Well says Q, the head of the ICU is back from sabbatical, you are free to rotate. Surgery wants your back, they say you have good hands. Surgery residency is six days a week with every three days on call, why can’t I work in the outpatient clinic and hand out ampicillin like everyone else says Dr. Wracks. You passed the boards didn’t you says Q, now you have to work. I have an alternative autistic choice paradigm says Q, how would you like to spend a couple weeks in the CCU, it is on the same floor, just doors down from the ICU. It is the same thing, just a Shepard looking over the flocks says Q seriously. OK says Dr. Wracks, I thought passing the boards would get me my shingle, and it doesn’t. When do I start. Right now, says Q, this is my realm and they are already waiting for you. Tally ho.
The situation of the ICU is nearly the same as the CCU except the heart monitors are bigger and all the patients are hooked up with electrodes like a Frankenstein movie. The nurses sit in a nest behind closed doors until they are needed, and the light is fluorescent, buzzing and bright and all the patients are sedated almost to a coma. Physicians like prescribing benzodiazepines. It is part of the heart thing I guess, says Dr. Wracks. A cardiologist sits at the bedside of a patient and watches the heart monitor for fifteen minutes at a time. The sine wave gives the status of the heart patient almost to a T. If the patients have color, they are surviving, if they don’t a physician must intently evaluate the monitor. The most important aspect of the EKG is the p wave and time till the QRS or heart contraction. If the p wave disappears occasionally, the heart doesn’t beat and there exists Mobitz type one phenomena. If this occurs a problem exists because the sinoatrial node pacemaker is not functioning correctly, and an infarct may exist or there is an electrolyte imbalance. An adrenergic agent like epinephrine or methamphetamine may correct the anomaly, and if not, cardioversion might be necessary. Fortunately, this condition does not occur frequently and is most often caused by an overdosage of beta blockers. This is the main reason why beta blockers should not be used. If the sinoatrial node depolarizes but the latency time before QRS contraction increases slowly over time a Mobitz type two phenomena exists and this occurs most commonly with an overdosage of Ouabain or other cardiac glycosides. Cardiac glycosides like Lanoxin while increasing the force of contraction, (inotropism) and rate of contraction (chronotropism), are extremely toxic so their use is indicated for the dying patients of congestive failure so they can get their estate together (6 months). QRS phenomena usually indicate massive infarct and the prognosis is unfavorable, See the work of Sokolov for details.
For the most of the patients that survive the infarct which for them evidences with T wave inversion, disappearance, or S-T wave anomalies. It is a good idea to check the monitor a couple of times every shift because a S-T wave depression signifies a developing subendocardial infarct and immediate necessary intervention.
The main drugs of the heart patient are beta blockers, adrenergic agents, cardiac glycosides and ganglionic blockers, all of which are toxic and must be titrated accordingly by body weight. Beta blockers and procainamide induce cancer, particularly cancer of the pancreas and should not be used. Morphine is the drug of the dying and the ancient told Dr. Wracks, “it is the angel of the elderly”. Morphine should be used in excess but the prescription hand delivered by the pharmacist, and signed for, must be injected by the attending, usually 10mg subcutaneously, because if left to the nursing staff, they will mainline half of it before injecting the patient. This must be kept in mind. Bretylium used to be used as a ganglionic blocker for Purkinje system anomalies but are now treated with calcium channel blockers like verapamil, but the slow onset of action and inhibition of the slow C channel is often non-efficacious. Nicotine, now anathema has an immediate onset of action, short duration of action (two hours) and immediate elimination by the kidneys. Other drugs exist but it has been fifty years and in the Wracks estimation, all heart patients should be maintained on morphine and nicotine, with injections of Benzedrine if necessary. It seems overly simplistic and supercilious, but heart patients should be morphine addicts and vape nicotine to survive and shoot Benzedrine if their autonomic pacemaker fails. Morphine is the angel and it decreases preload to the heart, is histaminic to increase vasodilation, and is negative bathmytropic to eliminate ventricular tachycardia.
Dr. Wracks sits in front of the monitors and makes notes on the patient chart. The older doctor in a walker comes into the unit and speaks with the nurses. He is making sure the staff does not kill Dr. Wracks. Dr. Wracks waves hi., Thanks to the immediate intervention in triage by the emergency room staff, the CCU is not an exciting place to work and the cardiologists are extremely meticulous and demand compliance because failure of one iota results in death and a malpractice suit. The next assignment for Dr. Wracks is in pediatrics, screaming kids, vaccinations and liquid ampicillin bottles, but as a bonus Dr. Wracks is placed in Pediatric Oncology and surgical ophthalmic trauma.
On a south swell the waves move into the point and give a long ride. The girls are in the briefest bikinis, designed by a talk show host, and the wind at two pm calms down and the waves increase with the upcoming tide. A beautiful place and a beautiful time in a peaceful era that the Wracks will never know. Now we have YouTube and the information superhighway and memories can be stored on a flash drive. Memories that will not occur, and the world turns and time goes on. And so, it goes.