Rosina's Rapid Rhythm, Part 1.
"Doctor, can I borrow you for a minute?"
Cate looked up from her notes, tapping away on the tablet in her lap. Nurse Teri was leaning down towards her, a friendly look on her face but with an expression that implied urgency. "Yes, of course," she got up from the chair, "…what have we got?" They began walking together through the busy ward.
"Something on one of our FCs. Looks like a weird rhythm I thought you should see." Teri motioned with her head to the other side of the ward, and Cate nodded.
As they walked, Cate mused about the day's events. SMC's First Cardiac promotion was turning out to be a complete success, more patient interest than anyone had suspected. It seemed that among posters, word-of-mouth, and piquing the interest of young folks, the public ward was full - and more were coming in. Cate looked over the rows of exam chairs, each with their tidy stack of cardiac monitors, each occupied by an eager patient getting hooked up for what in most cases was their first ECG. The admit staff were starting to run out of printed heart camisoles, Cate thought with amusement.
Cate couldn't help the spontaneous smile that formed on her face. Was this move unusual? Unorthodox? Of course it was. But at SMC, that's just good medicine, she thought as if by rote. And the patients were enjoying themselves! Of course, in some cases, they found something that needed attention. And that was also the point of First Cardiac.
Quickly they approached a patient in her exam chair, hooked up like all the rest. Teri quickly summarized as they approached. "Rosina is a caucasian female, 19 years, said her friend convinced her to some in today. She's visiting - Italian national, on vacation. She needed some convincing but eventually sat for an exam. BP 102 over 70, but variable, borderline hypo. HR peaked at 122 and didn't really come down, though, and the waves look a little…weird. Thought you should have a look. Oh, and I'd already marked her for follow-up, before I saw you at the table."
Cate nodded again as they arrived at Rosina sitting in the exam chair. Looks a little scared, Cate thought, but that's to be expected. The girl wore the surgical bouffant awkwardly, almost as an afterthought. That was a nice touch, Cate thought, even thought it wasn't strictly necessary. An inexpensive detail to give patients a 'real feel' for things. She introduced herself. "Hi there, I'm Catalina Palomo, Chief of Cardiology here at SMC. You can call me Dr. Cate if you like. What's your name?" She asked, but Rosina just looked at her nervously. The 5-lead electrodes looked big on her small frame, and she sat stiffly in the chair.
"Hi," the girl said. "I am…Rosina." Obviously the nametag should have told Cate that, but the introduction was more of an icebreaker. The girl had a strong Italian accent, and sounded nervous. "Is something - something wrong?" She asked. Cate now noted the "EXTRA" label that Teri had already placed on the sticky nametag, indicating for the staff that follow-up was recommended.
Cate had already glanced at the monitor when she arrived, but now she looked at it with some intent. "We just want to be sure we're looking at everything closely today, Rosina. That's why we're glad you came in for First Cardiac." Cate saw right away the borderline tachy rhythm as well as the mis-shapen waves. She suspected something real, not just anxiety. HR was now 115, and resps were a little high, too, at 22. "Rosina, are you having any trouble breathing today?" Cate placed her stethoscope in her ears and pressed it to Rosina's chest, right above the neckline of her tanktop.
"No, is okay." Rosina shook a little when Cate pressed the bell to her skin.
"Sorry, honey; it's cold. Not out of breath at all? Feel like your heart is racing?" Cate said, moving the bell around.
Cate shook her head briefly, as if to clear it. "Ah, sorry," she smiled. "Do you feel your heart beating fast?"
Rosina seemed to think about that as Cate pressed the steth below her left breast, against the fabric of the tanktop. "N…no, not fast. It's…same all the time."
"Okay, Rosina." Cate looked at Teri for a moment, and the nurse seemed to shrug with her eyes.
"Okay, honey. Breathe deep for me, please." Cate said, listening to the indrawn breath. "Again." Rosina continued to take deep breaths as Cate moved the steth around her chest, eventually lifting the tanktop slightly and slipping the now-warmed bell underneath for better contact. The ECG wires brushed her hand as she manipulated the steth. Eventually she drew back. "Just relax for me - I'm going to check your pressure. Teri, can you…thanks."
Nurse Teri had anticipated the request and her finger was already on the menu button. With a whirr almost muted by the sounds of the open ward, Rosina's cuff inflated against her pale skin, the straining velcro revealing the growing tightness. Rosina grimaced quietly as the machine beeped, the cuff quietly deflating. 105/72, and this was probably high due to anxiety, Cate thought. Cate touched Rosina's hands. "Do you feel cold, honey?" She reached down to touch her feet, could only feel her ankles.
Rosina looked down at Cate reaching for her feet, which struck her as odd. "No, is fine...in here."
Standing up again, Cate leaned in, looking into Rosina's frightened eyes. "Are you on any medications, Rosina? Even over-the-counter. Anything?" Gently, Cate positioned Rosina's face so her pupils were clearly visible, then carefully felt for the girl's carotid pulse and began to palpate her neck. "Look up for me, please…yes, thank you."
Rosina, craning her neck, responded briefly. "No. No medications. Ah - maybe…ibu-profen?"
Cate, nodding, gently relaxed Rosina's head. "Mm-hmm, ok. Are you on you period?"
Cate nodded, looked at Rosina, then at the monitors again. "Any drugs, honey? We need to know this." The question was curt and delivered with authority.
