Monday, June 9, 2008


He didn't even have chest pain. No shortness of breath, either. Just weakness and a little nausea without vomiting. He noticed it earlier this morning and though it bothered him, he let it go in hopes that it would resolve on its own. He had had a heart attack about three months ago and stents put in, but even still he remained doubtful that this was very much at all. "Probably just the heat," he said. And I agreed.

Nevertheless I thought I'd ride with him to the hospital instead of driving. Maybe he could use a little fluid I thought, or perhaps some medication to control his nausea and make him a little more comfortable. I hadn't teched a call all day and my own boredom probably played as much a role in this decision as any particular sign or symptom. What the hell, right?

The twelve-lead ECG was full of noise from the bumpy ride despite my best efforts, and there was a bundle branch block that further obscured the view. What I could see, though, were some ST depressions in the V5 and V6. They were maybe a two millimeters or so, and I had my doubts that they were much more than a reflection of all else that was wrong on that strip.

Besides, I have been down this road before. ST depressions in a few leads, inverted T waves, small elevations: they get scoffed at in the ED. Especially without a really good story, these minimal, inconclusive ECG changes often bring nothing more than eye rolls and a condescending pat on the back. "We'll look into it, good job." I've heard it many times before.

The hospital flipped out. The nurse's eyes widened when she saw my strip, pointing at the tiny ST depressions as if they were tombstones from the widowmaker itself. She rallied all her resources, worked the patient up and yelled for the doctor who came quick-stepping into the room as I shrank farther towards the corner. Right about this time the patient's family arrived at the patient's room. I had met them earlier at the patient's home and before I left I told them not to worry, that I would take care, and that they should drive safe. We left the driveway without lights or sirens, and I thought I had made a calming impression on the otherwise edgy and nervous relatives.

So much for that. They sensed the tension and the doctor wasn't helping. "The ECG does not look good at all," she said. "I don't like it one bit." The doctor explained the next few steps in quazi-technical jargon that whipped the family right up into a frothy frenzy, and in just a few minutes I wanted nothing more than to make a quiet escape to review the strips again for myself.

They looked the same as they had earlier. Just a few minimal changes. The same stuff that I've brought in plenty of times before and been disregarded and tossed aside. "Oh, that's cute," they'd infer. "Look how thorough the medic is trying to be." I squinted at the paper and looked as hard as my eyes and education could decipher. Nothing impressive. Not even close, really.

A little bit of experience has raised my index of suspicion for acute coronary syndrome to perhaps a ridiculous level. It seems when I print off twelve leads these days, the patient better have huge ST elevations and the most convincing story I've ever heard if I am going to truly consider ACS with any seriousness. T wave inversion? Hah. ST depression? Yeah right. Don't get me wrong, I'll pass the asprin and nitro out like I am supposed to, but as far as actually believing the patient? As far as being willing to present this to the ED as a heart attack? Not on your life. Doctors simply do not want to hear a paramedic's evaluation of the minute. Its cath lab or shut up about it.

But not this time.

1 comment:

Anonymous said...

Great post, I am almost 100% in agreement with you