Dave, guru of EMSBlogs tells me that readers like posts with lots of ECG strips. Being a ratings whore as I am, I’ve been trying to find lots of nice strips and interesting calls to go with them. The problem is that we often spend most of our shift chasing the output of the Fictions Writers of America, I mean highly trained call takers. Who have given up their dart board of triage and now often just randomly enter stuff to make our lives more interesting.
Still, like the proverbial blind hog, every once in a while they do find an acorn. To paraphrase David Frye in I Am The President, “Well, you can’t lose them all.”
Back to our story.
Dispatched in the wee hours of the morning for a women in her mid 50s with chest pain. We get a fair number of calls like this and most of the time it turns out to be nothing like what we were told. Besides, as I’ve said before women generally don’t present with typical chest pain symptoms. I’m a highly trained EMS professional so I know what I’m talking about, trust me.
We’re dispatched, the fire is dispatched, a BLS ambulance is dispatched. The BLS ambulance is right around the corner, literally, from the call and beats the fire in. Pretty good response time and by rights we should get an update, but more and more that’s happening less and less. In fact the only update we get is to come in via a particular street. Which we do and pull up behind the BLS rig. The fire engine is cruising off down the street and we wave as they pass by. Generally that’s a good sign because it means that no CPR is being done. Or maybe just that the allure of EMS has worn off for most of the fire fighters who actually work on apparatus. What ever.
We grab our life saving equipment and head upstairs (it’s always upstairs) and find the BLS crew treating the patient. Who looked very ill indeed. The patient’s lack of English made the details vague, but even I understood “Dolor en el pecho”, “Ai, Ai, Ai”, and “Hospital por favor”. The EMTs reported that the patient had vomited when they first got there, which was why she was on a nasal cannula and not a mask. Not that I’m a big fan of masks, but OK. “I can’t get a radial pulse or blood pressure.”. My partner was skeptical of this, which for some reason he always is. “She’s got a radial pulse.” he opined. “Not on this side.”, I countered, “Nor a brachial.” We decided that lying the patient on her couch just might be a good idea. Lying her down didn’t help her pain, but it did produce a blood pressure. Of 80.
I should mention that the patient had a very unhealthy pallor, cool skin, and was diaphoretic. Day three of EMT school back when EMTs still learned such things, this was taught to me as cardiogenic shock. Of course there were other possibilities, but they weren’t plausibilities.
Now that we had the BLS part of the call pretty much in hand we decided that maybe some ALS type activity was in order. The patient wasn’t really all that enthusiastic because she just wanted to go to the hospital. All well and good, because we wanted her to go to, the only difference being we’d really like to have her get their alive. Much better for the stats, you know.
We attached the monitor leads and powered up the machine and were rewarded with this visage.
Oooo. Not good. Keep in mind that this is a “rhythm strip” and often the diagnostic mode 12 lead shows different, usually less ST segment elevation. Sure, it does, Pollyanna, sure it does.
So, on went the chest leads for the full diagnostic ECG.
You’ll notice that the ever helpful interpretation says definitive things like “Abnormal ECG Unconfirmed” and “ACUTE MI SUSPECTED” and helpfully suggests that we consider injury or infarct. Thanks for using your highly trained computer algorithm to tell me that. Why even most residents could figure that one out. Somehow I have feeling that lawyers were involved in that decision.
Using my finest medical terminology I said, “Holy crap.”, and handed the strip to my partner. He said pretty much the same thing, only being more erudite than I it came out as, “I better call the hospital right now and give them plenty of notice.” If we transmitted ECGs, they would probably have said “Holy crap.”
My partner went out into the hallway to call the hospital while I started the IV. Since the patients lungs were clear the plan was fluid resuscitation, followed by Fentanyl for the pain if we could get enough blood pressure. Once the IV was in place, the patient went on to our ever versatile scoop stretcher, was strapped thereto, and then brought down the stairs head first.
Down in the ambulance things didn’t seem to have improved, so we redid her BP, which was now 90. Good enough for some Fentanyl, so she got 50mcg, which didn’t seem to help her.
Off we started for the nearest cath lab equipped hospital, hoping that their on call staff was coming in to treat this patient.
Time for another 12 lead ECG. You’ll note that these aren’t in exact order. We had a lot of trouble getting the electrodes to stick to her slimy (really) skin so we had to do a lot of ECGs to get useable ones.
Not a great tracing, but it certainly is quite graphic.
The Fentanyl wasn’t helping the pain, but it was making the patient sleepy. Which is an odd combination, but there you have it. Her color continued to get crappier, which I wasn’t sure was possible. Here O2 sat started to drop, and her ETCO2 was below 20. Shit. Double shit. On went a non rebreather, which improved her numbers if not her color.
