JUDDER BAR FLUTTER

On rounds one day I was presented a case of a elderly gentlemen with chest pain who had a episode of a life threatening heart rhythm disturbance “VFIB/VTACH" while being transported by the Ambulance Service to the Hospital. The Paramedic’s notes said the patients vital signs were stable with a BP of 136/74. The notes also said he looked remarkably well during this rhythm disturbance. At the bedside the patient told us they had taken a especially rough and bumpy road to the hospital. Looking at the rhythm strip I notice normal sinus rhythm followed by wide undulating complexes that return to sinus rhythm. The Heart tracing spikes or QRS complexes marched out unchanged so I concluded that this was artifact caused by the ambulance going over a rough patch of road or a speed bump. Speed bumps in New Zealand are called judder bars. So I explained the house staff that this was judder bar artifact. One of my colleagues suggested I write this up and call it "Judder Bar Flutter". So this is the world premiere of a new rhythm first described by Stephen Stowers MD FACC Senior Consultant in Cardiology Palmerston North Hospital. Cheers from Palmy on the North Island of New Zealand!

A SHOCKING STORY

I would like to relate a story about judder bar flutter that is not so funny. A young lady at home with chest pain called the community rescue unit which evaluated her and decided to transport to our hospital. She was placed in the back of the ambulance with a new trainee on a monitor that had defibrillation (shock) capability while the experienced veteran was in the front seat driving. While going over a rough patch of road the monitor alarmed and its automated voice blared out “shock advised”. Just as the trainee reached for the flashing orange shock button the veteran seeing the patient was sitting up in no distress and realizing it was judder bar flutter shouted out don’t shock the patient. It was too late the flashing orange button was already compressed, and the patient shocked. The veteran quickly pulled over the ambulance and told the trainee to get up front and drive he would stay in the back with the patient. In the hospital the patient expressed her surprise about being shocked. “I DON’T KNOW WHY THEY SHOCKED ME I WAS FEELING FINE “

FLUID AROUND THE HEART AND LOW BLOOD PRESSURE FOLLOWING ESOPHAGEAL SURGERY

I was roused from sleep at 2am by the tense voice of the intensive care physician who had called me to come in and perform a emergency heart echocardiogram on a postoperative patient. He was having a heart attack with low blood pressure that was not responding to his frantic attempts to raise it. Upon arrival with the echo machine to the dimly lit unit the patient was in the corner with clear plastic bags of medicated fluids supporting his blood pressure hanging on a metal pole next to his bed with multiple infusion pumps blinking like lights from a Christmas tree. The bedside echo showed moderate amount of fluid around the heart with normal heart function but some impaired filling from the external pressure from the collection of fluid around the heart . While performing the echo I sensed someone behind me and when I turned peering through the darkness, with the image from the echo monitor reflecting off his glasses, was the surgeon who had performed the operation . Could he have been cutting near the heart during the operation I asked. I "put surgical staples through the diaphragm to tack up the esophagus" he responded. Knowing the inferior wall of the heart rest on the other side of the diaphragm I instantly understood why the heart tracings and blood tests looked like a inferior wall heart attack. I immediately contacted Wellington our referral center for open heart surgery. My colleague in Wellinton advised us under echo guidance to put a needle in the fluid around the heart and drain it and they would transfer the patient in the morning. With my adrenaline surging I said rather forcefully the blood would just reaccumulate and the patient would not be around in the morning. Thankfully we prevailed in sending him to Wellington by life flight. In Wellington my colleague performed a coronary angiogram which should no damage to the arteries supplying blood to the heart and then tried to drain the blood around the heart with a needle only for it to reaccumulate. The patient subsequently had a cardiac arrest and was taken to the operating theater with my colleague sitting on the stretcher frantically draining blood from a tube in the pericardium. The cardiovascular surgeons opened the chest and found staples through the diaphragm into the heart causing bleeding from the cardiac viens.The bleeding was stopped with repair of the cardiac viens and the patient made a complete recovery. Lesson learned don't try to drain a traumatic pericardial effusion without a cardiovascular surgeon present.