Portal de Periódicos da CAPES

Change of shift

2004; Elsevier BV; Volume: 43; Issue: 1 Linguagem: Inglês

10.1016/j.annemergmed.2003.03.005

1097-6760

Matthew B Underwood,

Primary Care and Health Outcomes

Cardiovert me, I have marathons to runI have a great job. I enjoy the challenges and amusement of treating patients, but it is rarely inspirational wading through the overflowing mass of humanity that fills the emergency department (ED) “pit.” The “pit” is filled with land mines and sabotage, moaning and groaning, sickness and death. Much of my time is spent traversing through a mountain of obesity, a sea of self-destructiveness, and the abyss of addiction. Helplessness abounds everywhere. The pile we all shovel looms larger all the time (hospital closures, the Emergency Medical Treatment and Active Labor Act, uninsured patients, access issues, aging population, etc), we have inadequate help (nursing shortage and thinning call panels), and no place to throw it (unavailable hospital beds). Within a couple of years of completing residency, I was taking Prevacid and had taken up a try at marathon running to deal with the job stresses. I had completed my second marathon and ran a qualifying time for Boston. I was training for the big “granddaddy” of all marathons, but my training enthusiasm had become stale and stagnant. It was during this time that Mr. Fletcher 1Bob Fletcher has given permission to use his name and story. His book, Spaghetti Every Friday, can be ordered online at www.spaghettieveryfriday.com came strolling in. He needed my help, and I needed his inspiration.Mr. Fletcher (age 69 years, looking a fit 50) presented to the triage desk asking to be “cardioverted.” He said, “Medicines won't convert me, just shock me, then double my flecainide, and I will be on my way back to Texas. That's what my cardiologist always does.” He had just completed the Napa Valley Marathon the previous weekend and felt his heart suddenly going “haywire” during his recovery run today. For his athletically trained heart, his current resting heart rate of 80 beats/min was essentially atrial fibrillation with rapid ventricular response. Being an engineer, he was very good with numbers. He knew he had a limited time period in which cardioversion was deemed safe. This was his eighth time requiring cardioversion. He had completed his 193rd marathon. His plan was to run his 200th during his 70th year. I later looked up his results on the Internet, and despite the threat of atrial fibrillation, a hilly course, and a “bad race,” this senior citizen still finished in less than 4 hours! Wow!It seemed a little bit risky, an elective cardioversion without an echocardiogram, without anticoagulation, and without a cardiologist. “That's not necessary,” he said. Fair enough, someone who has conquered the last truthful miles of a marathon 193 times is someone that I believe and trust. The marathon tells the truth. Without the sustained training, even the most talented runners will be exposed as phonies. On the telephone, my cardiologist had no objection. OK, so here it goes. Oxygen, intravenous line, monitor, Versed, synchronize, paddles, 75 J, Wham! Pause … long pause … sphincter tightening … sinus rhythm, rate 46 beats/min. Whew!When the Versed wore off, we talked about running and marathons, Boston in particular. He gave me a signed copy of his book. It turns out that when he was 50 years old and a pioneer in the 1970s running boom, he took a sabbatical from work, bought a van, and completed a harried quest to run 50 marathons in all 50 states in 50 weeks during his 50th year. He chronicled his crazy adventure in a book that has become a runners' cult classic. Mr. Fletcher was no longer in atrial fibrillation, and my own heart had been infused with inspiration. Each working shift, I hope that there is at least one patient encounter that will make my day; Mr. Fletcher had just made my whole month leading up to Boston.The big day at Boston arrived. This conglomeration of people is a far cry from the humanity that occupies the ED pit. The runners (16,000 plus) are arguably a collection of the most healthy and fit people from around the world. No whining, helplessness, or phantom disabilities here, just a crazy addiction to endorphins. I felt like a rock star amidst the cheering crowds. Mr. Fletcher had armed me with lots of good advice. “Make sure you eat enough in the morning because of the late noontime start.” “Don't go overboard on the down hills at miles 15 and 19.” “Don't let the cheering girls at Wellesley College push you too much above your pace.” And most of all, “just enjoy it.”Marathons begin as a happy, festive, social event. The pace feels easy and comfortable. Hopkinton, Framingham, Wellesley, Newton, I passed through the towns and miles effortlessly. However, in marathon running, the Grim Reaper is always watching and waiting, and begins stalking victims in the last miles. I powered up the legendary Heartbreak Hill with ease and thought I had slipped passed his radar unnoticed, but alas, I felt his breath on my neck at mile 23, and at 24 he caught me. Like a crack-headed speed freak coming down from a 2-day rave party, my endorphin and glycogen stores were depleted. Lactic acid was searing pain throughout my body. I was starved, but too nauseous to suck down gooey energy gels. Tunnel vision. Light-headed. I discovered the true meaning of “weak and dizzy all over.” My mind began to hallucinate. I thought about adenosine triphosphate, the Krebs cycle, and oxidative phosphorylation. I wondered whether my sodium was too high or too low. I hoped my brain wouldn't seize like my legs were. I wondered if the leading Kenyans had already showered and were checking their luggage at the airport. And I thought about Mr. Fletcher. I wondered if he was still in sinus rhythm. As I