Now that we had time to actually breath and think, a 12 lead with a V4R seemed like a really good idea. It wouldn’t really do much other than scare us more, but it was a good idea.
The more I look at these strips in the light of day and some sleep, the more verklempt I get. As worried as I was that the patient was going to die right in front of us, I’m now amazed that she didn’t. Holy crap, was this lady sick or what?
My partner didn’t think that V4R looked bad, but I pointed out that it was a craptastic quality print out and even through that V4R looked bad. So, we did it again and he was amazed (as he perpetually is) that I was right. He should know by now not to doubt me. After all I’m a trained professional and have been doing this for several years more than he has. OK, it was a lucky hunch.
Here is another, better quality, tracing.
Better quality maybe, but not more reassuring at all. In fact, it looks worse. That thing that looks like a PVC isn’t, it’s an aberrantly conducted sinus beat. Wonderful, just f**king wonderful. Did I mention that I really thought that this lady might die on us?
Her blood pressure was good enough that we could give more Fentanyl. She might as well be comfortable. I wished that I was comfortable, but I was almost as diaphoretic as the patient.
It seemed like the EMT driving us had forgotten to start the engine and was pushing the ambulance to the hospital, but I’m pretty sure that she was actually driving. It just seemed to take a long time to get to the hospital.
We arrived in due course and she was rolled into a resuscitation room where the staff swarmed around her and started to prep her for the cath lab. Which of course wasn’t ready because the staff had to come in from home and get everything warmed up and ready.
In time she went off for her adventure in the cardiac cath lab and we went off to bail out a BLS crew that didn’t seem to understand that the post surgery patient that they were dispatched was displaying normal side effects from his Percocet and Oxycodone medications and really didn’t need ALS. Which is why we didn’t hang around the hospital to find out what happened in the cath lab. Not that the findings would be all that surprising to us. What I really wanted to know was if the patient lived through the night.
I have my doubts, but I can hope.
Being a rather slow nozzlenut, with no EMS certs to my name, I still find these posts interesting. Rhythm strips I can tell the difference between “bad” and “not bad”, and I even looked at that one and said, “Ooh! STEMI!”
Reminds me of a call I went on a few years back – driver/bag lugger in the EMS truck. 50s male with chest pain, history same.
We arrived and found this guy tripoded in a kitchen chair, ash-grey, dripping sweat, and unable to speak in complete sentences. EMT looked at him, tried to reach the ambulance to expedite. Portable wouldn’t reach. Sent me out to try the mobile; I came out just as they came around the corner. They backed in, said, “what do we need?” … “Everything.”
I helped them lug in their gear, and stood out of the way as they hooked up an ECG. The medic was putting on stickers while I had a clear look at the screen … and he turned around as my eyes got big. He looked at it, and the first words out of his mouth were, “Oh. Shit.” Grabbed his radio, didn’t work. Looked at me and said, “Go outside, call my base, and tell them I want the fly car NOW.”
So I did. And their base argued with me, because the fly car was on another call already. I suggested that their medic told me he wanted another medic ASAP, and didn’t really care where it came from – so they sent another full bus.
I went back inside in time to hear the patient trying to explain (three words at a time) that he had no interest in that damn hospital and he wasn’t going anywhere. The ensuing conversation involved sentences like, “You will die. Not maybe, not sometime in the future, today. You. Will. Die.”
He ended up going, and if memory serves, died later that week.
I wouldn’t have read this post if it didn’t have the strips.
Ha Ha
Excellent stories. Nice to have a preview of what it will be like when the cigarettes and booze finally catch up to me. Keep it coming.
The Fentanyl wasn’t helping the pain, but it was making the patient sleepy. Which is an odd combination, but there you have it.
That’s actually exactly how my sole experience with Fentanyl went. (Nothing emergency related; it was given to me in childbirth.) Made me pretty grumpy.
I just don’t think we gave enough or that you got enough. My experience with giving Fentanyl is that it takes more than the dosing guidelines suggest to get effective pain relief. A couple of years ago we had a burn patient that took a full 250 mcg before he got enough pain relief to stop screaming. He was fully awake and told me that he still felt pain, but that it was tolerable.
Fentanyl is weight based and a tolerance based narcotic, not to mention its primary function besides analgesia is sedation. Our protocols say 1-3 mcg/kg including re-dosing, just the other day I gave 300 mcg in two doses to a 510 lb patient that fell out of his wheel chair onto cement and literally hurt everything. It helped somewhat with the pain and maybe made him drowsy for less than 5 minutes.
