Closest Most Appropriate 2/7

He gives me a quick run-down of the situation.

“This is Josh, he’s 8 years old and has a birth defect in the heart. He was playing with the other kids outside when he had sudden onset 10 out of 10 chest pain described as pressure and associated shortness of breath. He had a similar event two weeks ago which required cardioversion and the Cath Lab.”

“Why cardioversion?” I’m still trying to reconcile the fact that my patient is a kid and not a man in his 50s.

He moves out of the way of the cardiac monitor which has a fast series of even little bumps where the perfect electrical conduction of an 8 year old should be. He says, “It looks like atrial flutter at a rate of 178 a minute and he’s got a blood pressure of 86 over 58 off the auto BP cuff.” All BAD!

I move around the fire medic to have a look at Josh. “Hi Josh, how ya doing?” I say hoping he doesn’t see the very real concern in my face, as I kneel down to meet him eye to eye. He takes a tiny little thumb and gives me the thumbs up. Wow! Josh is a veteran of the medical community at the ripe old age of 8. He has cardiac surgical scars like a 50 year old who’s had multiple bypass surgeries and he knows he can’t talk well with the mask on, so he gives me a thumbs up instead. I give him a smile while I hold his wrist with my fingers wondering if I’ll find the weak radial pulse tacking away at 178 miles and hour. He’s pale, cool, diaphoretic. It’s a term we use a lot yet it still astonishes me when I see it. Sweaty people shouldn’t be cold to the touch and no 8 year old should ever look like this. The pulse is there and presents as I expected, fluttering along like quick rapids in a river under my fingers. We call that thready.

The fire medic kneels down with me, “Mom said that last time he was cardioverted his heart sounded like a washing machine, and that’s pretty much what it sounds like right now.”

I pull the stethoscope from around my neck and place the bell on Josh’s exposed torso next to the fresh scar tissue. Damn, if that doesn’t sound just like a washing machine. Paramedics don’t usually work with heart tones, pretty much every heart tone I’ve ever listened to sounded just like the diesel engine of my ambulance – it’s a skill and diagnostic tool better left to the cardiologist in a controlled environment. But any paramedic could tell that this kid’s heart was not doing the normal “Lump Dump” of a healthy heart. I’ve listened to heart tones of leaky valves – on the internet anyway – and I understand the concept. But this is a leaky valve on steroids. This valve simply isn’t working.

The fire medic was watching my eyes as I listened. All paramedics are similar in one respect: they are trained observers. We get lied to by most patients – people give us conflicting information, exaggerate their symptoms and distort the facts. We quickly develop very acute observation skills with a finely tuned bullshit meter. He saw me play out this scenario half a dozen different ways, most with bad endings, and the resignation that we are on this path together for better or worse. All of that was in just one look but we had an understanding: Josh was our patient and we were going to see it through together.

“Hey Josh, we’ll take really good care of you, just hold tight while I talk to these guys for a second, okay?” He gives me another thumbs up. Wow!


~ by KC on May 30, 2010.

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