WWJD: What Would Joules Do?

An ambulance is dispatched for a low priority call to a nursing home. A patient is being referred through to the emergency department by their GP because, when conducting a physical examination, the GP auscultated a heart rate of approximately 180.

On your arrival, the patient is alert, oriented, seated on the edge of the bed. He speaks normally, interacts quite happily, and doesn’t really understand what all the fuss is about. The GP was only there to look at his UTI, which he is being treated for with oral ABs.

You’re told the patient has a history of hypertension and atrial fibrillation. He has no allergies, and takes digoxin, aspirin, frusemide, metformin, prednisone, and allopurinol.

At the scene, your vitals are:

GCS 15, HR74 irregular, BP120/85, RR16, T36.2, BGL6.9, ECG AF, with a 12 lead attached.


When you make the big move to the bed, the patient feels an urge to pass a bowel motion, which he does. You go to change him and notice a loose, green bowel motion. In addition to this, his IDC UTI appears more severe than the GP initially led you to believe.

During transport, just five minutes from the emergency department, you notice him become a little diaphoretic and his rate increase. The ECG is reattached, and you see the tracing below. There is no 12 lead ECG of this. He flicks between the two rhythms, seemingly unable to make up his mind. Denies any chest pain, palpitations, or discomfort.


1) What’s your interpretation?

2) What’s treatment? Would it be the same if you were 60+ minutes from hospital?

3) What are your concerns?

There likely will be a series of updates on this thread, so have a think about what’s going on, discuss (online or offline), and check back for updates!


5 Comments Add yours

  1. geehannah says:

    Maybe going down the completely wrong path but ? digoxin toxicity – possibly precipitated by dehydration associated with UTI. Management of wide complex tachy with fluids to see how it responds rather than treating with electricity


  2. Tatsu Kuwasaki says:

    For those unfamiliar with Amal and RRWCT, here is one of his lectures I was referring to;


  3. suziham says:

    Great case! I won’t spoil the punchline but will say this case had 3 consultants and 2 registrars debating the management!

    Liked by 1 person

  4. Andrew O says:

    Actual cases are best because sometimes others involved in the case might be able to give you a run down and a little closure…

    Liked by 2 people

  5. Tatsu Kuwasaki says:

    Great to see the actual case discussion.
    Thanks Andrew for your time in uploading the case!

    OK, I’ll be brave and put my 2 cents here…
    RRWCT? (Amal Mattu fans should know what I mean : )


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