I’m curious as to why though the author was so focused on fentanyl, and though fentanyl might negligibly decrease blood pressure just through relaxation hypotension isn’t a contraindication for it. Morphine has a contraindication of hypotension because it specifically vasodilates and reduces pre-load, which is why it’s also indicated for STEMI treatment over fentanyl to try and open up the blockage to re-oxygenate the myocardium past it. But neither of those are gonna save someone’s life like 324 mg of ASA and 0.4 mg nitro if you can get the BP at least to the 90-100 systolic range if it’s not already there. I think it was even the American Heart Association that coined the term “MONA” for treatment of STEMI’s (Morphine, oxygen if Sa02 <95%, nitro, aspirin – by no means in that order though).
We don’t carry Morphine any longer, so it’s not possible to give it. The theory about pre load with Morphine seems to have fallen out of favor, because it’s now given only for pain management. At which Fentanyl is better. The patient got ASA before we arrived, which I might not have mentioned in the post. SL NTG isn’t going to help the patient as much as the Fentanyl since the NTG isn’t going to help cardiac perfusion. In fact, I’ve never seen SL NTG help in a STEMI.
Her BP remained stubbornly around 80, so NTG was definitely out. More fluid was in, but we were at the hospital by that time.
I think that in general we underdose when we use pain meds. That’s a result of timid protocols from timid doctors and a lot of old mythology about patients going into respiratory arrest. That’s another good reason to use ETCO2 in this type of patient. I don’t think respiratory arrest is the potential issue, but respiratory insufficiency is.
In our area we’ve actually had a big push in Fentanyl for pain management due to our MPD being a big proponent of it. In terms of just effects alone from people who have had both Fentanyl and morphine we’ve talked to, they all stated something along the lines of with morphine they still had the pain but morphine just essentially made them care less about the pain, however fentanyl actually worked to both get rid of the pain and make them care less.
In our experience our vials are 100 mcg and if you’re going to give Fentanyl just give the whole vial of 100 or else it really won’t help much, and possibly even more if they’re heavier, and don’t be afraid to re-dose another 100 even in normal sized patients. It shouldn’t have much of a negative effect on BP if any, but may make them drowsy as you’ve noticed as it is also a sedative that some neighboring agencies even use to RSI. In the 510 lb pt I stated above we gave a first dose of 200 mcg, and a second a couple minutes later of an additional 100 mcg as we tried to move him. It helped somewhat, but we could have even gave more.
Just remember when giving an IV bolus to push over about 60 seconds or else you can have the possibility of an occurrence of “Frozen Chest Syndrome”. Essentially the actual muscles in their chest become rigid and unable to move, meaning they can’t even be ventilated. We’ve had one reported case of that locally that lasted about 30 seconds, and the biggest thing is just talking the pt through it because in theory even if it happens it shouldn’t last long. Besides this one occurrence which in theory can be avoided by pushing slower, we’ve had nothing but good things with fentanyl and between us and the neighboring cities we use a lot of it.
As far as for STEMI’s though the main goal is obviously to re-perfuse the muscles of the heart, since the lack of oxygen is causing both the CP and killing muscle tissue. ASA is the single best thing you can give to help dissolve the offending blood clot assuming that the blockage is in fact a blood clot. Besides that the next best defense is vaso-dilators to attempt dilate the vessels of the heart to allow blood past the blockage to re-profuse again. Even though arteries are thicker, more muscular, and harder to dilate; they absolutely will dilate as well. Morphine and nitro are both vasodilators, and this is exactly the reason nitro is prescribed to people with angina. You get cardiac chest pain because tissue is becoming ischemic from lack of oxygen, and nitro dilates the vessels and helps re-profuse by allowing more blood to flow past the partial or total blockage. In time vs benefit we usually focus more on nitro around here in lieu of morphine unless it’s an extended transport with time for both. Obviously with your patient either of those would have been a risk in dropping the blood pressure even more, but both just “require” a minimum of a 90 systolic.
So while Fentanyl might help with pain and relax them somewhat, I don’t know of any actual beneficial effects fentanyl would have for re-profusing heart tissue during an AMI. However from what we practice and also from our latest AHA ACLS classes; aspirin, nitro, oxygen, and morphine on a physiology level do work to actual lessen the damage done during an AMI. The longer the tissue goes without oxygen the more irreversible damage is done. This also just my 2 cents for the record so of course take it for what it’s worth and come to your own conclusion from your research and experience, because we all know the “right” treatment seems to change every new ACLS class!
A couple of points. ASA doesn’t dissolve clots, it prevents agglutination of platelets and thus stops the process.