carried the Grim Reaper home on my back the last 2 miles, I thought how great it would be to be able to do this at age 70, atrial fibrillation or not. Cardiovert me, I have marathons to runI have a great job. I enjoy the challenges and amusement of treating patients, but it is rarely inspirational wading through the overflowing mass of humanity that fills the emergency department (ED) “pit.” The “pit” is filled with land mines and sabotage, moaning and groaning, sickness and death. Much of my time is spent traversing through a mountain of obesity, a sea of self-destructiveness, and the abyss of addiction. Helplessness abounds everywhere. The pile we all shovel looms larger all the time (hospital closures, the Emergency Medical Treatment and Active Labor Act, uninsured patients, access issues, aging population, etc), we have inadequate help (nursing shortage and thinning call panels), and no place to throw it (unavailable hospital beds). Within a couple of years of completing residency, I was taking Prevacid and had taken up a try at marathon running to deal with the job stresses. I had completed my second marathon and ran a qualifying time for Boston. I was training for the big “granddaddy” of all marathons, but my training enthusiasm had become stale and stagnant. It was during this time that Mr. Fletcher 1Bob Fletcher has given permission to use his name and story. His book, Spaghetti Every Friday, can be ordered online at www.spaghettieveryfriday.com came strolling in. He needed my help, and I needed his inspiration.Mr. Fletcher (age 69 years, looking a fit 50) presented to the triage desk asking to be “cardioverted.” He said, “Medicines won't convert me, just shock me, then double my flecainide, and I will be on my way back to Texas. That's what my cardiologist always does.” He had just completed the Napa Valley Marathon the previous weekend and felt his heart suddenly going “haywire” during his recovery run today. For his athletically trained heart, his current resting heart rate of 80 beats/min was essentially atrial fibrillation with rapid ventricular response. Being an engineer, he was very good with numbers. He knew he had a limited time period in which cardioversion was deemed safe. This was his eighth time requiring cardioversion. He had completed his 193rd marathon. His plan was to run his 200th during his 70th year. I later looked up his results on the Internet, and despite the threat of atrial fibrillation, a hilly course, and a “bad race,” this senior citizen still finished in less than 4 hours! Wow!It seemed a little bit risky, an elective cardioversion without an echocardiogram, without anticoagulation, and without a cardiologist. “That's not necessary,” he said. Fair enough, someone who has conquered the last truthful miles of a marathon 193 times is someone that I believe and trust. The marathon tells the truth. Without the sustained training, even the most talented runners will be exposed as phonies. On the telephone, my cardiologist had no objection. OK, so here it goes. Oxygen, intravenous line, monitor, Versed, synchronize, paddles, 75 J, Wham! Pause … long pause … sphincter tightening … sinus rhythm, rate 46 beats/min. Whew!When the Versed wore off, we talked about running and marathons, Boston in particular. He gave me a signed copy of his book. It turns out that when he was 50 years old and a pioneer in the 1970s running boom, he took a sabbatical from work, bought a van, and completed a harried quest to run 50 marathons in all 50 states in 50 weeks during his 50th year. He chronicled his crazy adventure in a book that has become a runners' cult classic. Mr. Fletcher was no longer in atrial fibrillation, and my own heart had been infused with inspiration. Each working shift, I hope that there is at least one patient encounter that will make my day; Mr. Fletcher had just made my whole month leading up to Boston.The big day at Boston arrived. This conglomeration of people is a far cry from the humanity that occupies the ED pit. The runners (16,000 plus) are arguably a collection of the most healthy and fit people from around the world. No whining, helplessness, or phantom disabilities here, just a crazy addiction to endorphins. I felt like a rock star amidst the cheering crowds. Mr. Fletcher had armed me with lots of good advice. “Make sure you eat enough in the morning because of the late noontime start.” “Don't go overboard on the down hills at miles 15 and 19.” “Don't let the cheering girls at Wellesley College push you too much above your pace.” And most of all, “just enjoy it.”Marathons begin as a happy, festive, social event. The pace feels easy and comfortable. Hopkinton, Framingham, Wellesley, Newton, I passed through the towns and miles effortlessly. However, in marathon running, the Grim Reaper is always watching and waiting, and begins stalking victims in the last miles. I powered up the legendary Heartbreak Hill with ease and thought I had slipped passed his radar unnoticed, but alas, I felt his breath on my neck at mile 23, and at 24 he caught me. Like a crack-headed speed freak coming down from a 2-day rave party, my endorphin and glycogen stores were depleted. Lactic acid was searing pain throughout my body. I was starved, but too nauseous to suck down gooey energy gels. Tunnel vision. Light-headed. I discovered the true meaning of “weak and dizzy all over.” My mind began to hallucinate. I thought about adenosine triphosphate, the Krebs cycle, and oxidative phosphorylation. I wondered whether my sodium was too high or too low. I hoped my brain wouldn't seize like my legs were. I wondered if the leading Kenyans had already showered and were checking their luggage at the airport. And I thought about Mr. Fletcher. I wondered if he was still in sinus rhythm. As I carried the Grim Reaper home on my back the last 2 miles, I