It was one of those shifts. One that dragged on and on and was mostly spent with the nurses huddled together at the station, giggling over something ridiculous a patient said.  It was low-key and low drama.  Perfect for seasoned nurses; a real bore for new ones.   Our manager, a gem of a lady, came through handing out shots of expresso to boost us.

We were all laughing and having fun when my charge nurse said quietly, “ Do you think we could move this group into bed 7?”  

I looked at her surprised.

“How come?” I questioned immediately.  Her response was equally quick.

“He was just made comfort measures, they are starting morphine … and he has no family here or that’s coming.”  

We all immediately stopped lounging and got up.  Our orientees dogging our steps, we filed into the room.  All 9 of us on the floor.  We took turns murmuring our hellos or simply squeezing his hand.  He peered at us and nodded.  He had been on our unit for a few weeks and we had all, at some point, encountered him.  He was simply adorable.  His wife had severe dementia and didn’t know him anymore.  His only son was estranged.  His neighbors had already said their goodbyes.  

One of the nurses who had him the most leaned over to him and said quietly in his ear.

“Your wife is ok.  She will be taken care of…” she paused and squeezed his hand, “You’re with friends now, ok?”  

He opened his eyes and looked around glassy eyed as his oxygen levels dropped.  9 figures in blue surrounded him.  He nodded briefly and closed his blue eyes.

“My friends.” He repeated to himself over and over.

Tears clouded every eye in the room and the ones closest laid a hand on him as we watched silently as the color drifted from his cheeks.

The new nurses looked around nervously as death came into the room.  The rest of us were stoic with shimmers of tears threatening to spill over as we watched the last bit of life drain from his face.

I stepped back and discreetly surveyed the room.  All eyes were either looking down or at him.  Bittersweet smiles on their faces as they knew he was at peace.  9 nurses, side by side, grieved for this man whose family was unable to do so.   It was in that moment that I could see how lost the hospital would be without nurses, how sterile and heartless it would become.   I stood with 9 of my coworkers who work short staffed constantly and nearly half have been hit or bitten since I have worked with them.  They are degraded, ignored and yelled at by patients, families and staff… and yet they are the most humane, sincere group I have ever known.

This patient died without family.

But he did not die alone.

Cardiac distress symptoms in women

In the wake of Carrie Fisher’s death four days after she suffered a massive heart attack, one thing that was reported by some news outlets was that she had been in “significant distress” on the flight. We don’t know the exact details of this, but in my experience as an EMT, it often means “hysterical woman having a panic attack and thinking she’s dying…*woman dies* …oops, guess she really was dying.” 

It is SO IMPORTANT to remember that many women present in what medicine considers an ‘atypical’ manner for heart attack, but it actually IS typical…for women. Women are more than twice as likely to die from cardiac emergencies, not because our physiology is that much different than men and thus gives us a worse chance at survival (it’s actually better if treated promptly and adequately), but because our symptoms are more likely to go unrecognized or to be dismissed entirely.

Thus, please take a moment to review and pass on this list of cardiac distress symptoms as seen in women: 

Shortness of breath - This is the most common one. If a woman, especially one without prior history of respiratory issues or shortness of breath, seems to be having trouble catching her breath and/or complains of such, pay very close attention. If she continues to feel winded after sitting or laying down, it’s probably time to call for help.

Feeling of impending doom - This can range from a sense of general unease to a full-blown panic attack. This one is extremely important, and is the symptom most commonly disregarded by doctors and hospital staff. If a woman tells you that she feels ‘not quite right,’ or like something terrible is about to happen, or that she’s about to die, LISTEN TO HER FFS. 

Nausea and “indigestion” - Also common. Heart attacks frequently present as a feeling of vague nausea or indigestion, but unlike typical heartburn, antacids and other OTC treatments will not alleviate the symptoms.

Hiccups - Unexplained hiccups, especially if seen with any of the other symptoms listed above, can be indicative of heart muscle that is being acutely or chronically starved of oxygen.  The exact mechanism isn’t known, but it’s thought that the enzymes released by the dying muscle irritate the pericardium and adjacent diaphragm, causing spasms in the healthy muscle. 

Fatigue - This is another commonly seen symptom, and is often overlooked or ignored as just transient tiredness. Many women having a heart attack will complain of feeling “flu-like” symptoms of nausea, sweating, fatigue, and shortness of breath, and they’ll lie down for a nap and never wake up. 

Lightheadedness - A feeling of being lightheaded or about to faint isn’t terribly uncommon in many benign conditions, and many women experience it on a monthly basis. However - be aware when it appears unexpectedly or unexplainedly, and/or with one or more of the other symptoms on this list. 

Sweating (diaphoresis) - Heart attack does funny things to the sympathetic nervous system, which is behind reflexes such as sweating and hiccups. If a lady is experiencing unexplained or excessive sweating, pay attention to anything else that might be going on with her. 

Tingling or numb extremities - A feeling of numbness or “pins and needles” tingling in the extremities can be an important sign that cardiac function is being impaired and those body parts aren’t receiving enough oxygen. 

