TOMBSTONE T-WAVES

It was fairly slow in the emergency department for a Thursday night. It was 2100 and I had one hour to go before I could go home. My area of four beds had no patients. There were a total of three patients in the entire ER and they were all considered “urgent care.” Those beds were located in the back hallway. All of the monitored beds were empty. It was a very unusual night to say the least. I was stocking my beds with oxygen equipment, 2x2’s, monitor patches…etc. so they would be ready if needed. As I walked towards the nurse’s station I saw Becky quickly wheeling a man down the hallway. As he got closer it was obvious he was in distress. His skin was ashen grey in color, he was extremely diaphoretic, and his right hand was grabbing his left chest. Everybody knew this man was having a major myocardial infarction (MI). The nurses, technician, and physician jumped up as Becky wheeled him into one of my monitored beds. There would be a lot of work to do in a very short period of time. Our new patient could easily code at any second.

All of the nurses and the technician (Josh) knew what needed to be done. The secretary called the x-ray department for a STAT portable chest x-ray, the lab for quick blood transport for quick analysis, and respiratory for arterial blood gases and possible ventilation support. As everybody was doing their job Dr. Smith was asking the patient questions about when the pain started, what was done for it to make it better or worse, and the quality and quantity. It was determined our new patient’s name was Bill and he was 50-years-old. He smoked 1 to 1 ½ packs of cigarettes a day since he was 18-years-old. He had never had a heart attack before but stated his father had his first MI when he was 48-years-old and died from another MI when he was 59. This was significant family history. Bill rated his chest pain as a 10/10 and described it as crushing. He told us he felt sick to his stomach. Josh grabbed a basin off the counter in time before Bill vomited. This was a classic sign of an MI. We had to move quickly. Josh placed the blood pressure cuff, pulse oximeter, and monitor pads on his chest. The button was pushed to get a blood pressure and set for every 3 minutes. It was 122/54. Then Josh started placing the stickers for the 12-lead ECG on Bill’s arms, chest, and lower legs. Another nurse placed a nonrebreather oxygen mask at 15 liters. Bill did not tolerate this and quickly took it off. He was agitated and in pain. It was obvious it would not stay on no matter what anybody said so she applied a nasal cannula at 5 liters. I grabbed one arm to get IV access while another nurse grabbed another. Bill was extremely diaphoretic. Everything that was being done for Bill was happening almost simultaneously. We explained to Bill everything that was being done. Bill knew he was in trouble. Once the cardiac monitor was turned on everybody looked up. We saw tombstone T-waves in lead 2. Once the 12 lead ECG was done we noticed the patient had tombstone T-waves in leads 2, 3, and AVF. He had reciprocal changes in leads I and AVL. The underlying cardiac rhythm was sinus at a rate of 94. Our patient was having a significant inferior wall MI. Chuck the charge nurse asked Bill if there was anybody he could call for him. Bill gave him the number of his son who lived about 10 miles away from the hospital. Chuck quickly went to the nurse’s station to make the phone call. It was important to have family notified and hopefully at the bedside before something happened.

Sarah and I were both attempting to get 18 gauge IV catheters into Bill’s veins. He would need a minimum of two large bore IV’s because of all the medications he would be receiving. Some were not compatible with others and had to be infused in different IV tubing and different ports. I had Bill’s left arm while Sarah was working on his right. Bill was still extremely diaphoretic. He had large veins all over his arms. The first time I tried to get an IV into one of his veins on the radial side of his forearm there was no flash back of blood. It was strange because I knew I was in plus it was a fairly good sized vein. I tried to advance it and flush it with normal saline anyway but it infiltrated. That was strange since I was extremely good at starting IV’s. Sarah had the same problem on Bill’s right arm. We looked at each other in frustration. Bill probably had significant coronary artery disease with plaque in his veins and major arteries. I continued to try on the left arm and Sarah continued on the right. I finally went for the antecubital fossa because we needed quick IV access. I would get another site later once Bill stabilized. I got in and got a good flash back of blood. I wanted to draw labs while I had a good vein. I filled a tiger top, lavender, blue, and red blood tubes. These would be tested for electrolytes, cardiac enzymes, troponin, coagulation studies, complete blood count, and blood type. Josh was standing beside me as I handed him the blood tubes. He would label them and write my initials and the time the blood was drawn. He gave the tubes to the phlebotomist standing by to quickly bring to the lab. The radiology tech was standing by to get a portable chest x-ray. Sarah finally got her IV site. Bill was still extremely diaphoretic. We knew it would not matter how much tape we used to secure the IV. It would not last and we did not want to loose our IV’s. I secured my IV site with Coban. Sarah did the same. We needed to monitor them closely.

Dr. Smith wrote his orders. Bill’s chest pain began approximately 20 minutes before arriving to the ER. He drove himself. Dr. Smith wrote the standard MI orders as Sarah and I were pulling the medications out of the pxysis before he placed the chart in the rack. Bill’s condition had not changed and his ECG remained the same. I looked at the monitor at the nurse’s station and saw his blood pressure was 124/52 and his heart rate was 82. The orders were a baby aspirin 81mg to chew STAT, Tridil drip titrate 10-20 mcg/minute for pain control, Lopressor 5 mg at a time up to 15 mg depending on heart rate, Heparin 5000 unit bolus with a drip at 1000units/hour, Morphine 5 to10 mg for pain, and  Reteplase which had a standard dose of 10 units IV over 2 minutes followed by a second dose of 10 units 30 minutes later. The Reteplase is the thrombolytic that will hopefully dissolve the clot in Bill’s coronary artery. A careful history was obtained and determined there were no contraindications for giving the thrombolytic. An order was written for an ICU bed and to place a call to the cardiologist who was on-call for the ER. The unit secretary was already talking to the cardiologist’s answering service.

