Unique Cases - Creativity Becomes Critical When Resources are Scarce

     A 50-year-old male came into the clinic with dyspnea, shortness of breath, and palpitations. On exam, his extremities were cool to touch, he had a very faint pulse, and noticeable edema. Since we are resource limited and do not have access to a 12-lead EKG machine, we performed a quick bedside ultrasound revealing a heart arrhythmia and tachycardia, which we initially suspected to be atrial fibrillation.

    Fortunately, the hospital had recently acquired a cardiac monitor - something we don't take for granted in this setting - so we quickly connected him. The rhythm confirmed our suspicion: atrial fibrillation with rapid ventricular response (RVR), with his heart rate spiking between 200-250 bpm and occasionally jumping into supraventricular tachycardia (SVT).

    With no access to cardioversion and extremely limited medication options, we had to rely on clinical judgment and resourcefulness. The only cardiac medications available were atenolol, amlodipine, and digoxin, so we started him on those immediately. Despite our efforts, his heart rate remained dangerously high throughout the day. We brainstormed, trying to think of any other options.

    The next morning, his heart rate was still in the 200s. That's when we discovered an emergency kit tucked away - almost forgotten. Inside, we found a few vials of adenosine and amiodarone. It wasn't much, but it was something. We administered them and also increased his dose of amlodipine. By the end of day 2, his heart rate was fluctuating between the 120s and 180s, still in atrial fibrillation. 

    Then, on day 3, something remarkable happened - he spontaneously converted back into normal sinus rhythm, with a stable heart rate in the 80s. His symptoms steadily improved, and before long, he was well enough to be discharged. This case was a powerful reminder of how critical adaptability and teamwork are in this setting.



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