Tuesday, November 13, 2007

On Being Sure

My eyes must have been as wide as saucers as I looked at the strip. Though I have seen EKGs like these during my training and passed between friends at work, I had yet to have a patient capable of printing anything like this.

We were called for the "possible heart," and though the patient was without complaint and looking fine, the nurses pulled me aside and told me that he had a MI a few weeks ago with emergent angiocath and two stents placed. They were drawing a routine troponin today and got a reading of 7.65. Extremely high, and coupled with the significant cardiac history and ECG changes, I was absolutely sure this was the real thing.

I have taken care of a few critical patients thus far during my time as a paramedic, but the occasion still makes me extremely nervous. The urgency set me off balance a little bit, and though I remembered clearly what it was that I was supposed to do, I felt a slight tremor in my voice and a constant nagging pressure of excitement that pushed me right out of my comfort zone. The stress stressed me.

The nurses took a really long time with the paperwork and I snapped harshly at them. I told them flatly that they needed to hurry up because this patient's heart was wasting as we spoke. I criticized that the paperwork should have been done before we got there, or at least assembled during the 5 or 6 minutes we were getting the patient ready and taking the ECG. I wasn't over the top, but I was most certainly rude and they glared back as they handed me the necessary papers. Without apology we rushed off.

In the ambulance on the way to the hospital with the lights flashing, I reassessed. The patient was without complaint, which I thought was odd, but he also had a history of dementia and had a baseline confused mental status. Besides, I thought, plenty of people feel the "pain" of AMI in odd ways: the absence of discomfort amongst all of the other evidence surely mattered very little. It nagged me though, and added to my stress. I asked myself if there was anything I missing, assessed repeatedly, and took several copies of the ECG. All signs pointed to AMI, and though this presentation is foreign to me in the flesh, I was pretty sure I knew what I was dealing with.

I gave a radio patch to the hospital, forgetting that this was not one of the facilities that allowed EMS to activate the cath-lab from the field. When I mentioned the prospect into the microphone, the answer back was confused. They asked me if I was calling for nitro and asprin orders, which I told them I had already given to the patient. Why the hell would I need to call for those meds anyways, I thought to myself. Stress continued to build.

At the hospital, the triage nurses kept us in queue for much longer than I was expecting. Usually they will usher critical patients right through into the trauma rooms for immediate evaluation, but this time they wanted me to linger as they completed the lengthy registration process. They asked me for the patient's social security number, his entire medical history, meds, and allergies. They took the time to print out an identification bracelet, and attach it to the patient's wrist. I showed the nurses the EKG and told them the story, but they seemed somehow unimpressed. They sent us, frustrated, stressed, and confused, to a low-acuity section of the Emergency Department. When he told us, I unknowingly made a disgusted face to the nurse that my partner laughed about later. "You should have seen your expression," he said.

The story was no different with the nurses in the patient's room, who silently listened to my report and without fanfare helped us transfer the patient to his hospital bed. They thanked me and walked out of the room, as if I had just brought them an earache or hangnail.

Again I re-studied the ECG and rehearsed the patient's story. There must be something I am not getting here, I thought to myself. I needed to know, and decided to talk directly to the doctor. She was busy but I interrupted as politely as I could, showing her the ECG and telling the story as thoroughly as possible. She stopped me when I mentioned the recent cardiac surgery, her eyebrows raised with suspicion. "Yeah," I said, "the cardiac history is pretty significant, which is why I was so suspicious this is an MI..."

The doctor swung around in her chair and typed a few things into a nearby computer. She came up with the patient's discharge ECG following the surgery, which looked exactly the same as the ones I had taken not 15 minutes earlier. She let out a sigh of relief. "It's nothing," she said. "Just residual ST elevations." She explained that some patients retain their ST elevations following cardiac surgery, sometimes for weeks after they have left the operating room. Troponin levels are also notorious for remaining high for lengthy periods afterwards. I didn't do anything wrong, she said, admitting that paramedics need to treat "as if," but in the light of this evidence it is clear that the patient is not having a heart attack.

It was news to me, and my heart sunk as I thought about how I had behaved throughout the call. I was stressed and rude, nervous and assertive. I remember reading in class that ST elevation marked the acute phase of a MI, but new knowledge had surfaced to prove that sometimes incorrect, and my face was red as I snuck back to the ambulance to write my report.

We have learned a lot of things as absolutes in school which have turned out be not quite so in real life. There is so much in medicine that relies on the "not always" caveat, often I am frustrated by the inconsistency and struggle to find footholds amongst endlessly shifting ground. A MI will not always present with pain. An altered diabetic's sugar will not always be low. Sometimes patients with critical conditions will display them, sometimes they wont. It is incredibly difficult to tell the truth sometimes, often it is best to conclude that we truly have no idea what is actually happening, and admit that transport to the hospital is the only viable solution.

