Tuesday, January 22, 2008

Proof in the Pudding

It was our third dispatch for chest pain that morning, and when I heard the call I rolled my eyes anticipating more of the same. The first two were "nothing" chest pains, pleuritic at best and nonexistent at worst, my partner and I were both sick of carrying these people from their third floor apartments without elevators, huffing and puffing as our visible, exasperated breaths lingered in the winter air.

It made it worse to find that the 12 lead ECGs read normal, that the chest pains were reproducible on palpation and respiration, and that there has been a productive cough for a week and a half. Still, these people insisted that they could not walk. They complained of shortness of breath, that they felt nauseous and weakened to the point of exhaustion. They were sick, probably, but not as sick as they (or I) seemed to hope. Sometimes I wonder if these patient's wouldn't share a high five with me if the ECG paper would spit out a few millimeters of ST elevations for once. ...Throw us both a bone, make it all worth it.

Walking into this patient's apartment to find him writhing in bed and clutching his chest did nothing for our attitudes. This was a common presentation, learned perhaps from a cheesy medical soap opera or dramatized movie scene, the complaints of pain were over the top in almost comical fashion, unreal in both magnitude and character. Real heart attacks don't look like this.

Usually, anyways.

Keeping that caveat in mind as we are supposed to, we asked the routine questions in a routinely respectful and interested manner. Tell us the story, what the pain feels like and where it goes. Tell us if you have ever felt this before, when it started and what you were doing at the time. The questions flowed in an almost mindless manner, automatic in their practiced repetition. I listened as the answers tumbled down and collected into their respective categories, and the "not a heart attack" bin was getting full.

There was time to do an ECG while the firefighters helped set up the stair chair (it was the third floor again), so I started to attach the stickers. On the man's chest was a CABG scar, which raised an eyebrow, but we carried on:

I let out a groan. My least favorite kind of ECG: just inconclusive enough that it probably means nothing, just abnormal enough that it can't be ignored. The 12 lead ECG is one of the most objective examinations we can perform, purported to be the gold standard in isolation of cardiac injury. Still, this one waffled.

I gave the guy oxygen, nitro, and asprin, then carried him down the 2 flights of stairs with the help of fire and police officers. The trip to the hospital was uneventful as the patient described to me the remainder of his story. The nitro hadn't changed his pain at all. I performed a more detailed assessment without significant finding, started an IV, and noted stable vital signs in my chart. Routine as can be, I had a good portion of my run-form written before we arrived at the hospital.


The doctor looked at my pink ECG strip carefully, and then back at the patient, to the monitor, and again to my ECG strip. He looked VERY interested. Concerned, even.

I watched him with interest and a bit of fear. I wonder what it was that he saw, whether I missed something or perhaps there was a change. I followed his eyes from the strip to the monitor and to the patient, looking for something. ...I couldn't pick it out.

He dropped the paper to the floor and asked the nurse what we had for IV access, his white coat flowing back in the wind as he walked briskly to the medication cabinet. He handed to the vials to the nurse, designating dosages of each. When they changed hands I got a glimpse of their labels: Lopressor and Cardizem. He wanted them both pushed, and right away.

Hushed silence as the nurse drew up the medications.

The nurse pinched my line and pressed the drugs into the IV. The doctor nodded when it was done, staring at the ECG monitor. Still confused, I bent over to pick up my dropped ECG strip.

The man let out a weird sounding grunt, and I could see from my bent position his legs jolt upwards from their rest on the hospital bed. I stood up to see the man with a funny look on his face, at the same time intrigued and releived. The monitor was moving much more slowly now, capturing a normal sinus rhythm at 70. The doctor was smiling.

"What the...?" I started to mumble under my breath, not fully understanding what happened exactly. The doctor heard me as he walked around the stretcher, and pointed at my strip.

"It was two to one AV-flutter," he said. "Look at the rate. Do you see any P waves?"

Still off balance, I stammered about the first-degree block, and that I thought the P waves were buried because the interval was so long.

