Take A Look At My Heart

Starting last Fall (09') I became sort of vaguely aware of a change in the way I felt on my bike commutes to work. I pretty much attributed it to the fact there was all this BS going on at work and I wasn't handling it very well. You know, stress. But I figured since I am over 50 now I should probably have it checked out. I had just gone through an insurance physical in anticipation of needing a term policy if I did indeed changed jobs. My rating status for that came back as "Super-Preferred". My financial guy said he had never had anyone get that rating, let alone a 50yr old client. So I'm feeling pretty puffed up with myself. Eventually I get around to seeing a cardiologist. The appointment was pretty much unremarkable. Talked to a cardiology fellow and an attending, the opinion is whatever I'm feeling probably isn't heart related. I'm OK with that, at this point the symptoms I'm having don't really present as cardiac and are fairly nonspecific. They do recommend a stress echo. Yea, whatever.

Over the next couple of months shit gets more specific. Colder weather, less biking, more jumping rope, which has been my indoor cardio work for years. I also started wearing a HR monitor during workouts. After about 15min, with my HR running about 150 or so, I feel the same sensation in my chest as I felt on the bike, with a new twist. When I stop and my HR slows, my heart starts skipping beats. This can't be good. PVCs. Premature Ventricular Contractions. Basically what happens is the ventricle contracts before it's full, ergo, no blood to pump, no pulse. Exercise induced PVC's. Great. I do all the research I can and find out PVCs are common, a lot of people deal with this shit their whole lives and they're mostly benign if there's no underlying heart disease or structural heart defect. In very rare instances they can degenerate in ventricular tachycardia. (that's foreshadowing, do you see where this is going?) Also cardiologists don't take them very seriously. Maybe now is the time for that stress echo.

I go in for the stress test in the first week of January. The set up is a treadmill with all the telemetry equipment and a table with the echocardiogram machine. You get the on the treadmill with gradually increasing rate and incline until your heart rate is crazy high, then they shut it off and hustle you over to the table to take the echo of your heart to get a picture of function during the period of high stress. Some background here. I'm really not much of an endurance athlete. I've never been a guy with a slow HR. Even when I was in great shape ( young, running track, etc) I'd sit around with a resting HR of 72bpm while other guys in similar shape were about 10bpm less. Anyway, fast forward to now, put me a stressful anxiety producing environment and I'm sittin' there about 85pbm without even moving. The test starts and I'm almost immediately at 90bpm, not unusual for me. The woman waiting to do the echo is sitting there watching all the telemetry info and she keeps making comments about how fast my HR is increasing. SHUT UP bitch. After about 30min my rate is 190, the nurse shuts it down and hurries me over to the table for the echo. I'm laying on my side, the imaging tech is doing the echo and I'm starting to recover. I'm catching my breath and my HR is coming down, then the fun starts. I feel the PVC's start up in a big way. Even though I'm laying down I start to get a little dizzy. I hear the nurse say, "oh!". Out of the corner of my eye I can just glimpse the EKG on the screen. Fuck. I'm no expert but I'm pretty sure that's not a normal wave. There's nothing there that even resembles a normal QRS complex. The nurse leaves the room and I can hear him trying to remain calm as he asks the attending cardiologist "can you come here a take a look at this?". I'm recovering a little by now, although my rhythm is not exactly back. The attending looks at the EKG and asks echo girl if she could see this coming. Echo girl says no. Doctor says, "It's just an arrhythmia" and leaves the room. They keep me for about another half-hour until I've recovered completely, then send me on my way. My cardiologist's office calls me the next day, no heart disease and no structural defects. They want to start me on a beta-blocker and need to know what pharmacy to call. They don't even want me to come in to the office. I find out later that there was no printed record of the episode of ventricular tachycardia because the fucking nurse had shut down the fucking machine. What a jackass.

