My Birthday

So, apparently I am 37.
Good opportunity for some self assessment.  I sure don't want to be this heavy at 38 for example.  Possibly the cake won't have helped with that though. (If you think this one looks good, you should have tasted Liz's sticky date cake with caramel sauce).

My birthday celebrations started with being allowed to stay in my dressing gown while Damien took the girls to Dancing.  Nice for me to have a more relaxed morning (plus, there was no way anyone else would have been ready in time without lots of help, and I couldn't get myself ready at the same time as them...).

My actual "party" started at about 5: 20 when Granny arrived with Libby and her 3 girls.  They suprised me, because Libby doesn't currently have a working, registered car.  Mum actually drove all the way down to Dover to pick them up.  Then she went back to get Dad, because her car only seats 5.

Later on Matt and Liz arrived with their kids (minus Lewis).  We ate, and talked and the kids played all over the house, then we headed downstairs to show each other our favorite youtube clips.  We still don't have a couch downstairs, so we roughed it on an inflatable mattress, cushious, various small chairs etc.
Here are some links: boomwhackers more boomwhackers, evolution of dance, musical prank, and Badgers.  Badgers was from Damien, in case you haven't guessed.  I should have added in potato salad too.
It was nice to get my set of Boomwhackers out and watch the cousins play with them.  Jordan was particularly impressed.

Next time Granny goes to extraordinary lengths to bring Libby to something, I think we will be helping out too.  Somebody else should have dropped Granny home so that Grandpa didn't have to the trip and then come back to Lauderdale to collect the Burton Family for the return run to Dover.  Poor Rhiannon got way too tired while waiting and things got nasty.  Sorry Libby, we should have thought that one through.

Just as we were waving Matt's family goodbye I got another call-in.  Third call in for the same guy in a week.  I got a sympathy cuddle with Damien on the couch for 5 minutes because I was depressed at the whole idea of having to go to work again (and on my Birthday too).  I already had a 5 hour paper work backlog.

Because this is MY blog, and it is about MY birthday, I'm going to gratuitously add the following rundown of my case that night in the CCU ward, and hope I'm putting it in English:

MY VERY INTERESTING DEFIBRILLATOR CASE

I am called in because the emergency staff witness an arrhythmia that is too slow for Mr R's implanted defibrillator to detect.  They think that the nurses cured the arrhythmia with an injection.  Would I please alter the lower detection rate?  It is already on the lowest setting I could get it to do earlier in the afternoon.

I arrive, and do a quick internet search on this particular devices rate limitations.  I will have to change multiple parameters to get it to let me anti-tachy-pace at 145 beats per minute.  I ring the device specialists to discuss what I have concluded.

A little after midnight I use a computer to talk to the patient's implanted defibrillator.  It tells me it has saved Mr R's life twice since I saw him in Emergency earlier in the day (he got a shock from the device this morning).

The above graph plots the interval between heart contractions, big light blue dots for the atrium and tiny dots for the ventricle.  Lower dots = faster heart rate.  At the start of this graph, the ventricle is going twice as fast as the atrium, and the rate pattern zig-zags.  I have only ever seen this pattern on this patient (this week).  Horizontal lines show the intervention zones.    You have to get a high proportion of dots within the zone before therapy will be initiated,

So, (from left to right) slow ventricular tachycardia (patient felt awful, but was not treated by device, because the rhythm did not consistently fall beyond that first detection line).  Very unusually, the atrial rate is half the ventricular rate, and seems to be in sync.  There is then a sudden increase in ventricular rate, falling within the second therapy zone (he's gone from slow tachycardia to a faster more dangerous rhythm - too fast for a detectable pulse).  Device detects arrhythmia, and saves his life by delivering a VERY fast run of paced beats, painlessly tricking the heart out of the arrhythmia and back to normal.  If that hadn't worked, or if the rate was faster than the lowest line, it would have smacked him with a painful electric shock to save his life.  I conclude that the emergency staff didn't save him, the device did.

The next picture shows what the device was doing at the time of the slow ventricular tachycardia:  It was pacing over the top!!!  "Hey, the heart's going inappropriately too fast, lets try and trigger heart beats along with it".  It seems that the atrial pacing is triggered by the ventricular rate (firing off after every second contraction).  Very strange indeed.

I realise that for every second ventricular contraction on the previous interval plot the device is counting the pacing spike, not the sensed beat underneath it, and that this is why the interval plot zig-zags.  This is interfering with accurate rate detection.  I tried to send this picture to the device specialist (who needs to get a new mobile phone that will show pictures!).  He can't explain my observation.  We decide that I'll fax him the rhythm strip on Monday.

My job was to reconfigure the therapy zones so that the slow arrhythmia would be treated (before things got really nasty).  Turns out that there is an extra algorhythm turned on to help stabilise the ventricular rate (it helps in the presence of atrial arrhythmias).  It is called V rate stabilisation, and delivers a paced beat (both chambers) following an early native ventricular contraction (or ventricular ectopic beat).    I turn off the algorhythm, because it is blocking me from resetting the lower detection rate.  I also adjust how fast the device will crank up too in response to physical exercise, because it was too close to the arrhythmia zone. I print out, disconnect and say goodbye to the patient.

While I am writing in the notes, he does it again.  At 133 beats a minute, still below my new detection rate.  Patient feels like rubbish.  I plug my machine in to manually deliver some anti-tachy pacing therapy, but while it is loading up, he deteriorates, the rate gets higher, and the device saves him automatically.
That wasn't particularly cool, because he suffered for a bit too long before the therapy was delivered.  What was cool (well, hey, I was excited) the device didn't try to pace over the top of his arrhythmia this time, and displays the slow VT as a regular row of lines, not a zig-zag.  It was that darn V rate stabilisation algorhythm.  I have heard of V rate stabilisation before, but didn't know that it would be active even if there wasn't an atrial arrhythmia.   My zig-zag graph makes sense now, and I LOVE THAT.  I must point out to the company that it can prevent arrhythmia detection (they probably already know, but slow VT like this isn't very common).  I wonder if my cardiologists have even heard of V rate stabilisation.  I love my job.

I ring the Doctor, and tell him I'm resetting the detection zone to 130 beats per minute.  This is the lowest I've ever set a tachy therapy zone in my career.  They take Mr R off amiodarone on the basis of nasty things happening to his resting 12 lead ECG, and I write in his notes all over again.  I decide that it is too late at night to bother with the rest of my paperwork, and I get home at about 1: 45 am.

The End.

What happened next?  Well I dropped in on him again on Sunday afternoon (after being called in for another case) and he hadn't had a problem since last night.  I'm sure he's going to be the subject of much discussion on Monday.  I nearly fell asleep trying to drive home, but got to have a nap when I arrived.

I am not really looking forward to work tomorrow (I have to do an extra day to make up for sessions canceled due to my Melbourne trip).  If you could drown in paper work I'd be dead.  I love my job, but I hate not being able to keep up with everything I need to do.  Craig comes back in August, so I'll save my nervous breakdown until them.