thought how great it would be to be able to do this at age 70, atrial fibrillation or not. I have a great job. I enjoy the challenges and amusement of treating patients, but it is rarely inspirational wading through the overflowing mass of humanity that fills the emergency department (ED) “pit.” The “pit” is filled with land mines and sabotage, moaning and groaning, sickness and death. Much of my time is spent traversing through a mountain of obesity, a sea of self-destructiveness, and the abyss of addiction. Helplessness abounds everywhere. The pile we all shovel looms larger all the time (hospital closures, the Emergency Medical Treatment and Active Labor Act, uninsured patients, access issues, aging population, etc), we have inadequate help (nursing shortage and thinning call panels), and no place to throw it (unavailable hospital beds). Within a couple of years of completing residency, I was taking Prevacid and had taken up a try at marathon running to deal with the job stresses. I had completed my second marathon and ran a qualifying time for Boston. I was training for the big “granddaddy” of all marathons, but my training enthusiasm had become stale and stagnant. It was during this time that Mr. Fletcher 1Bob Fletcher has given permission to use his name and story. His book, Spaghetti Every Friday, can be ordered online at www.spaghettieveryfriday.com came strolling in. He needed my help, and I needed his inspiration. Mr. Fletcher (age 69 years, looking a fit 50) presented to the triage desk asking to be “cardioverted.” He said, “Medicines won't convert me, just shock me, then double my flecainide, and I will be on my way back to Texas. That's what my cardiologist always does.” He had just completed the Napa Valley Marathon the previous weekend and felt his heart suddenly going “haywire” during his recovery run today. For his athletically trained heart, his current resting heart rate of 80 beats/min was essentially atrial fibrillation with rapid ventricular response. Being an engineer, he was very good with numbers. He knew he had a limited time period in which cardioversion was deemed safe. This was his eighth time requiring cardioversion. He had completed his 193rd marathon. His plan was to run his 200th during his 70th year. I later looked up his results on the Internet, and despite the threat of atrial fibrillation, a hilly course, and a “bad race,” this senior citizen still finished in less than 4 hours! Wow! It seemed a little bit risky, an elective cardioversion without an echocardiogram, without anticoagulation, and without a cardiologist. “That's not necessary,” he said. Fair enough, someone who has conquered the last truthful miles of a marathon 193 times is someone that I believe and trust. The marathon tells the truth. Without the sustained training, even the most talented runners will be exposed as phonies. On the telephone, my cardiologist had no objection. OK, so here it goes. Oxygen, intravenous line, monitor, Versed, synchronize, paddles, 75 J, Wham! Pause … long pause … sphincter tightening … sinus rhythm, rate 46 beats/min. Whew! When the Versed wore off, we talked about running and marathons, Boston in particular. He gave me a signed copy of his book. It turns out that when he was 50 years old and a pioneer in the 1970s running boom, he took a sabbatical from work, bought a van, and completed a harried quest to run 50 marathons in all 50 states in 50 weeks during his 50th year. He chronicled his crazy adventure in a book that has become a runners' cult classic. Mr. Fletcher was no longer in atrial fibrillation, and my own heart had been infused with inspiration. Each working shift, I hope that there is at least one patient encounter that will make my day; Mr. Fletcher had just made my whole month leading up to Boston. The big day at Boston arrived. This conglomeration of people is a far cry from the humanity that occupies the ED pit. The runners (16,000 plus) are arguably a collection of the most healthy and fit people from around the world. No whining, helplessness, or phantom disabilities here, just a crazy addiction to endorphins. I felt like a rock star amidst the cheering crowds. Mr. Fletcher had armed me with lots of good advice. “Make sure you eat enough in the morning because of the late noontime start.” “Don't go overboard on the down hills at miles 15 and 19.” “Don't let the cheering girls at Wellesley College push you too much above your pace.” And most of all, “just enjoy it.” Marathons begin as a happy, festive, social event. The pace feels easy and comfortable. Hopkinton, Framingham, Wellesley, Newton, I passed through the towns and miles effortlessly. However, in marathon running, the Grim Reaper is always watching and waiting, and begins stalking victims in the last miles. I powered up the legendary Heartbreak Hill with ease and thought I had slipped passed his radar unnoticed, but alas, I felt his breath on my neck at mile 23, and at 24 he caught me. Like a crack-headed speed freak coming down from a 2-day rave party, my endorphin and glycogen stores were depleted. Lactic acid was searing pain throughout my body. I was starved, but too nauseous to suck down gooey energy gels. Tunnel vision. Light-headed. I discovered the true meaning of “weak and dizzy all over.” My mind began to hallucinate. I thought about adenosine triphosphate, the Krebs cycle, and oxidative phosphorylation. I wondered whether my sodium was too high or too low. I hoped my brain wouldn't seize like my legs were. I wondered if the leading Kenyans had already showered and were checking their luggage at the airport. And I thought about Mr. Fletcher. I wondered if he was still in sinus rhythm. As I carried the Grim Reaper home on my back the last 2 miles, I thought how great it would be to be able to do this at age 70, atrial fibrillation or not.