Atrial Arrhythmia and Other Adventures

Atrial Arrhythmia and Other Adventures

[as background, the guitar riffs from Arlo Guthrie's Alice's Restaurant are recommended]

17 March 2015

by Willie Crear

On March 11 I decided to tend to a new symptom of some potential heart trouble, shortness of breath, by checking in with the local medicine men (and women). I had experienced shortness of breath in the fall of 2008, diagnosed at that time as atrial arrhythmia, or atrial fibrillation, by Louise, CNP, of Ridgeview Clinic, Howard Lake, who marched out of the back of the clinic double-time, took me by the ear, marched me back into the bowels of the clinic at the same aforesaid double-time. After a minute with the stethoscope and a confirming electrocardiogram (ECG), she informed me that I had atrial arrhythmia.

Everyone after that referred to the condition as 'atrial fibrillation', which I believe is because virtually no one can spell 'arrhythmia' correctly on the first go.  Kind of like 'diarrhea' or 'diarrhoea' (for all you Pommies).

I had seen actual cardiac fibrillation in a test subject, a dog, at St. Paul Ramsey Hospital in about 1972 whilst undergoing training for first responders. It was a very impressive demonstration of AC and DC voltage, and what they do to stop and restart a mammalian heart. The terms 'arrhythmia' and 'fibrillation' got my attention.

The diagnosis at Ridgeview in 2008 was complicated by the lack of supply of the adhesive electrodes; they kept their hands on me, literally, until a nurse was dispatched to Waconia Hospital and arrived back in Howard Lake with the new inventory.

In 2008 the condition was corrected by the oral administration of Diltiazem 240mg over the period of a few days; I wore a 'Holter halter' for 24 hours to confirm that the heart rhythms had returned to something approximating normal.

Last week, Wednesday, 11 March, I started with a call to Dennis Showalter's office, and got 'Sarah' on the phone. She was not bashful…she said that if I were her relative, she'd be in her car to drive out to pick me up and haul me off to the closest clinic. She encouraged a trip to Ridgeview at Howard Lake, as it was only 3/4 mile from me; Wayzata, and all of the competitive medical facilities ensconced there, were about 32 miles away.

Ridgeview Clinic set up an appointment for me for the following day. This wasn't what Sarah had in mind. I called her back, and got information as to local Park/Nicollet Urgent Care facilities. I had told Sarah that after my experience with three Emergency Rooms throughout the country as a result of a wild cat bite in July (that's a whole 'nuther story, my brush with rabies), I was going to make ER avoidance a primary goal.

I went to the Park/Nicollet Urgent Care facility at Highway 55 and Highway 101.

There, either 'Joy' or her sidekick put a stethoscope to my chest, and immediately remarked, with refreshing candor, something like "Yowee! THAT ain't right!"  The ECG machinery rolled into the room, it spit out some recording tape, which was reviewed outside by a couple of MDs, at which point McDaniel strode into the room, introduced himself (everybody introduced themselves, except the room cleaning crew-more on that later), put a stethoscope to my chest, and said, "I've/we've called an ambulance, and you are going to the hospital."  WIllie: "That was a short debate."

McDaniel also said, in yet another burst of amusing candor, something like "Before transport, we are going to give you an intravenous dose of Metoprolol." [Wikipedia: Metoprolol is a selective β1 receptor blocker medication. It is used to treat high blood pressure, chest pain due to poor blood flow to the heart, and a number of conditions involving an abnormally fast heart rate]. He continued: "We have chosen Metoprolol because it is the only thing we have available."

So, along about this time Joy and her sidekick fell to the task of inserting a 'soft' IV. One said to the other: "A 16!?!…isn't that a bit brutal?" "OK, I'll put in an 18." This also was hilarious, to me; I full well knew what the 'gauge' of 16 meant. The smaller the number, the bigger the needle. A gauge of under 16 means that assistance (hydraulic ram) is necessary to insert the needle. Think 'horses'.