There are no restrictions/guidelines for my workouts so I go back to doing what I have always done, except that now the PVCs start up every time I work out instead of just occasionally. As this progresses I find myself sometimes getting dizzy and having to sit down while I recover. If you miss 2 or 3 heartbeats in a row, it'll fuck with ya. Now we're getting into a gray(er) area. If you pass out from PVCs it's considered to be like dying only with the advantage of waking up. Sudden Cardiac Death (SCD). You know, those guys who fall over dead while they're working out. (he looked fuckin' great 'till he died) I have a scheduled cardiology follow up in March. Pretty much unremarkable again. I tell them the latest stuff and they increase the beta-blocker dosage. The fellow tells me that as PVCs go mine aren't really that bad. Oh, ok.

This uneasy accommodation with my heart continues until mid-April when shit finally comes to a head.

Wed 4/15--I'm at home working out, have finished jumping rope and am doing some light dumbbell work. I have found through trial and error over the past few weeks that my HR recovers faster with fewer PVCs if I bend at the waist while I'm between sets of exercise. That's the position I'm in, standing and bent over, while watching my HR monitor on my wrist. I straighten up. Rubber legs and lights out. I'm aware of myself staggering backwards, but I can't do anything about it. I hit the wall and the weight machine behind me and end up sitting on my ass with the dumbbells still in my hands. I remember saying out loud "that was it". I sit there trying to gather myself. I never really lost full consciousness, but it was close. I took it easy over the next few days and even did a couple light workouts without incident.

Wed 4/22--Been wanting to see Mark Knopfler since the days of Dire Straits. I bought these tickets about 6 months ago. I meet a buddy for a few PVC inducing alcoholic beverages before the show. Dinner and 2 beers later we head off to the concert. We end up parking about 4 blocks away from the venue and walking slightly uphill to the Fox. By the time I get to the theatre the PVCs are rollin'. Bad. I wasn't in a normal rhythm the entire night. The worst night of my life. Probably back and forth between PVCs and V-tach the whole show. By the end of the show I'm kind of settled down. After the show we head back to the car and I drop him back at the restaurant where he's parked. The walk back to the car has lit me up again. I limp home. I have to pull over and stop during the 4 mile ride home. In hindsight I was probably in V-tach the whole way. Why I didn't degenerate into V-fib I don't know. I should have gone to the hospital that night, but I just laid down. I remember thinking there were worse places to die than your own bed.

The next day found me still alive so I called the cardiologist office and they ordered an event monitor for me. It's basically a device that you activate when you feel something strange and it records heart activity and what was happening a minute or so prior to when you activated it. I also made an appointment with my primary doctor. I had only started seeing him the previous October and I was pretty impressed with him. At the time of my first appointment this heart thing wasn't a blip on my radar so I wanted bring him up to speed and get his impressions.

The next 4-5 days aren't very good. PVCs all the time with minimal exertion, like walking DOWN a flight of stairs. I go see my primary physician on Tue 4/28. I fill him in on everything, we talk about it, there's really nothing to be done until the event monitor shows up in the mail. He says "you know where this is headed don't you?" I say yea, ablation or ICD. That evening I start to walk to the pharmacy to pick up a prescription. I get to the end of the library parking lot, about 150ft from my back door, and I can't walk any farther. In retrospect, V-tach. Again.

Wed 4/29--I feel ok in the morning, no PVCs. So it's time to go push it and see what I can do. Right? I start mowing the grass. That's walking behind a self-propelled mower. It becomes quickly evident that this isn't going to work. Again. By now I been in full blown V-tach about a half dozen times and it always resolves spontaneously. I re-challenge myself a couple more times over the course of the day. Same result every time. I call the cardiology office and leave a message. I don't get a call back from the doctor. I call my primary late in the afternoon. He calls me back from his car on his way home from the office. He says it's pretty obvious my body is trying to tell me something. Head to the E.R., he'll call ahead. At this point I figure I'll wait until my wife gets home from work. I'm back in normal rhythm and fine unless I exert myself (i.e. walk more than 50 paces). She gets home, we head to the hospital.

