Chances are that just the mere sight of the 12-lead ECG above has already piqued your interest in what will follow! It was recorded during an actual code-blue and the patient expired a short time later but I'm posting it here in order to graphically illustrate my point. Incidentally, the above ECG was diagnosed by my former Chief of Cardiology as "Wide QRS Tachycardia" but is clearly "amorphous" ventricular fibrillation.
You are working an unremarkable evening shift on a cardiac step-down ward when your patient on telemetry abruptly converts from normal sinus rhythm at a rate of 70/min into ventricular fibrillation (V-fib). Immediately, a cacophony of bells and whistles are urgently alarming all around you. You and the rest of the "cavalry", with crash-cart in tow, spring into action and burst into the patient's semi-private room only to find them calmly relaxing in bed and quietly watching television. What the *!#/%&??? Not at all what you were expecting to encounter. You were anticipating a need for deploying the defib pads, artificial ventilations, chest compressions, and copious amounts of epi. The patient and their roomate both look horrified at the complete lack of the social graces exhibited by the staff at this late hour. You glance at their bedside monitor and it is still displaying V-fib. The patient is completely oblivious to your concerns and has not a care in the world as they continue to flip through their favorite TV channels.
How can this be? You had always been taught that ventricular fibrillation is not just a "life-threatening" rhythm but rather a bona-fide "lethal" rhythm 100% of the time. What kind of voodoo black magic is at work here? This patient should be dead or, at the very least, gorked out and in their death throes. You dare not initiate CPR as it is contraindicated here. The code team has already been activated but there is little for them to do as they file into the room one-by-one. As you quickly evaluate the patient, you find them to be A&Ox4, pulse = 70/min, BP = 120/80, and all other vital signs are within normal limits.
In the heat of the moment, one nurse has the mental fortitude to verify that the patient is correctly matched up with the right piece of equipment (i.e., the telemetry monitor box) and this is confirmed to be the case. A mix-up of equipment might mean that another patient, at a remote location, is actually the one who is in V-fib and is coding elsewhere on the ward. In the past, this has also happened!
This is the very definition of "an enigma wrapped in a paradox": The rhythm is unequivocally verified to be V-fib however the patient is asymptomatic and has no chief complaint.
- Question: Under what circumstances can a patient's rhythm be in V-fib and yet they are able to maintain consciousness, a pulse, and a blood pressure?
I had a clinical nurse specialist pose this very question to me about a decade ago. Being the "seasoned" telemetry technician that I was, I naturally said that there was no way that a patient could be in V-fib and be among the living at the same time. How wrong I was. She told me that this real-life scenario actually played out at the hospital we were both working in at that time and I've even seen a similar case published in one of the textbooks I own in my personal library.
Source / Reference:
1.) Rimmerman CM, Jain AK. Interactive Electrocardiography: CD-ROM With Workbook. 1st ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2001. p. 209
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