MS is out in our system for a couple of reasons that I won’t bore you with. There isn’t any hard proof that MS reduces preload or vasodilates, which is why it’s no longer used in CHF. NTG promotes peripheral vasodilation, but even if were to dilate the coronary arteries in STEMI, all that would seem to do is allow the clot to move further into the coronary arteries.
Read the current guidelines for ACS, which includes, but is not limited to STEMI. NTG is to promote coronary artery in chest pain suggestive of ACS. This includes angina (and equivalents). MS is given if NTG fails, but it is given for pain relief, which is why we give Fentanyl. In a patient such as ours, the last thing you’d want to do is drop BP or reduce preload. We’re giving fluid to increase preload because we are dealing with pump failure. To add tank problems would only make the patient worse. That’s the same reason we didn’t give NTG. In fact, I’d probably skip NTG totally in the face of confirmed STEMI since it won’t help. Our protocol still calls for NTG x 3, but frankly I think that’s a hold over from the days when we couldn’t do 12 leads in the field and thus NTG was a trial drug to differentiate between Angina and MI.
Again, if you look at the current guidelines MONA comes BEFORE 12 lead interpretation. After the confirmation of STEMI, provided the symptoms have persisted for less than 12 hours, the treatment is PCI or fibrinolysis.
I think your ACLS instructor needs to update his thinking on why we use NTG and Morphine.
Nicely put (and classy) summary, TOTW. A while ago I browsed the literature trying to find the evidence supporting a mortality benefit for nitro in AMI; mostly it shows no benefit or perhaps a very slight boost. I mostly consider it pain management nowadays.
Excellent case and good ECG to teach “the rule of proportionality”. Any amount of ST-elevation is significant when the QRS complex is less than 5 mm! That’s an important thing to keep in mind with modified leads like V4R and V7-V9. Thanks for sharing you ratings whore you!
Anything for a few more hits, even a picture of a train wreck!
Other than that general rule, as far as V4R specifically I just try to remember that the right heart is small potatoes relatively speaking, so expect everything to be littler….
Except the effects of loss of preload, which in this case were pretty large.
It seems I have seen a hundred inferior STEMIs yet it never gets old seeing a strip like that. I am not sure what this says about me. The manner in which you described the patient is so classic. Great post!
The funny thing is that I know some medics that have taken in EKGs like these, albeit without the craptastic looking patients, and told the charge nurses that the patient had “non-cardiac chest pains.” Fortunately, we now have the technology to transmit the EKGs to the ED & all but one of our hospitals have PCI capabilities. Just by the presentation of the patient & the 1st EKG, I expected to see STE on V4R. Great case, I’d be interested to hear how she turned out.
Sending strips is no substitute for paramedics who know what they are doing. If the paramedics don’t bother to send a strip, then it’s no different than if they read the strip and don’t recognize or care what’s going on. If they don’t recognize a STEMI and thus just saunter into the ER and tell the nurse it’s just chest pain, then they aren’t doing the patient any good. If they don’t bother to do the ECG in the first place, then maybe they should consider a rewarding career in the fast food industry. Since I don’t eat that crap any longer, they can’t even ruin my meal.
No arguments. Unfortunately, my system has dropped the ball when it comes to educating & training medics. I quickly found that out as a new medics intern & had to adjust quickly & learn what they felt we would “learn in the field,” 12-leads being the biggest thorn in my side. The EMS Duty officers have told me about some of these incidents & I’ve witnessed other medics firsthand doing things backwards. I’m not perfect, but its annoying to be the new guy that “doesn’t know jack” watch other medics push me aside & screw up.
Of course it’s not just EMS. I’ve seen doctors and nurses follow ACLS guidelines that were one or even two generations old. Still, if we want to fancy ourselves professionals we have a responsibility to stay current on the protocols and trends in pre hospital care.
Good read and loved the strips. Did y’all consider dopamine for the cardiogenic shock and morphine instead of fentanyl once you got a decent pressure?
As noted no Morphine. As to Dopamine, I’m think it would be more likely to harm than help. I rather think it might spread the infarct and not even increase the pressure. No, fluid and Fentanyl are the things that were indicated here. Since our transport times are short, we’re not overly adventurous in most cases. I don’t know what the hospital hung before she went to the cath lab, so I don’t know if they gave a pressor or not. The definitive care for her would be the cath lab and either stents or an emergent CABG. Or maybe stents until she’s stable enough for a CABG.
How about some Asa, Plavix, and heparin? This would have been more beneficial to the patient.. Just sayin
I don’t know about your system, but we have neither Plavix nor Heparin. ASA was given by the BLS crew.
Thanks for sharing ems stories and the 12 leed , i am a fairly new medic and really enjoy and llearn alot from these stories . Keep up the good work. Mike