Now, the last thing I want to do is show up at the mess that is the the E.R. with a normal rhythm, wait there for 3hrs with the rest of huddled masses and then tell some nurse that "4hrs ago I was having an arrhythmia" and then hear, "well you seem to be ok now". I make a plan. We're going to park at the north end of the medical campus and do a brisk walk to the E.R. at the south end, about 4 blocks away. My plan works to perfection. About half way there I feel everything in my chest start rolling. We walk into the E.R. and it's packed , they got 'em hanging from the rafters. I'm about fourth in line to the desk. I tell the nurse I'm having PVCs and if they want to see them they need to hook me up right now. She checks my pulse, says it's way too high and hustles me into one of the trauma rooms.

The next 15 minutes were impressive as the trauma nurses sprang into action. I've had some less than stellar visits to this E.R. from a patient care standpoint, but these nurses were great. In a matter of minutes I had 18 gauge bilateral IV access and a 12 lead EKG hookup in place. This is a teaching institution and obviously I was the most potentially interesting case in the house at this time. A crowd soon gathered. At one point the E.R. attending came back to check in on me, sees the mob of onlookers and says, "WHY is everyone standing around staring at Mr. Haynes?". They were just waitin' for me to go into V-Fib so they could break out the paddles. Sorry to disappoint. The amiodarone bolus did its job. I was in normal rhythm. Move along folks, nothing more to see here. I was left literally, completely alone while they tried to figure out what to do with me. What a difference an hour makes.

They put me in the CCU. Probably overkill, but all they really knew was some guy showed up in the E.R. in V-Tach. I knew as long as there was no exertion I was fine. I was the healthiest guy in the cardiac care unit. My wife said that was like being the tallest midget. The intern doing my work up loved how I managed to be in V-Tach when I came into the E.R. He told the story that night to the cardiac fellow on call who then walked into my room, said "Don't do that again", then turned and left. The story had legs and was retold numerous times during my stay until pretty much everyone in the unit knew about it. Like any good tale it became a little more fantastic with each retelling, until I had sprinted to the hospital from somewhere in the Central West End.

They have some good pictures from the V-Tach in the E.R. The electrophysiologist decide cardiac ablation is the best option. I'm not going to go into great detail on the procedure. You can look it up on any number of sites.

http://www.mayoclinic.com/health/cardiac-ablation/MY00706 is a good one. Also a cyclist named Craig Cook did a much more thorough blog a couple years ago while he went through this (v-tach.blogspot.com). However, I will say that if I never have to have another foley inserted it would be OK with me. Also the part where they say you will be sedated and not feel/remember much is bullshit. I was awake for the entire procedure. The current thinking is that sedation makes it more difficult to keep the foci active for mapping and ablation. The area where they were working on me is apparently sensitive because it stung like a motherfucker when they burned it. I went to the E.R. on Wednesday night, ablation on Friday and home early Saturday afternoon.

So how am I now, 5 months post procedure? Well, it wasn't a magic bullet for me anyway. June was a great month with no PVCs. In July/August I began having a few "resting" PVCs, which I had never had before. Then in September some mild runs post exercise and during stress situations, but the resting PVCs have pretty much gone away. Alcohol definitely lowers my threshold, more than it seemed to prior to the ablation. To date no V-Tach and I'm working on managing the whole thing better. More moderate workouts with max HR 130-140. No more balls to the wall stuff. Still it's a disturbing trend for me. Interesting thing about the stress/anxiety PVCs is the thing I'm most anxious about is having and extended run of PVCs or slipping into V-Tach. So it's a chicken/egg thing. I've relayed the resurgence of the symptoms to my EP, but as long as there's no V-Tach there doesn't seem to be much interest. Remember what I said about cardiologists and PVCs. A big part of my problem is I don't know what the new "normal" is or even if there is one. Probably shit changes week-to-week or month-to-month from here on and I just deal as it changes. Mayo Clinic has a sports cardiology clinic and I'm thinking about taking a run up there to see what they say. So all in all--we'll see.

