Pulse(3)

‘I did, and I couldn’t find anything obvious.’

Puncture marks in the skin were telltale signs of an intravenous drug user – and we saw far too many of those.

‘We could just wait for the results of the bloods,’ the staff nurse said. ‘They’ll surely be back soon.’

If it had been a weekday between eight and six, I’d have simply phoned a fellow consultant from the coronary unit for some advice but, at nine o’clock on a Saturday evening, they’d all be either at home watching television or out socialising.

Should I page the on-call duty cardiologist? Drag him into the hospital from his dinner?

Decision time.

I was the consultant here. If I made the call, the duty heart surgeon would likely be a registrar, my junior. So it would be my decision anyway.

Do nothing or do something?

Which was right?

I could feel the ends of my fingers beginning to tingle and my right leg began to tremble slightly.

Breathe, I told myself. In through my nose, hold for a second or two, and out through my mouth – just as I’d been taught.

Breathe deeply, and again, and again.

The trembling in my knee slowly died away.

I looked again at the now-alarmingly uneven rapid trace on the monitor. Even if I paged the heart specialist, I was worried that the patient’s condition might deteriorate before he arrived.

‘I don’t think we can wait any longer,’ I said.

‘OK,’ the nurse said. ‘I’ll get it.’

‘Also get someone in here with the shocker.’

She went off, leaving me alone in the cubicle with the patient.

I glanced down at the man.

He appeared even more vulnerable than when he’d first arrived, probably because all his clothing had since been removed, replaced by a faded blue hospital gown that was not properly secured around his shoulders.

It was not that uncommon for unnamed trauma cases to arrive at A&E, such as lone pedestrians knocked down by cars, but I thought it was a little odd for someone wearing a pinstripe suit plus a tie to have no identification on them whatsoever.

I touched his forehead. It was damp with perspiration.

‘Who are you?’ I asked quietly into the stillness. ‘And what’s wrong with you?’

He didn’t reply. I hadn’t expected him to. Instead the monitor above his head simply went on showing me his erratic pulse and over-high blood pressure.

The staff nurse returned holding a small syringe containing the adenosine and a much larger one full of normal saline solution that would flush the drug round to the man’s heart.

She was followed in by one of the emergency junior doctors who was pushing a small metal trolley on which sat the shocker – the electrical defibrillator that would be used to give the patient’s heart a restarting electric shock in the unlikely event that the adenosine caused a cardiac arrest.

The staff nurse connected both the syringes to the cannula on the inside of the man’s elbow such that their barrels sat at right angles to one another.

‘OK?’ she asked, looking straight at me.

‘Ready?’ I said, looking at the junior doctor.

‘Can I assume that the patient doesn’t have a pacemaker fitted?’ he asked.

‘He does not,’ I confirmed. It would have been obvious on the CT scan. But it was a good question. Shocking someone who had a pacemaker was still possible but greater care was needed in positioning the electrode plates.

‘OK,’ said the doctor. ‘I’m ready.’

‘Right,’ I said. ‘Go.’

The nurse swiftly depressed the plunger of the small syringe and then immediately followed it with the complete contents of the larger.

Adenosine was rapidly metabolised by red blood cells with a very short half-life. Consequently, it was important to give it very quickly, together with a large bulk of saline, in the hope that enough of the active drug made it to the heart to cause a temporary block in the atrioventricular node, which in turn should reset the heart back into a normal rhythm.

Our three sets of eyes were firmly fixed on the monitor screen. If the adenosine was going to work, it would do so almost immediately.

Initially nothing happened, but then the trace went flat as the drug arrived at the heart and the block occurred.

I held my breath.

It was only a few seconds but it seemed like an age before any spikes reappeared. Erratic at first then more regular, but still overly fast, the pulse counter almost immediately going back up to over 190.

The adenosine had failed to do the trick.

‘Bugger,’ I said.

‘Double the dose and try again?’ asked the staff nurse. It was normal practice.

I nodded and she went off to fetch new syringes full of drug and saline.

‘Are you sure it’s SVT?’ asked the junior doctor.

‘No,’ I replied, ‘I’m not sure. We’re still waiting for the results of his bloods to come back from the lab.’

We stood in silence and waited.

‘Double adult trauma call, six minutes,’ said a seemingly disembodied voice over the department Tannoy system.

Saturday night in A&E.

Busier than an ice-cream seller in a heat wave.





2


‘Chris, I need you.’ It was Jeremy Cook, my fellow emergency consultant.