I hate when it looks like TV.
It is a phrase that has run through my mind in the past. It is rarely a good thing and usually stressful. After three decades in emergency medicine, I can see it unfold.
Scene 1: A man in a wheelchair is being pushed rapidly by a nurse with his harried wife talking and going through her purse. A young man in scrubs is practically running in front of them with a piece of paper.
Loudspeaker: SVT coming from triage to the resus bay.
ED Tech: Here is his ECG. (She shoves the piece of paper in front of the pod's attending and intern.)
Scene 2: An entire medical team is assembled in the resuscitation bay. Two people in scrubs are helping the man out of the wheelchair. A third person is getting leads from the monitor and placing stickers on his chest. A fourth person is placing a blood pressure cuff on his arm. The resident makes his way to the patient's side. The ED attending is at the curtain of the room. The ED pharmacist arrives.
ED pharmacist (looking at the monitor): Are we doing diltiazem?
ED attending: Just got him in bed. We don't even have an IV yet. The QRS is wide but not concordant. I don't think its V-tach. I think there is aberrancy.
ED intern (her voice is heard over all the noise in the room): I want you to take a deep breath and blow out on this syringe for as long as you can. (Pan to the ED intern.) Harder. … Go longer. As long as you can. … Keep going. … OK. Lift his legs.
Suddenly, she puts the back of the bed down, and the nurse lifts the patient's legs in the air. The heart rate increases at first to 200 and then it breaks to 100.
ED intern: Let's get another ECG.
It reminded me of a scene from the TV show “ER." There was a man in SVT, and everything was going wrong. The intern put ice water in a basin, thrusting the patient's face forward. When he came up sputtering, he said, "What the hell are you doing to me?"
Scene 3: (All in my mind.)
Patient: What the hell? What type of medicine do you practice here?
(Camera pans around the room showing astonished faces.)
ED nurse: I've never seen that really work.
(Camera stops on the intern's face.)
ED intern: We reverted you. It's called a modified Valsalva maneuver, and it uses your body's nerves to slow down the heart. It has been studied, and it worked well in the REVERT trial. Keep the syringe in case it ever happens again. You could do it at home.
Sometimes this job is really great when it looks like TV.
Tip to Remember: The modified Valsalva maneuver and the ice stimulated diving reflex can convert SVT. These can be particularly useful if you don't have an IV. (Watch a video demonstrating the modified Valsalva maneuver at http://bit.ly/3UauDDt.)