Whilst in A&E the other day, there were two patients in adjacent bays of both noteworthy medical student interest. One of them, was a tradesman who severed a tendon from playing with tiles. Something that is managed by the surgical team. The other was a man from a town 2 hours away, who GP was alerted by an abnormal ECG reading and decided to send him down, believed to be in SVT. Something managed by the medical team.
This fork in the road, was exactly a reflection of my future career options. Should I bend surgically or medically? This was a tough choice for a rural medical student who has to freedom to roam and decide whatever he wants to encounter throughout the year.
The culture of the hospital almost views this, to some extent, to be akin to sexual orientation. Of course, they also cast certain stereotypes between the two branches of medicine (largely based on generalisations stemming from early medical history - with the Barbers of Seville, and the early physicians; also worth noting the statement in the Hippocratic Oath which disapproves invasive techniques).
I tried to keep my head in both, but this was hard to keep up. And in the end, I decided to stay with Mr. C, the 69 year old gentleman with abhorrent heart conduction. C's story was interesting in that, here was another story of a stoic farmer with potentially life-threatening condition who did not want to be seen unless pestered by his wife. He had been having chest pains since a couple of days ago, but did not do anything about it until this day when he saw his GP who decided to do an ECG. The ECG revealed border-line wide QRS complexes, ST depression and T wave inversions, and signs of LVH. When he came in he was hypotensive and tachycardic, with a BP of 80/60, HR of 190, was still conscious and moving about and able to talk. He was put onto oxygen, given two large bore cannula, and monitored for hemodynamic stability. A continuous heart monitor and 12-lead ECG was employed to mark any changes. He did not respond to carotid massage or valsaveur techniques, which was the first clue that this could have been something more sinister than an SVT like a conscious VT. He had a background of Ischemic Heart Disease, but had not had any stents implanted to his knowledge. Despite our efforts in getting an old ECG from his cardiologist, these had all been difficult to retrieve since his last admission 10 years ago. A decision with the medical team to administer adenosine was carried out. C received 3 lots of increasing doses of adenosine as per SVT protocol. He sustained some chest pain as a result of the adenosine administration but his arrhythmia did not resolve. C was given morphine to ease the pain, whilst infusion of magnesium and Amiodarone were also given. This slowed his heart rate down slightly by about 5 beats every hour, and he was taken into ICU.
Overnight, his rate and rhythm did not improve and he was transferred to a major tertiary hospital to be further evaluated by specialist cardiologist services. The conclusion was that he was in conscious VT. Would have been a great case to follow through, although there were other things on my mind especially with exams looming in the not so distant future. It did make me revise my anti-arrhythmic drugs again, paying attention to some of the side effect profiles of things like adenosine (which causes chest pain) and amiodarone (which can cause acute respiratory fibrosis, thyroid disorder, etc). Perhaps, I will choose the medical path in the future?
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