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Tachycardia in the Emerald City

Keeping it together over the holdays

It was probably Christmas Eve-Eve and I was in my paramedic internship.

Medic 2 was dispatched to a family restaurant for "cardiac problems." Traffic was near gridlock as the restaurant was across from a regional shopping mall on the south side of "The Emerald City."

We started working up a thin, thirty-something male who said that his heart was racing.

Protocol says …

Chief complaint was that his heart started racing and he broke out in "flop sweat" while finishing dinner.

He was no longer sweating, was tachycardic at 136 with a blood pressure of 146/90.

Recoiled when I unfurled the IV starter kit. Did not allow me to put a tourniquet on his arm.

Plan B, aspirin and a quick transport … patient not interested in that either.

Situational Awareness

I was focused on completing my clinical assessment and clicking-off the required paramedic skills.

Completely missed the two elementary school age boys who were being very brave. The fire company captain took the boys on a tour of the engine as we expanded our assessment.

Divorced dad with custody of his kids today – Daddy's Christmas. They will spend the real holiday with mom and her new beau.

Things not covered in paramedic school

My preceptor, Joseph B., conducted through and detailed assessments. Kept notes and EKG strips. Would call patients days later to see how they were doing. Recorded information in a "run sheet" for each patient.

Given a specific patient complaint – like belly pain - he could assemble a collection of patient assessments and eventual outcomes. This made Joseph a sophisticated clinician.

When the focused assessment was done, the pulse was now 118 with a 130/86 blood pressure. Joseph felt there was something missing.

With just the three of us at the table, the patient removed the non-rebreather face mask and provided the missing item.

Competent cocaine user

Turns out that dad is a "moderate" cocaine user, who bumped-up his dosage today.  In 1978 the clinical documentation of functioning cocaine addicts was thin. The Eighties provided much research opportunity.  

Tom Decorte's 2000 book The taming of cocaine. Cocaine use in European and American cities. (VUB University Press) provides a perspective:

Decorte says that ‘our data and those from some major community samples… show that cocaine provides a wide range of positive effects to those who use it in moderation: more energy, an intellectual focus, enhanced sensations and increased sociability and social intimacy. Social, sexual or recreational activities and work can be enlivened, and many respondents use the drug not only in pleasurable but also in productive ways’ (p. 260.)

“Usually, health professionals, law enforcement agencies, politicians and media reports take the position that in the long run, illicit substances can only have adverse effects……Contrary to this official discourse, our repondents’ accounts show that well known adverse effects are often experienced as minor discomforts, and that level of use (including dose and frequency of use) set, and setting factors all have important impact on the balance of positive and negative experiences with cocaine ”. (p. 261)

This was my first encounter with this type of patient. We spoke with him for another ten minutes.

When his pulse remained at 110, we had him sign the release. 

Keeping your stuff together

The brutal incidents this month had me reflecting on the challenge of parenting when there are monsters over your shoulder, both internal and external. And a patient encounter 34 years ago that remains troubling.

Mike "FossilMedic" Ward

If you are working, may your day be boring.

I hope that it is full of food, laughter, fellowship & joy.

Please spend a minute thinking about our brothers and sisters in the armed forces that are deployed in hostile, desolate or dangerous environments.

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