The ambulance guys were ready to rock and roll long before we were; in an amusing 'aha!', I saw their uniforms with the very neat appearance, complete with epaulets. For a moment I thought that the medical types had called the police, to keep me from running. I never let on. My own confusion was hilarious. Why the hell would they call…the police?

I told the ambulance guys that I had been trained to Firefighter One (kind of like 'EMT Lite', with the emphasis on Lite), so no serious faces or demeanors would be tolerated. They were all in.

Throughout all of this emerged a common thread: people asking me again and again, "What is your name?" "What is your date of birth?" "Where are you?" "Why are you here?", all of it designed to reveal whether or not reduced blood flow to the brain had caused my main halliard to jump the sheave, heralding a further decline into the final death spiral.

It was early on when I began to understand the comedic value in all of what was happening. To their credit, virtually all of the Park/Nicollet personnel whom I happened across in the next forty hours understood it, too.

The ambulance ride…remember the ambulance ride? That's where we are now, rocking down the West suburban streets and byways, while the attendant riding shotgun attempts to get the automatic blood pressure cuff to work correctly, which it refuses to do. He switched it to the right side, then gives up and starts with manual monitoring. The whole trip took all of 20 minutes. I don't know if we were running under the lights, but there was no siren. The rig had the legend 'North Memorial' on the side. Somehow associating 'memorial' with 'ambulance' is unnerving.

We passed the time with me regaling him (in my dreams) of my prior ambulance ride, out of a training fire in Maine about 1999, where I was the training fire…I was on the sharp end of a hose line, and took 2nd degree burns to my left shoulder while in the kitchen of a house we were burning down. What impressed me about that ride was, the rig was bouncing down rural two lane blacktop, and the attendant established an IV line while rocking and rolling along that section line road.

I believe that the next stop was the 'stabilization' unit at Methodist Hospital. Although I didn't know it at the time, I had been there a couple of times, to see Daniel Kuyper for my Parkinson's stuff.

The 'stabilization' people started in with the stethoscopes, the ECG monitor, and the questions. "What is your name?" You get the drift.

My paperwork accompanied me in the ambulance. After my name and the names of the urgent care physicians (Smith, McDaniel) was the first piece of information:

SOB (shortness of breath)

I had seen the acronym 'SOB' before, often referencing me, but this is the first time I had seen it as shorthand for 'shortness of breath'.

I agree with the diagnosis. What I don't know is how did they figure it out so quickly?

It got better. They attempted to stabilize the wild fluctuations in heartbeat (50-140 BPM) with more 5 milligram intravenous doses of Metoprolol; it worked in the short term, but it then spiked up shortly after to the old levels.

In between all of this, during quiet interludes, the questions devolved into those about my own personal situation:

"DO YOU FEEL SAFE AT HOME?"

This, along with another one, "Are you over 75?" cracked me up. I am 66, and live alone with four Scottish Terriers.

They have to ask these questions. I was entertained, to say the least. Out of control of my own destiny, for sure, but at least I was entertained.

For all of this time, I am hooked up to a continuous ECG monitor that was giving data in real time, and transmitting that same data out to some nurses' station that I never saw. Once, that monitor measured the gap between two heartbeats, did the math, and came up with 200 beats per minute. That would be fine, if just for a second, but it transmitted that data to the station. About six nanoseconds later, three people showed up in the room I hadn't seen before. I wasn't breathless (for a change), but they sure were.

Since the Metoprolol didn't seen to be working in the long term, the medical types slid a bolus of Diltiazem into the IV catheter. Yowzah, that did the trick, at least in the short term. The heart rate dropped to 60-70, and stayed there. They had readied a post-bolus Diltiazem drip, but they never used it.

If you think I'd be leaving at that point, well…you'd be wrong. They informed me that they were readying a bed 'upstairs', which was in 3-E Telemetry (I presume the 'E' means East). We made the trip up sometime along about 1930-2000 hours, and I was put into a 'double' room. I had a roommate, whom I couldn't see, but I could certainly hear him. We'll just call him 'Art'.