Such consistent uncertainty makes it difficult to remain assertive about our decisions and advocate for our patients as strongly as we would like. I am embarrassed that I was rude to the nurses, but at the same time I defend the choice as important to the patient's welfare. For every story like this there is another about a paramedic's urgency buying his patient a critically necessary and life-saving evaluation. We have limited tools, limited knowledge, experience, and education. There is an incredible wealth of what we do not know, and yet we must sometimes stand firm and make a decision, baring ourselves completely for either important discovery or embarrassing ridicule.

Handicapped, we find our way through the dim light by grasping to that which matters most: the welfare of our patient.


Anonymous said...

I still think that those nurses were "calm" because they had no clue what you were talking about...

Patrick said...

I won't ascribe any motivation or lack of knowledge to the nurses. Obviously they wanted you to transport because they thought SOMETHING was up.

Does this fall under the general category of "treat the patient, not the monitor"?

fiznat said...

Patrick, I don't know: what do you think? Would you be able to ignore that ECG? The history and enzymes too? The guy was demented and hardly saying anything at all... His vitals and general presentation were fine but people sometimes look like that during an MI. It is really hard to tell, and I think I absolutely had to treat - like the doctor said - "as if" this was the real thing.

Blue Ridge Medic said...

I agree completly with you. I had a simular call, but without the lab work. It was a 90 year old female with a history of diabetes and DVT. ECG showed almost the same as yours, in the same leads, yet the patient had no complaints and all vitals were fine. The original call was for syncope. I treated like an active MI, although I wasn't able to find out what happened to her after we dropped her off at the ED.

Patrick said...

Well, there are some gaps in the history. If the troponin is to be considered in the mix, and it's not something usually available to 911 responders, then I'd want to know what it was the last time it was taken. (I'm 51, and when I had my MI, it took two weeks for it to come down from a high of 76). My EKG was normal right after the stent, however.

That's where the hospitals have an advantage over us (traditionally), as they have history and old labs / EKGs / xrays they can look up and compare to.

You didn't mention where this call was at. Physician's office? Doc-in-the-box? Did they have the history and previous records available? Having a little more patience with the sending facility staff might have yielded more clues, (better hx or other info) and you already copped to that.

I sort of lean the other way. A patient with pain and a normal ECG is not ruled out, but a patient without symptoms who has positive signs (ECG, labs), hard to say. I doubt you can go wrong giving him ASA (unless he's already been medicated), but the NTG would be a harder sell - what do you have to compare it to (pre/post-pain?)

I usually see the opposite. Crushing chest pain radiating, the whole thing. One NTG. Whoo-hooo, we got his pain down from an 8 to a 6, it's Miller Time!

When faced with a complex situation, one of the things that is hardest to do is reconcile conflicting clues. A patient who "was without complaint and looking fine", but has out-of-whack labs and ECG - not so clear, and could benefit from more information and analysis.

The best thing about this is the patient had a good outcome, and you added a bunch of more information to your and others' knowledgebase for future patients.

fiznat said...

Good points Patrick. To answer your questions, this was at a SNF and the nurses truly had no more information to give me. In fact, they specifically complained that they were unable to contact the recieving hospital so they could compare lab and ECG results. That's why they called 911. ECG "changes" and abnormal labs without anything to compare with.

True I could have been nicer to them, but while this may have had other benefits I don't think I would have been able to elicit any more of a history than I already had.

Also I was unfamiliar at the time with the fact that ST elevations (and labs) can hang around for so long following surgery. Though my understanding is more complete now, at the time I didn't see the need to search too much more in-depth into the history, as I had more or less made my decision already.

Next time, as usual, will be different. Thanks for your comments.

Patrick said...

I compliment you on your attitude. If we are going to continue to move forward as a medical profession, we (the "baby medics" right through the 30-year-plus snaggletooths) must be willing to accept that: 1) we're not Gods, 2) we can learn and be taught every day, and 3) technology will continue to change our jobs and we must keep adapting, without ever becoming complacent or stagnant.

Medicmarch. said...

If I had taken that EKG I would've have been in just as much of a rush, and would've treated the exact same way.

I had no idea that you could have residual ST elevations like that.

Although I'll treat elevation the same way (I really don't want to walk in to an ER with a patient showing elevation and me stating "No, it's ok, probably just residual, and then the guy craps out in front of God, the Doctor, and Everybody) this is something I'll keep in mind for the future.

I can't believe that the SNF couldn't get contact with the hospital.

Thanks for the post!


Kristen said...

I enjoy your posts. Would you mind if I linked you on my page?

fiznat said...

Not at all Kristen, thank you!

Anonymous said...

This is so useful! I'm in medic school now, and had no idea that the ST segment and Troponin levels could stay elevated that long. thanks for the story!