Rosina looked alarmed…or was it insulted? Cate thought. "…no drugs." The girl said, flatly.
Cate stood straight; turning to Teri, "I'd like to check something - can you place another BP?" Teri nodded, moving quickly and efficiently. To Rosina: "Honey, I'm going to put another blood pressure cuff on you, just for a moment. Just checking everything, ok?" Rosina nodded as Teri got the second cuff wrapped around the girl's arm and hooked up to a spare monitor channel. In a few seconds, it was also inflating.
A beep soon signaled. 98/65. "Mm-hmm," Cate mumbled, thinking. She patted Rosina on the thigh. "Rosina, honey, just relax for a bit, ok?"
Cate moved a few feet from Rosina, facing the monitors, and turned to Teri. "Let me tell you what I notice." She casually motioned to Rosina, who still sat stiffly, as if the monitors attached to her prevented her from moving. "Cool extremities. Resting tach, persistent hypotension. Slightly elevated resps, but no frank hyperventilation. Do you agree?"
Nodding, Teri signaled agreement. "Uh-huh, yup. She's also agitated, right? So BP might actually trend lower."
"I'd expect so." Cate nodded approval.
"And…" Teri thought she was interrupting a thought, so she hesitated. She knew Cate was a good, but firm teacher.
Cate looked expectantly at the junior nurse. "What is it?"
"It's…weird that she isn't aware of her tachycardia, right?"
"Let me ask you a question." Cate was in teaching mode. "How sure are you that she would admit it?"
Teri looked as if she would blush. "Right, ok. How do we get that answer, then?"
"Sometimes we can't. So we use the data and trust instinct." Cate said, as if quoting from a book. Which she probably wrote, Teri thought with amusement.
"Okay, so what else?" Cate asked. "Take a look at her ECG and give me your first impression. Remember anomalous waveform training, and look at Lead II."
Always teaching, Teri thought. She stared at the waveform display, even blurring her eyes a little, just to get an overall sense. She adjusted the display to feature Lead II. It took a short bit, but something occurred to her. "Oh! There's…QRS narrowing." Teri was pleased to remember the term. "Wait. And…ST depression?"
Nodding, with - a satisfied smirk? Teri wasn't sure - Cate said, "Great, you see it as well. Yes, and that makes me suspect some sort of tach syndrome - there are a few to investigate. But we can't do it down here."
Cate turned back to Rosina, who obviously was able to see, but probably not hear their dialogue over the din of the ward. She sat on a portable stool that was set up next to the patient chair. "Rosina, honey, I'm really glad you came in today. I'm seeing some things in your ECG that we should take a closer look at.
Rosina's eyes were large as she looked straight at Cate. "But I…feel fine. Feel ok." The young patient stammered slightly, and Cate could tell that she was anxious. As if by instinct, Teri gently placed her gloved hand on Rosina's shoulder.
"I know, honey - that's good." Cate also made contact with Rosina, placing her hand on the girl's knee. "That's why it's really great that you decided to have your First Cardiac with us today. Sometimes these conditions don't make us feel sick right away. You have a kind of rapid heartbeat - we call this tachycardia - and it's there even though you might not be aware. Do you see that number on the screen? The green one?"
Cate motioned to the patient monitor, on a rolling stand next to the chair. The HR indicator now glowed 125 next to a dense forest of QRS complexes bouncing away as Rosina's heart clattered in her chest. Rosina turned her head stiffly to look, squinting her eyes a bit. She looked somewhat confused, so Cate looked at Teri, and nodded subtly.
Teri looked kindly at Rosina, and spoke softly. "These electrodes are sensing your heartbeat and we're reading it out on the monitor." The nurse gently touched the micropore electrode on Rosina's nearest shoulder. "For your age and body type, and considering your general good health, that number should read more like 72. So this is rather fast, and that's why we want to look closer. Do you see?"
"Mm. Yes." Rosina said, quietly.
Cate nodded approval. "Thank you, Teri. Now Rosina, without more tests I can't be sure of the cause. It may be simple - sometimes these things clear on their own." She paused, glanced briefly up at Teri and back to Rosina. "…but it could be a kind of arrhythmia - er, a 'rhythm mistake' that we may have to correct."
"Correct?" Rosina turned away from the monitor - she looked almost fascinated by it, Cate thought - and looked from Cate, to Teri, and back.
Cate patted her knee. "Let's take it one step at a time, honey. First, I'd like to have you come up to Cardiology and we'll have a closer look. Does that sound ok?"
"My…my friend is here. I need to…" Rosina was craning her neck, trying to look around the ward.
Teri spoke up first. "We'll all find your friend before we go up, and let them know what's going on. Does that sound ok?"
After a pause, Rosina looked down at herself. She seemed to take stock, lifting both arms slightly, still wrapped with the cuffs. "…is ok."
"Great," Cate said, smiling, quickly shifting gears. She stood, speaking rapidly to Teri. "I'm going to order a 12-lead and get the stress lab prepped. Can you bring her up in a few minutes? We'll admit her once we're there. If the friend wants to join us, that's ok for now."
"Consider it done. Would you like my help upstairs?" Teri asked.
"Of course. Please." Cate nodded definitively. Turning to Rosina, "Rosina, I'll see you upstairs. We'll get things figured out, ok?"
Rosina looked at her plaintively, and with some resignation. "Ok."
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