Somewhere in all this, an indentured servant (hospital staff) took a swab of my mucous membranes, testing for Methicillin Resistant Staphylococcus Aureus ('MRSA'), which I found out a week later was negative. Yay! What astonishes me is, they never ran an AIDS test, or if they did, they never let on. My dentist isn't so cavalier….

A prior discussion had occurred down in the stabilization unit as to 'dinner'. It was after the regular kitchen crew had gone home. I said that missing one meal didn't violate my Constitutional rights, and not to worry about it. The crew in 364 (that was the room number) nodded off to sleep…for a while.

About 2200 hours 'Art' decided to get up without the benefit of normally abled people, i.e., nurses. This set off all sorts of alarms…LOUD alarms…which respond to the loss of pressure, patient weight, on the bed. They caught him halfway to the bathroom (there was a half bath in the room, about 2.5 feet from my bed), got him there, where he proceeded to eject a poop that measured roughly to the same level as the Loma Prieta earthquake (6.9). When he got back to his bed, the nursing staff discovered that he had pissed all over himself…before he went to the head. What the hell, you may ask, why didn't they have Depends on him, or some such device? I don't know how long he had been there, at that point, and I am sure the nursing staff would have loved to see such a solution. I can only conclude that he wouldn't let them…after all, he was only about 83 years old. They changed his gown, sheets, and the rest of it, and put a piss-resistant pad in the middle of his bed.

He pissed in his gown/bed/pad/sheets three more times that same night. I would have been bullshit, had I been the nursing staff.

For the two people over the next two days who occupied the bed next to mine, 'denial' is a thought that passed through my head often.

In all of this, there was one common theme. The nursing staff were relentlessly cheerful, nay, virtual Polyannas. ALL of them, to a man/woman. I mused about the hiring possibilities, thinking that they must screen these people with MMPIs (Minnesota Multiphasic Personality Inventory) and the like to find people with the kind of temperaments that I saw.

I expected at least ONE Nurse Ratched (made famous in One Flew Over The Cuckoo's Nest). I never found her.

Throughout the night, the questions from the nursing staff never let up. "What's your name?" "Where are you?" "What is today's date?". These were directed at both of us; 'Art' could never seem to remember what year it was, and when queried as to where he was, he always responded, "Memorial Hospital". Huh? We were in Methodist Hospital.

Between waking up every 2 hours to drain my own bladder, and the almost perfectly staggered 'emergencies' emanating from 'Art's' bed #364-2, I was awakened at least every hour, all night long. None of this had anything to do with the nursing staff and their efforts to keep things on as 'normal' a keel as possible, it was all because of the inmates. Granted, between monitoring machinery, carts, people coughing three rooms down, doors, toilets flushing, and the like, it sounded like a light manufacturing facility on triple shifts. There was a constant din. See 'Bedlam' in Wikipedia.

After the first time I got up and set off all the alarms, the nursing staff made a command decision that I could get to the head on my own, and shut off the most onerous of the alarms. For the next 40 hours, whenever I had to unplug from the heart monitor to go to the head, I firstly reported into the nurses' station: "364-1 is going to the bathroom." "364-1 is brushing his teeth." Otherwise, they had to get up and come in to find out what you were up to.

WIth the morning light it was apparent that the Diltiazem was not going to be the deus ex machina that it had been in 2008; my heart rate hovered around 100, and spiked whenever I so much as moved an arm. Bosmans observed all of this while sitting next to me, with the monitor right over my head. With those monitors, they don't even have to ask you how you feel. If they do ask, they know right away who the liars are.

In the early AM I underwent a TTE (Transthoracic Echocardiogram), this is pretty much just like a fetal sonogram, except their major focus is on the heart, not the lower abdomen. Having said that, I was really sorry there was no one there to document the procedure on film, because at one point the Cardiac Sonographer put the wand on my stomach…the possibilities for such a photograph would have been limitless. "Willie's having twins!" Y'all would have gotten a copy….

