In anticipation of episode 20 on atrial fibrillation, I got with us Dr. Claire Atzma to do her best case ever related to atrial fibrillation.

Claire, let her rip.

So I was working in the emergency department and the charge nurse, who's a very senior nurse, came up to me and said, we have a lady outside

in the ambulance bay who's 35 and she's 760 pounds.

And we don't know how to get her from the ambulance bay into our resuscitation room because

she's in at about, at least I think it is, about 170.

And they don't have any kind of wheelchair that could bear her weight. And we don't have a bed that will bear her weight once she gets into our resuscitation room.

So she was talking about calling the fire department.

And while they were working on all this, and I suggested, why don't she just walk?

Like, surely she can, because she's 35.

I started debating what I was going to do with this patient. And word got around that there was a patient who was 760 pounds out in the ambulance bay. And one of the other doctors came over and said, what are you going to try? I'm going to try porcantamide. I think you should try porcantamide. And I said, you know, maybe I will. But I don't know how much she really weighs because she can't really waste 760 pounds. But what's the maximum dose of prokinaide? And what if she, you know, goes hypotensive or what if she goes bradicardic? How am I going to handle that? What doses of atropine am I going to use?

Am I going to try and pace her? Because if she really is that big, trying to get the heart without cooking the lungs and the chest and the thorax, you know, it's going to be incredibly difficult to pace someone who's, if she truly is 760 pounds, which at that point I didn't think she really could be. but whenever you give a drug you have to think about all the side effects and how you're going to handle them and some who's 760 pounds, which at that point I didn't think she really could be. But whenever you give a drug, you have to think about all the side effects and how you're going to handle them. And it's something who's 760 pounds, obviously, a problem. Anyway, they finally got her in and I walked into the room and all my uncertainty was immediately resolved because she was really 760 pounds. In fact, she'd had a panellectomy three weeks before another hospital. So she, so she was actually lighter than usual. And as soon as I looked at her, I knew that I was not going to be giving any meds. She was stable and breathing, and her blood pressure was fine. I think it was about 120. She was very anxious in the palpitation. She had a touch of chest pain. She's sort of off and on, and she was going at about 170. So I decided I would rate control her,

but to do a procedural sedation on a woman who is 760 pounds, whether or not you can ramp the

patient and get the tube in or how big the tube is and the meds are going to use and all the maximums

are just way off the chart, This is a patient where you just

step back and say, no, the ASA score is way too high. And so I did exactly that. I gave a pocadamide.

I brought a heart rate from about 160 to 140, but not much else. And I called the cardiologist

who came down and then offered to try one of the type 1 antirthymics.

And again, I said, and what if the QRS widens? Are you prepared to handle that? You prepare to

handle hypertension? You prepared to intubate her if things go wrong because that's an antirthmic

and you don't know how much you're going to have to use. And after going through this with him,

he decided to take her to the OR. And the anesthetist

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