Max an' Annabelle

Treatsie

I feel it necessary to comment on the current state of the 5900 satellite and express my concern over the issues of workflow and staffing.

When the BMT service moved to the north campus the initial pharmacist staffing was as follows: 3 RPh 0700-1200, 4 RPh 1200-1500, 3 RPh 1500-1700 and 2 RPh 1700-2200. While the BMT service as well as Med Onc have continued to expand, the number of pharmacists responsible for these areas is down, and now stands at 1 or 2 for the entire day with the exception of approximately 1-1.5hr from 1200-1400 when there is an overlap of a third pharmacist. By way of contrast, the clinical pharmacy staff responsible for these areas has increased from 1 to 5 with a 6th position already in the budget. Recently, the opening of 24/7 oncology center has added approximately 8-10 oncology patients to the daily chemotherapy count. The nature of an out-patient infusion center dictates these infusions are prepared on a STAT basis. Compass chemotherapy entry and verification has placed additional constraints on total preparation time. Also, not to be discounted in importance, is the loss of 1 of the 2 day shift IVRM technicians to the 13 CAM pharmacy.

Staffing of the area was one of the main highlighted issues during the Risk Management root cause analysis of the chemotherapy preparation sentinel event of about four years ago. As noted above we are currently working with 1/3 -1/2 of the staff we had at that time. Another outcome of those meetings was a follow up with other similar institutions to compare policies on staffing. To my knowledge, nothing ever came of these contacts because none of these institutions was doing anything comparable to the 5900 sat IVRM, with its combination of chemotherapy floors, ICU's, surgery and out-patient areas at the volume and staffing that we have.

The RIE of last year left the satellite with a totally inadequate filling/checking area. The current procedure of checking bins full of different patients’ chemotherapy amid the myriad of distractions in the satellite is increasing unworkable and potentially dangerous with regard to patient safety. In my opinion, this is the major flaw of the original workflow design and a contributing factor, if not the main reason for the most recent and probably most chemotherapy errors. If underlying causes of errors are in fact system breakdowns and not errors of individuals, then what we are experiencing fits that definition exactly. A system, suspect from the beginning, no longer workable.

All chemotherapy and IV admixtures should be checked by an IVRM pharmacist BEFORE IT LEAVES THE IVRM. The staffing of the IVRM by a single unsupervised technician has always been less than ideal. Our current staff of technicians are of varying experience and competency, the former not necessarily indicative of the latter.

Any chemotherapy safety RIE could address these core problems only marginally. For example the recent directive to assign responsibility by designating chemotherapy checking to a specific pharmacist at a specific time is unrealistic in the context of a staff of only 1 or 2 pharmacists. Any additional guidelines to assign responsibility without control only serve to sidestep the real issues and make the current process more cumbersome with negligible positive effect.

The addition of 1 pharmacist FTE would be a major first step. I would suggest a Mon-Fri 8-hour evening 1500-2300 shift. This would allow the shift time of the 1000-2000 7on/7off pharmacist to be changed to a start time of 0830. This position becomes the IVRM pharmacist, working and checking in the IVRM until 1900. This obviously adds morning help to the 0600 pharmacist, who currently works alone until 1000. The 1900 shift end time is late enough to have the majority of the evening scheduled chemotherapy completed. I would also foresee this position to do the majority of the chemotherapy verification in addition to helping the clinical staff enter orders when necessary. The new 1500 8hr position coincides with the end of the 0600 day shift, as well as help later into the evening/night shift when home medication sheet entry/checking has become an increasing problem in addition to the usual late chemotherapy new order starts.

I realize adding additional FTE's can be problematic. At this point I don't believe any procedural changes can make enough of a difference to solve our current problems. Steps need to be taken to prevent further chemotherapy errors. I hope that this can be accomplished in lieu of discussing a problem I've outlined here at a post error root cause analysis meeting.

Respectfully,