Sometime early on the medical staff got a bright idea to send 'Art' up to Occupational Therapy/Physical Rehabilitation. There weren't enough hours in that day, any day, to get that job done, but it did get mercifully quiet in the room; he was no longer berating the nursing staff that he couldn't operate the telephone (it was complicated…one had to dial '9' for outside). I don't know if he pissed in his pants up there, too.

Along about mid morning a decision was made to probably put me through two more procedures: the Electrical Cardioversion-that's where they hook up a set of jumper cables to your chest, stop the heart for 2-3 seconds, and then re-start it so that the atria, and hence the rest of the heart, can achieve normal 'sinus' rhythm. I have no clear idea what any of that means, I'm just repeating what I heard.

Earlier, the duty nurse Brandon had stopped me from eating breakfast, as he informed me that they wanted at least a six hour fasting period before going into the procedures to be done mid-afternoon; if we didn't have that fasting period, my tenancy at Methodist would be pushed out another day.

Note that eating before a procedure where one is under even a mild relaxant/anaesthetic can result in vomiting. Vomiting sometimes results in aspirating the puke, and the puke then chokes you to death. Not eating before such events is a very good idea. At this point, I was pretty clean going in…I hadn't eaten since breakfast the day before…27 hours earlier.

In order to assure that the cardioversion procedure is less hazardous, a TEE (Transesophageal Echocardiogram) must first be performed, to insure that there are no large blood clots in the heart which, one presumes, could be jarred loose by the joules input of the jumper cables.

http://en.wikipedia.org/wiki/Transesophageal_echocardiogram

In advance of the procedures, Brandon brought in a medical release form which was the stuff of a Jon Stewart skit on The Daily Show. It asked, among other things, if I wished to be resuscitated if, say, my heart stopped in the middle of the procedure. This caused more than a small measure of amusement on my part, inasmuch as my understanding  of the procedure is, they stop the heart.

During this whole time I probably had less than six conversations with non-hospital personnel, but on at least two occasions, when I made passing reference to my heart, the incredulous response was, "They found one?".

I signed the waiver. The staff brought 'Art' back up from rehab, and then they started in with what it was clear they saw as challenges on the home front. There were about 4 duty personnel in the hospital to take care of 'Art', but from what they could glean, only his wife was back at the ranch. In the course of rehab, they had also discovered that his speech capabilities had been somewhat curtailed. He was essentially bedridden, incontinent, not able to express himself, and not permitting the use of Depends. I can't imagine what the home front must be like today. They released him later in the afternoon, before I got back from the jumper cable procedure.

On the way down to Electric Alley, I repeated the procedure to the guys around me who were wheeling me down to 'the room'. I had been advised by the release form that I would be asked what I was having done…this is to make sure that I understood the gravity of this process (less than 1 in 1000 have esophageal perforation, and even fewer die), and also to be certain that the medical people perform the correct procedure. I recited:

Transesophageal echocardiogram with moderate sedation, and electrical cardioversion with deep sedation.

http://en.wikipedia.org/wiki/Cardioversion#Synchronized_electrical_cardioversion

I opined to the guy next to the cart that I wished to make certain they didn't, say, remove my left leg. He responded: "That's nothing. Nowadays the wrong procedure means you could come out of the room a different gender."

Bloody hilarious. He really said that. As I observed earlier, they all had a keen sense of the underlying comedic value of all of this. If you primed them, everyone had a one-liner.

The setup for the TEE and eventual jumper cable routine had some comic bits, again. They went through the usual questions designed to ensure that the person on the morgue slab in front of them was really Willie Crear, and same questions were also designed, I believe, to assure the legal types that I was lucid enough to give informed consent. Remember that medical release/consent form mentioned earlier? We were now in the belly of the beast.

One of the pre-op procedures which was comical on it's face was the gargling…with LIdocaine. This stuff was the consistency of epoxy resin. The whole point is to depress one's gag reflex so that you don't ruin those beautiful scrub suits all around you. I suspect that in the olden days this preparation would have been cocaine, until those killjoys at the FDA stopped the flow because of some alleged recreational off-label usage.