Peripheral and/or central cyanosis - Often accompanies tingling or numbness, and is considered a later-stage symptom of cardiac distress and heart failure. Finger and toe tips will turn pale or blue first, and lips and gums after that. Important to remember that darker-skinned women may present cyanosis as ashen, grey, or darker purple rather than pale or blue. 

Back pain - Pain between the shoulder blades, in the cervical spine, or even further down in the torso or lumbar region can be a symptom of heart attack. Alone, it isn’t that suspicious, but if it’s unrelenting and presents with any of the other symptoms above, keep a watchful eye on things. 

Classic “crushing” or “tight” chest pain or pressure - Women DO experience this classic pain, too, just not as frequently as men do. This may be due to our higher pain threshold, or differences in blood volume, or maybe we’re just not sure because nobody’s bothered to really study it. Whatever the reason, some women do still experience the crushing or tightening pain, and others may experience less painful pressure or tightness that doesn’t seem to be relieved by anything.

Arm and jaw pain - Another “classic” heart attack symptom, and a bit more common than central chest pain. Unexplained pain in the left arm or shoulder, and on the left side of the neck or jaw, should not be ignored by anyone.

March 1, 2017 >> A little early morning early morning studying of my favorite body system for my patho test later today ft. breakfast smoothie. Pro-Tip: there’s spinach in that smoothie adding all kinds of nutrients and you can’t even see or taste it 👍🏼

My heart skip skips a beat

HEARTBEATS!!

The pause is to allow the atria to fully empty into the ventricle.

Heartbeat on an ECG trace

P Interval (Ventricular Diastole)

  • Atria and ventricles are relaxed
  • blood is flowing into the atria from the veins. 
  • Atrial pressure increases above that of the ventricle, AV valves open allowing blood to flow into the ventricle

P Wave (Atrial Systole) P-Q

Signal transduction from SA to AV nodes. 

  • SA node fires 
  • Atria contract causing atrial systole 
  • which forces all blood into the ventricles
  • emptying the atria.

Q Interval (End of Ventricular Diastole)

Depolarisation of interventricular (IV) septum 

  • AV valves remain open - all remaining blood squeezed into the ventricles. 
  • impulse from the SA node reaches the AV node 
  • which spreads the signal throughout the walls of the ventricles via bundles of His and Purkinje fibres
  • R peak is the end of ventricular diastole and the start of systole.

R Interval (Ventricular Systole)

Ventricular contraction

  • All blood is now within the ventricles
  • so pressure is higher than in the atria - AV valves close
  • ventricles start to contract although pressure is not yet high enough to open the SL (semilunar) valves

ST Segment (Ventricular Systole)

Ventricular contraction

  • Pressure increases until it equals Aortic pressure,
  • SL valves open
  • blood is ejected into the Aorta (and pulmonary artery) as ventricles contract
  • At this time the atria are in diastole and filling with blood returning from the veins.
  • plateau in ventricular arterial pressure

T Wave (Ventricular Diastole)

T= moment of Ventricular repolarisation immediately before ventricular relaxation

  • Ventricles relax
  • ventricular pressure is once again less than the aortic pressure 
  • so SL valves close

So about 2 months ago this happened. It was scary to be experiencing something that I normally treat at work. I had just walked into the gym and had only started stretching when I had a feeling in my chest of my heart skipping a beat. After a moment I realized my heart was racing so I stepped outside to try and figure out what was going on. I had a hard time feeling my pulse but when I placed my hand on my chest I could tell something wasn’t right…..my heart was racing!! I tried vagal maneuvers without any luck. I walked back into the gym and grabbed my boyfriend and told him WE HAVE GOT TO GET TO THE ER. Luckily for me, there was one across the road. He dropped me off at the door so I could go in while he parked. At this point my ears and ringing, I’m feeling extremely light headed and I know I’m about to pass out. I tell the tech at the front desk “ I’m a paramedic and I think I’m in SVT.” I got a strange look and she quickly grabbed a nurse. I explained to the nurse who took me back and placed me on the 12-lead. This was my EKG when I walked in. My heart rate was in the 260’s, my ears were ringing and I was about to pass out. I was quickly taken back to a room and placed on a cardiac monitor and had an IV started. A physician came in and started to explain what was going to happen. I told him I completely understood, just to please fix me. 6mg of adenosine later and I was back to a heart rate of 100 and finally had a blood pressure.

I was taken out of work and had an ablation 3 weeks after the episode. I am 27 years old, healthy and mostly fit. I have no medical problems and definitely no cardiac issues. This was the first time this has ever happened. Quite possibly one of the scariest days I have had.

To an EMS provider this can seem like no big deal but when you are the patient in the moment, it seems like you are about to die. Granted, most people don’t go into SVT at a rate of 260. I’m finally back to work and feeling great. I still get a little paranoid it will happen again but there is a 95% success rate with ablations. It’s always strange to be the patient and not the provider but this was an eye opening experience for me. Now I can actually tell my patients why they will be feeling with that nice push of adenosine.

An incredible image of Swaroup Anand, 23, who was awake during cardiac surgery performed at the Bangalore Fortis Hospital, India
Doctors chose to numb his body with an epidural to the neck rather than send him to sleep with general anaesthesia. The patient stares out at the camera, his fragile heart exposed during life-saving surgery !