Back to Reality

Back to reality! Morning report this AM had 2 cardiology cases. The more memorable was a 65 year old man from about an hour away who presented with at least 1 week of weakness, exertional incapacity, and difficulty breathing. His liver was enlarged and mildly tender, definitely pulsatile. His heart rate was nearly 140 beats/minute. The ECG revealed atrial flutter, and it was plain that electrical cardioversion was indicated. This became a case of Little Red Hen syndrome, where I needed to bring together the resources to do the procedure safely. At home, we'd do a TEE, but that was unrealistic in this setting. I administered low molecular-weight heparin, gave instructions for initiation of beta blockers to begin to slow the heart rate and treat heart failure, and set up the cardioversion. I had brought ECG stickers with me, so we were able to deliver synchronised (monophasic) current. However, I had to obtain electrolyte gel from another part of the hospital to enhance paddle conduction and avoid burns caused by arcing. We also found midazolam in the pharmacy! We were all set and the procedure went smoothly, successful on the first shock, and the patient voiced no discomfort.
The post procedure echo showed him to have serious cardiac dysfunction, which was in part due to the previous days in atrial flutter at a high heart rate. We'll see how he does over the next few days with unloading and other anticongestive treatment.

Barbara and I are having the Penn house officers and students for a chili dinner, and invited the Pilane court maids, too. They are eager to see the Madikwe pictures, so it will be fun to have a little slide show.