Archive for April, 2017

Zip-lining in the Magaliesburg

Posted: April 29, 2017 in Family

Being in the time-demanding careers we are in, with limited finances, N and I decided when we reached our 40’s, not to buy presents, but rather celebrate experiences with our family.

For my birthday this year, N got me a zip-lining voucher for 3, which we cashed in this weekend. An experience I was fortunate to have whilst working at the Sports Illustrated “Ruff Stuff” Challenge  in  Swaziland back in 2010, one which I’ve been saying for years we should do.

We arrived early at the Magaliesberg Canopy Tours, in the Ysterhout Kloof region of the Magaliesburg Mountain Range in the North West Province of South Africa.

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After the briefing and kitting  up, we drove a short distance to the cliffs to begin our adventure

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….off our brave little one went… (with the odd squeal or two to awaken the local habitat )

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….way above the trees…

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enjoying the views…

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the smile getting bigger after each slide…

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precarious cliff face photography..

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some a little faster than others…

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Ultimately, a family adventure I highly recommend for anyone!!

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Within our profession (Emergency Medical Services) we have challenging and “head scratching” cases which no amount of education and experience can ever prepare you for.

I have been a degree Advanced Life Support (ALS) Paramedic for 14 out of 20 years, the first 6 years spent as a National Diploma and having recently updated my  Advanced Cardiac Life Support (ACLS) certificate thought I could deal with just about any case thrown at me, until I was faced with that very strange, head scratching situation recently.

I am attempting to explain the case taking into account medical professionals as well as trying to explain the case to the non-medical followers.

I responded to a chest pain case, and upon arrival at the scene, was greeted by fellow ALS Eutimia Garces, who had assessed the patient and requested assistance. She has been qualified over 2 years as an ALS and has experience in excess of 10 years in the industry, but had never encountered a cardiac patient this critical. Her assessment of the patient revealed some interesting information with regards to basic vitals and she had initiated treatment with intravenous cannulation (drip) and oxygen via nasal cannula in an attempt toward maintaining a SPO2 (oxygen saturation) of greater than 90% since the probe was not picking up pulsatile blood flow.

The patient’s vital signs were as follows:

  • Palpable thready carotid pulse at a heart rate of 214 (the ECG “heart” monitor confirmed this rate)
  • Electrical Cardiogram (ECG) presenting a Ventricular Tachycardia (V.Tach) – for the non-medical folk, this is an abnormal heart rhythm that can prove fatal.
  • Non-palpable blood pressure, recorded as 50 mmHg (dangerously low) systolic via a manual sphygmomanometer (blood pressure cuff).
  • Skin condition was grey, pale and clammy.
  • Patient initially was responding to verbal stimulus only, but with a small 50 ml bolus of fluid, became alert and orientated with a blood pressure of 60 mmHg (still dangerously low, but at least his brain was working)
  • The patient presented with severe chest pain throughout the initial interaction prior to sedation.

With regards to history, this proved to be even more interesting:

  • 65 year old male patient with an extensive cardiac history: 10 Acute Myocardial Infarctions (Heart attacks) and 26 minor non-debilitating strokes over the past 6 years.
  • Patient was on an extensive list of medication all specific to chronically managing aberrant heart arrhythmias.

Identifying the severity the condition, we all realised that the only effective method of treatment would be synchronised electrical cardioversion.

For my non-medical followers, allow me to briefly explain a few of the terms used:

  1. Ventricular Tachycardia 
  • A V.Tach is a type of regular and excessively fast heart rate that arises from improper electrical activity in the muscle and electrical pathways of the ventricles of the heart. With a normal heart rate ranging between 60 and 100 beats per minute, I’m sure you can imagine how hectic and dangerous a pulse rate of 214 would be. The ECG for the patient can be seen below

2.  Synchronised Electrical Cardioversion

A synchronised (perfectly timed) electrical shock is delivered through the chest wall to the heart via pads that are applied to the skin of the chest. The goal of the procedure is to disrupt the abnormal electrical activity in the heart and “reset” the heart to allow the natural pacemaker of the heart to restore a normal rhythm. The interruption of the abnormal beat allows the heart’s electrical system to restore a normal heartbeat.

Shocking someone who is conscious is an extremely painful experience and can be mentally traumatic for the patient, which means that some form of sedation is both compassionate and beneficial to the patient.  The dilemma Eutemia was facing, was that the patient clearly needed sedation before the procedure,  but the extremely low blood pressure excluded the use of the only two medications that ALS Paramedics carry for this purpose namely Midazolam (Dormicum) for sedation and Morphine for sedative analgesic effects. Fortunately, as ECP’s we carry a wider range of medications capable of have similar benefits without as significant side effects.

My wife, Nicole de Montille (who was with me at the time is also an ECP and an ACLS Instructor) and I debated the merits of Ketamine or Etomidate (Hypnomidate) to use for the sedation of the patient. These two medications are known in the anaesthetic and emergency environment for their anaesthetic and analgesic benefits.

Being concerned about the cardiac effects Ketamine may produce, it was decided to use half dose Etomidate, which was successful in its sedative qualities, and the patient was sedated without compromising his breathing effort.

With the patient sedated, synchronised  cardioversion was performed .  In my personal capacity I have done this many times during my career. Normally after cardioversion, I have seen a brief period of asystole (flat line) as the heart resets itself, followed by a relatively normal heart rhythm.  What occurred with this patient however left us all feeling more than a little worried and relieved in the space of approximately 15 seconds.

 

Click on image to view in full screen – ECG edited to protect case information

As you will note in the above ECG, the cardioversion successfully shocked on the R-Wave as expected;  What was not expected was that the patient went from V.Tach straight into Ventricular Fibrillation (V.Fib).   This abnormal and erratic twitching of the heart muscle can be likened to a bag of worms all wanting to move in different directions, however the problem is that this situation fails to produce a ventricle contraction which is necessary to keep the patient’s blood flow moving.

I’ve never experienced nor witnessed this happening ……….ever!! Neither Eutimia nor Nicole had ever been exposed to a patient presenting like this either.  Within a matter of seconds the monitor was set to 150J (as recommended by the manufacturer) and defibrillated (shocked the patient without synchronisation) and successfully converted the rhythm to sustainable heart rhythm with contractions and sustainable blood flow.

The patient was transported to the nearby emergency department at a hospital with extensive cardiac facilities, where he woke up a few minutes after arrival, conversing with the staff and looking far better than before sedation and treatment.  As for his vitals, a radial pulse rate of 82 and a blood pressure of 110/70 – both definitely within normal ranges.

Whilst the case was mentally challenging and, to be honest, quite scary, it was one of the most satisfying one.  Witnessing a rapid turn around in the patient condition from life threatening to conversing and looking as if he had experienced a minor “episode” at the hospital.

Thank you Nicole and Eutemia, we made a dynamic team and saved a life that day.