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.