The staff in turn introduced themselves, and I quizzed the 'electrician' as to what horsepower levels of electrons they would be using for the cardioversion; he said 50 joules. A 'joule' is named after a guy named Joule, and it is 1 watt of current for the duration of 1 second. The power to light a 100 watt bulb for 1 second, therefore, is 100 joules. Later research taught me that cardioversions generally use 50-100 joules; AEDs (Automated External Defibrillators), which are used in the field to re-start stopped hearts, generally use much more horsepower, now 120-200 joules. The electrician confirmed that the current was DC (DIrect Current), as opposed to AC (Alternating Current). AC is what they use in electric chairs to kill people. It is also what's in your house.

The drug dealer (aka anaesthesiologist) gave me a rundown of the 'relaxants' used in the procedure; the one that stuck out in my mind was Propofol. That's the happy drug which killed Michael Jackson. It is also referred to as 'milk of amnesia', a play on 'milk of magnesia'. It's a very cloudy solution, and one seldom remembers any of what went on, even though one may be conscious, and talking, throughout a procedure. I think they used that during my most recent colonoscopy.

The records show 75 micrograms of Fentanyl, and 4 milliliters of Midazolam. Happy, happy, happy. I weigh 113 kilograms, and I don't know what that converts to in stone. The lists of contraindications for Fentanyl and Midazolam are longer than the Dead Sea Scrolls.

The staff wheeled me over onto my side in preparation for the procedure. Now, this was an interesting bit of caution, as I know from the rescue trades that rolling a victim/inmate/patient onto their side is so that when they throw up, one hopes the puke drains, by gravity, from the esophagus, and doesn't back up into the trachea. Hope springs eternal.

The last bit was laid on the pillow in front of me, a device that, if ever discovered by the porn industry, will birth a whole new genre of 'B' movies. It is a 'fairlead' which is placed into the inmate's mouth, and has a circle which guides the ultrasound wand down into the esophagus. See picture/Note 1 below; when one looks at it, the first thought is, 'ball gag'. Subsequent research lends a couple of names: 'mouthpiece' and 'bite block'. Cardiac sonography meets Deep Throat.

Speech becomes impossible, even though I woke up partway through the TEE; I tapped on the bed stand next to me so they would know I was awake/remembering/whatever. "Willie, we're almost done! Hang in there!" Then I felt the wand moving up and down in the esophagus, and was awestruck at how hard they seemed to have to push to get it in there.

At that point, i'm sure they slammed more Propofol/whatever into me; the next thing I recall is one of the technicians/MDs/nurses face to face, telling me they were all done. I came out of the anaesthetic rapidly, and was astonished at how much stronger I felt. Proper blood flow, with proper oxygenation, can do that. It really was a deus ex machina.

There had been wishful conversation earlier in the day about going home after the procedure (conversation not even initiated by me), but that was the stuff of dreams.

They took me back up to 364-1, and I seem to recall them using a 'slip sheet' to transfer me from the gurney to the bed.

Nan Peterson was there; I had correctly predicted that they weren't going to let her anywhere near the TEE/cardioversion gig, and Brandon reinforced that: "No way you're going down there", or words to that effect.

I was still more than a bit stupefied, but ordered breakfast (at about 1800 hours), ate same, and went to sleep. Given the lingering effects of the drug cocktail which I thought also included Propofol, coupled with the peace and quiet yielded by a now 'private' room ('Art' had gone home while I was off doing battle with the electrician), I fell hard asleep.

Until about 2100-2200 hours. At that point a 'cleaning crew' came in to make up the bed and clean up 364-2 for the next inmate. I was still groggy, so didn't sit up to take notes on how they were managing to make so much noise, but they were clearly experts in that discipline (of making noise). These places really do run on triple shifts, 24-7.

At about 2230 hours, they brought in the next inmate, whom we will call 'Zeke'. Zeke, like Art before him, was born in the 1930s, and didn't understand why he should be in the hospital, any hospital.