"It's a tricky one," he said, "but the proof is in the pudding. Look at him now!"

He smiled and left the room.

I stood in the same spot for a moment, staring intently at the ECG strip. It still didn't look like a flutter to me, it wasn't even that fast, I thought I could pick out some (not fluttering) atrial activity, and anyways the patient was stable...

I take pride and special interest in ECGs, but this time I just didn't see it. I tried to look harder, but was interrupted.

"Hey man."

It was the patient from his bed.

"You did a good job."


naturalfree said...

great article ....

by : strato


Brett said...

While I dont dissagree that if slowing the rate fixed the pain, that the rate was the problem... but that 2:1 so came out of his...........

BillyBob said...

Holy shit! Man, I don't understand half of that , but what I got out of it is that in another city, in another time, or maybe a different paramedic, maybe this guy would have died. You are good.

myPARAMEDICspace said...

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If so send me an email.

Brendan said...

Consider yourself lucky to get an ECG that clean. Our main LP-12 cable is too @#$%ed up from being rolled into a 2-inch ball by idiots.

Eric Augustus said...

You know what? Your patient didn't care whether or not you saw the correct rhythm. He only cared that you cared, that you treated him like a person, that you were kind, compassionate and got him to the hospital.
I firmly believe that holding a hand is much more important than being the most technologically adept Paramedic out there.

JOBO said...

#1. Eric Agustuss' comment was right on. The patient will not remember if you got a little mud on his/her carpet or notice a mistake as long as you are compassionate, gentle, have a gentle and friendly demeanor and act as if you genuinly care; in fact, many times patients do NOT sue if a mistake IS made if the health care professional is as above! Disgruntled and rude doctors get sued the most. #2. I would STRONGLY suggest you NEVER give nitro to a patient that you dont have at least a saline lock in (you can gamble if the patient takes nitro on a regular basis, but then again, why did they call EMS). I dont like to gamble. I have been at this a LONG time and have seen patients 'crump' 2 min after recieving the nitro. With your call volume you are more likely to have an adverse reaction due to the amount of times you have to give nitro. It is NOT worth the risk *trust me*. I once gave a patient 2 nitros while moving down because we were on the top floor of a 6 story walk up. I did not want to carry an IV. I forgot about putting a lock in. I had a bad day/it was a mistake/I had a brain fart. Either way I got burnt. The patient 'crumpt' as we were wheeling him into the rig. Thank G0d we had central line protocols because I had to use a 16g long angio to access his internal jugular. EVERY vein either dissapeared or collapsed/blew! I have been following your blog and you have been really getting the hang of this faster then a lot of guys I work with! :) You should now be at the point where you are doing your "suspected MI" verbal assessment while concurrently starting a lock. If you start with putting the leads on (or let your EMT do 02 & leads), you can do your entire verbal while gaining peripheral IV access. PS I think that all paramedics should rally for central lines. Other countrys allow them and this new "easy IO" crap is just a band aid for lazy medics who have either lost their skills or are nervous. When working in the ER I cant tell you how many times a NURSING STUDENT got an IV when a code came in with an 'easy IO'. I mean easy sites too like the AC and the fore arm. They are also not great for volume ressautation (sp) either! There is no reason why ALL medics can't be trained and refreshed (rural medics) every 2 years by working with an intensivist every 2 years and puttig in a few. Sorry bud, I had to rant on that one, I am just pissed that they are slowly taking that skill away from us! I also worked for a service that used to have chest tubes. One time I put one in and they are NOT hard. It was just as the video and lab taught us. Now they are mostly extinct except for medics in the air. We need to rally for our skills or we will start to be replaced with EMT-I's. KEEP UP THE GREAT BLOG. WE LOVE YOUR STORIES! TELL US MORE ABOUT YOUR FREQUENT FLIERS AND EDP's!!! YOU REALLY MAKE US LAUGH ON THE GOOD ONES!!! :) Joey

strato said...

ok..i'm sorry,....i hope i can learn much more in here

Lucian said...

I defiantly didnt catch the flutter!