electrical system of the heart was working, but the heart wasn’t actually pumping any blood.
“Get a set of labs, stat, continue CPR and give me a history.” Seth scowled, hoping this wasn’t another cerebral aneurysm like his mother had suffered. “We need to find the source of her PEA.”
“Labs are in process,” one of the nurses said. “Her pulse ox is low at eighty-two percent, despite being on one hundred percent oxygen.”
“Double-check the tube placement,” Seth ordered. “Did she have surgery recently? Is there a reason she might have thrown a pulmonary embolus or a tension pneumothorax?”
“No surgery, according to the husband, and no other reason to have a blood clot or tension pneumo that we’re aware of.” The female paramedic responded without hesitation. “Her history is fairly benign. The only complaint she had prior to passing out was nausea, lasting from the night before, and some vague complaint about neck pain, so our working assumption was that she’d suffered a myocardial infarction.”
Since women experiencing a heart attack generally didn’t present with the same symptoms of crushing chest pain, shortness of breath and dizziness as most men did, Seth was forced to consider the paramedic might have nailed it right. The honey-blonde looked young, with her hair tied back in a bouncy ponytail, but she obviously knew her stuff. A myocardial infarction would explain the patient’s lack of oxygenation.
“Should I get a cardiology consult?” asked Alyssa, the brunette trauma nurse beside him.
Cedar Bluff Hospital, located in the less populated rural area off the shores of Lake Michigan, only had two cardiologists on staff, and if their patient needed something complicated like open heart surgery they’d end up transporting her to Milwaukee.
“Yeah, tell them they need to get down here ASAP. Make sure a troponin level and cardiac enzymes are being run on the blood sample, too.”
Alyssa hurried off, and he continued running their resuscitation efforts. “Let’s give a dose of epinephrine and get a chest X-ray. Have we verified tube placement?”
“I did when I placed the tube.”
The female paramedic’s tone was defensive. He didn’t have time to tell her not to take it personally. He would have verified anyone’s ET tube placement, even his own.
“I’ve listened. There are breath sounds bilaterally,” Cynthia, another trauma nurse, spoke up.
Alyssa returned. “Dr. Hendricks is on the way.”
He nodded, somewhat relieved his colleague and friend Michael Hendricks happened to be the cardiologist on call today. He trusted Michael’s judgment and didn’t mind the extra help.
A radiology tech wheeled in a portable X-ray machine. As they shot a quick chest X-ray, another nurse spoke up. “Lab results are back. Electrolytes are a little abnormal, her potassium is low, but her hemoglobin is within normal range so she’s probably not bleeding.”
Seth took a deep breath. Okay. So far they’d ruled out two of the six possible causes of PEA. “What about her troponin and cardiac enzymes?”
“They’re still being processed.”
He pinned the radiology tech with a fierce gaze. “I want to see that film now.”
The young tech nodded and scurried off, downloading the image onto the designated radiology computer terminal. Seth waited, and was forced to admit technology was amazing when the chest film image was available on the screen in less than a minute.
“No tension pneumothorax. There might be some blood around the heart, though.” Finally a potential diagnosis. Cardiac tamponade was a potential cause of PEA. He spun back toward the patient. “I’m going to do a pericardial tap, to see if that helps.”
He drew on a pair of sterile gloves as the nurse on the right side of the patient pulled out a sterile cardiac needle and syringe, carefully opening the packages so he could grab the items. The nurse on the other side of the patient doused her chest with an antibiotic solution while he connected the needle and syringe and picked out his landmarks. He took a quick, steady breath and slid the needle into the V beneath her sternum, hoping and praying he didn’t cause more harm than good. When he saw the flash of blood, though, he knew he’d hit the right spot. Pulling back on the syringe, he drew out a good fifty milliliters of blood.
“Nice job,” Michael drawled from behind him. “Why did you bother calling me?”
Seth spared his friend a quick, exasperated glance before putting another syringe on the needle to see if there was more blood to be removed. He withdrew another eighteen cc and then glanced up at the heart monitor. “Hold off on CPR. Let’s see if she finally has a blood pressure and pulse to go with her rhythm.”
There was a moment of complete silence as several staff members, including Michael, felt for a return of the patient’s pulse.
“I feel a pulse, but it’s weak.” Michael spoke up.
Alyssa nodded, confirming she felt it, too.
“She has a blood pressure, but it’s only sixty-five systolic,” Cynthia added.
“Start a dopamine drip, and find out what that troponin level is.” Seth stepped back and stripped off his sterile gloves. “Michael, our working diagnosis so far is an acute myocardial infarction with a pericardial effusion. I called you so you can take her to the cath lab if needed.”
“It would be nice to see the troponin first,” Michael said.
“I have it—her troponin is 0.51, which has been reported as critical,” Alyssa informed them.
The number didn’t sound high, but anything over 0.03 was considered indicative of an MI, so 0.51 was way above the accepted range.
Seth glanced at his friend. Michael nodded, understanding his unspoken question. “Okay, she’s mine now. Let’s prepare to get her transferred immediately to the cath lab.”
The nurses sprang into action, placing the patient on a portable heart monitor and then gathering all their paperwork together. Seth noticed the female paramedic stood off to the side, watching as the events unfolded. Once the cardiology team had taken over Seth could sign off on the case, although he knew the odds weren’t in this poor woman’s favor. She wasn’t out of the woods yet. It was a sad fact that women who suffered from acute myocardial infarctions had a much lower survival rate than men, mostly because of their atypical presenting symptoms. At least in this case the paramedics had realized the potential and had treated the patient accordingly.
“Excuse me? Dr. Seth Taylor?”
He turned when he realized the female paramedic was speaking to him. “Yes?”
She held out her hand. “I’m Kylie Germaine, the new paramedic education coordinator here in Cedar Bluff.”
This was Kylie Germaine? He’d seen the honey-blonde a couple of times but he hadn’t known her name. He’d heard about a new paramedic education coordinator coming on board, but for some reason he’d expected someone older, more experienced. Kylie looked too young to have the expertise needed to provide education and training for the entire paramedic team. But then again she had pegged this particular