The 'nurse alarms' started anew. It was like Art had never left. I was woken again at midnight, then 0200 hours, when the nursing staff came in and discovered that 'Zeke' had:

-pulled out his IV (it drained the entire bag of saline solution out onto the floor);
-pulled all the ECG monitoring patches off of his chest;
-gotten up out of bed, and gotten dressed, into his street clothes;

When the hastily assembled nursing staff asked him what he was doing, he said, "My son is coming to pick me up."

Staff: "Your son is coming to pick you up…at two o'clock in the morning?!?"

Zeke: "No, it's two o'clock in the afternoon!"

Apparently it had never occurred to Zeke to look out the window next to his bed. It was 2 AM. I'll bet at that moment it was even dark above the Arctic Circle.

After a long harangue, they got Zeke back into bed. He rang the nurses' alarm again every other hour until dawn. Yikes.

Later, when he had raised yet another ruckus, they started in again with the 'questions'. Like Art, Zeke couldn't seem to remember what year it was, at least not without thinking about it. When they asked him where he was, he said 'France'. When they asked him what facility he was in, he stated, "I'm in a military hospital." He kept blowing the answers (I figure every time you blow an answer, you're good for another day in stir), until finally the nurse asked, "Who is the President?" He must have been a right-of-Attila-the-Hun Tea Partier, because he couldn't even choke that answer out. Too funny.

At 0633 hours, he pressed the red nurses' button again (this always set off 90 decibel alarms), and when the nurse came in, asked, "Where's breakfast? You said breakfast was at six-thirty."

Like Art, the phone system was too much for Zeke, so the nursing staff called in his breakfast order for him.

A wee bit later I decided that since my teeth hadn't been brushed in 48 hours, I'd tend to that. They brought me the basic elements, as my planning on Wednesday afternoon did not include being in a St. Louis Park hospital on Friday morning. I unplugged from the ECG monitor, and walked out to report in with the indentured servants at the nurses' station: "364-1 is brushing his teeth." Referring to myself in the third person was ill-advised, as one of the staff, still dazed from the previous night's circus, jumped up to run into 364 to apprehend Zeke. Willie: "364-1 is ME." They all laughed. Then I said, "Everyone asks if I feel safe at home. Sure…I live alone." I then pointed back to the asylum that was 364, and said, sotto voce: "I don't feel safe THERE." More howls.

I didn't have breakfast for at least another two hours; with the pace of things around the hospital, one had to stretch out the exciting stuff (such as breakfast).

The pace quickened for me; all of the medical types, including Bosmans, came by pretty early, and all were fairly positive in their resolve that it was time to put me back out on the street. Having said that, I opined to the day nurse 'Kelly' that I didn't give it 50-50 odds I would be out by noon. Kelly: "I'll take that fifty cent bet."

The glove was down. I told Bosmans that I'd made a bet with Kelly that I wouldn't be out by noon; for him, that was a call to arms. He set to the business of not only issuing all of the prescriptions necessary before they sprung me, he ran down the other medical types (you know them on sight-they've all got Littmans hanging around their necks) and either got them into my room, or got an all clear.

My heart rate stayed at 'normal' sinus rhythm, about 60-70 beats per minute. I got sprung at about 1000 hours. I paid off the bet with Kelly before I left…best fifty cents I ever spent.

I pity the indentured servants that are stuck with Zeke, because as far as I know, he is still in there.

Nan drove me back to the Urgent Care Center at 101 and 55, and my car had not been towed. Hallelujah.

The other 'good' news? Once you've had an atrial arrhythmia/fibrillation, the question isn't whether you'll have one again; it's when. Sort of like, "Other than that, Mrs. Lincoln, did you enjoy the play?"

Finally…in closing: kudos to the staff at Urgent Care and Methodist Hospital. Every. Last. One. of. Them.

Willie Crear

P. S. All of this shit really happened. There are more stories…about the other two inmates…that I cannot tell you because of that ^&%$#*& HIPAA.
 
Note 1: this is the 'bite block':