Sarah and I prepared the medications and quickly went to Bill’s bed. Josh had already retrieved several IV pumps from the supply room because he knew the routine. Bill had thrown up four more times. Josh got a wet washcloth and wiped Bill’s mouth. He was very appreciative but still in extreme pain and discomfort. It was very satisfying to work as a team. Chuck was at the bedside to help with documentation. He was able to get a hold of Bill’s son who would drive to the hospital to see his dad. Working as a team reduced the stress level of an already stressful situation. Bill was given the Baby Aspirin to chew while Sarah began hooking up the medications on the pumps. Bill’s chest pain was still 10/10 and described as crushing. I hung a liter bag of normal saline to help the medications infuse at a to keep open rate. I pushed the Morphine 5mg over 2 minutes and then the Lopressor 5mg over a couple of minutes. Sarah needed to program the number of milliliters to be infused into the IV pumps so they delivered the correct amount of medication in the correct amount of time. She then gave Bill the Heparin bolus and set up both the Heparin and Tridil using double port extension tubing. The pumps were set for each medication to go at their pre-programmed rates of infusion. I prepared the Reteplase and pushed the first 10 units over 2 minutes. Bill’s blood pressure was 109/50 and his heart rate was 76. The vital signs needed to be monitored closely because Tridil can lower blood pressure significantly and the Lopressor can lower the heart rate. Tridil’s blood pressure effects were usually temporary as the body became used to the medication. We had been through severe bottoming out of blood pressures from Tridil in the past to the point of putting the patient almost in the Trendelenburg position. Vitals were being charted every 3 to 5 minutes. Bill was tolerating all of the medications he was given. His pain level went from a 10/10 to 6/10. We wanted him pain free. Sarah programmed a higher dose of Tridil to be delivered via the IV pump. I gave another 5mg of Morphine. Bill was becoming less diaphoretic and his color was improving. He did not have that ashen grey color he came in with. It appeared he was becoming more relaxed and the medications were beginning to work. There was still a long way to go before he would be considered stable.  

Several minutes later Bill was asked about his chest pain. He told us it was 3/10. His blood pressure was 105/48 and his heart rate was 72. I drew up another 5 mg of Lopressor and gave it through his IV on his left arm. Sarah increased the Tridil drip. Chuck continued to document everything that was done. I looked at the clock on the wall. It was 2130. The next dose of Reteplase would need to be given at 2145. The unit secretary told us there was an ICU bed ready for Bill and the cardiologist had already called and accepted his new patient. He would see him tonight while in the ICU. I looked up at the cardiac monitor and noticed the tombstone T-waves were slightly smaller than they were before. The first dose of Reteplase appeared to be working. I hoped after the second dose the T-waves would level out to normal. I had seen this happen only a handful of times. Most of the time these patients coded. Only a few survived three days after their MI. The statistics were usually not optimistic when treatment was delayed. Bill may do well since he only had chest pain for 20 minutes before arriving to the ER.

It was 2145. Bill’s chest pain was 0/10. The T-waves continued to decrease in size. Another 12-lead ECG was ordered. The stickers needed to be reapplied because the others came off due to Bill’s diaphoresis. He was no longer nauseated or diaphoretic. He looked more relaxed and his color was now pink. The lab work was back and showed everything was normal except for his troponin, CPK, CPK-MB, and total cholesterol. This was expected in an inferior wall MI. Bill’s blood pressure was 102/54 and his heart rate was 60. I would not give him anymore Lopressor. It was time to receive the second dose of Reteplase. I gave the second 10 units over 2 minutes. The Tridil and Heparin drips were still infusing via pumps in his right arm. It was time to call report to the ICU nurse who would be taking care of him tonight.

Report was called to the ICU nurse on the second floor. The cardiologist had just arrived and was waiting for his new patient. It was 2200. Another 12-lead ECG would be done before he was transported to the unit. Bill’s T-waves had normalized. The Reteplase had worked. The cardiologist would still want to do further testing to determine the condition of Bill’s heart. The paperwork was completed and copies were made to bring to the ICU. A portable oxygen bottle and cardiac monitor was placed on the stretcher for transport. There always had to be a nurse current in advanced cardiac life support (ACLS) present during transport for any monitored patient. Bill’s son had arrived just before we were going to take him to the unit. He hugged his father and looked relieved to see him. Bill had a tear in his eye. I think he knew he was very lucky tonight. If he would have waited to come to the ER his outcome may not have been so positive. We then transported Bill to the ICU with his son close behind.

Bill would be in the ICU for several days. He would get cardiac enzymes drawn every 8 hours for the first 24 hours to determine if the levels returned to normal or not. The CPK and CPK-MB should normalize within 2 to 3 days and the Troponin should normalize within 10 to 14 days. The cardiologist will probably do a cardiac catheterization at some point to look inside Bill’s coronary arteries to determine if he would need further interventions. Although the T-waves did normalize, Bill may still have some occlusion or narrowing in one of his coronary arteries that may require a stent, angioplasty, or coronary artery bypass graph surgery. This needed to be determined by the cardiologist.

Bill will have to make some major adjustments in his lifestyle including quitting smoking, exercising, and diet. He would need cardiac rehabilitation once discharged from the hospital. Bill’s health would be in his own hands. I actually wished this scared him enough where he would do the right thing. But I knew not everybody did and ended back in the hospital within a year after their first MI. I left the hospital at 2245. I was more than ready for a glass of wine. I had three days off. 

(This is not the ECG from this patient but gives those who do not know what tombstone T-waves look like. Look at leads II, III, and aVF.)