A Fib with RVR

Jake Stein, MS3, Internal Medicine

 

The monitor was howling when I stepped into the cramped ER room.  EKG lines jumped like an Appalacian silhouette, and the O2 sat was stuck in second gear, never quite revving up to the 90% that would silence that incessant beeping.  The furrowed brows and quick, loaded glances from the family told me as much as the irritated telemetry monitor.  The patient himself looked serene amidst the fray, like a veteran ship captain in yet another hurricane.  His thick, wet cough and distant gaze told a different story.  Or simply suggested that he may be going down with the ship this time.

“How are y’all doing?” I extended a hand to whom I presumed was his wife, and then to the other unnamed family members surrounding the bed.  “My name is Jake, I’m a medical student working with the inpatient medicine team, and I’m here to kinda get the ball rolling.”  They looked at each other skeptically, or anxiously.  I couldn’t discern whether their concern was about their young-faced doctor or about their husband, brother and granddad, who had never looked so old.  “What’s been going on?”

“We don’t know!” exclaimed the brother, as best as I could guess.  “We get a call that he’s got a cough, and this is what he looks like.  Last time we saw him, he was doin’ just fine!”  My eyes darted back up to the monitor.  Atrial fibrillation skipped along the baseline and random shocks traveled down his heart to give this bizarre, irregular rhythm that danced across the monitor.  The alarm screamed at me to do something. His heart rate, in the 150s, blinked in sickening crimson.

“Mr. Fraylon?”  I put my hand on his arm and shook him.  “Mr. Fraylon, how are you feeling?”  His eyes remained fixated on the hand sanitizer bolted to the wall, beckoning us all to stop passing all our goddamn germs to each other.  Yet here we were.  I checked a pulse, which was hopping around like it was on the monitor, rattling to try to escape his rapidly failing body.  His lungs popped and crackled like infected rice krispies.  His belly was sunken in and tugged with each breath, joining in on the fight to keep some air moving in and out.   Eyes still cloudy and distant, he reached his hand down to push me away.  His grip was strong – a hand that was accustomed to wrenching things loose and tightening screws down.

His granddaughter grabbed at his wrists.  “Stop it, gramps!  Leave him alone, he’s just listening!”  I felt his gnarled hand tighten around my slender fingers and looked into his face for signs of life.  His mouth hung open, gnawing on some invisible strap of leather, his eyebrows peaked with an expression between panic, pain, and fierce determination.  His chest heaved to suck oxygen from each raspy breath.  I didn’t have to check the monitor again to know he wasn’t getting enough.  His grip tightened, and I felt my fingers begin to tingle.

“Stop it, gramps!” The granddaughter was pulling, leaning her body against the edge of the bed for leverage.  The wife looked paralyzed, nauseated, and exhausted. I looked down at my fingers, beginning to lose color. I finally wriggled my hand free.

“Well, he’s definitely going to need to stay the night,” I said.  “I’ll go chat with my attending and the other doctors.  We’ll do whatever we can.”  I tightened my face into an awkward smile.  The wife didn’t look up.  Her eyes looked eerily similar to his cloudy, distant gaze.  So this is what dying looks like, I thought.  The alarm screamed at me to do something.