We were sent way out of our primary area while the slackers who’s call it was slacked off under the guise of “restocking” their ambulance. Which coincidentally had to be done just before their shift change time. As the Church Lady would say “How convenient.” Sharp Cheddar if you’re asking what kind of cheese I’d like with my whine.
As it turned out, it was better that we went because the patient was sort of sick and needed good care.
On with the story.
The address was one familiar to the BLS crew because they go there every day. Literally. There is one apartment in this building, well one occupied apartment, and various BLS crews are in it every day. Seems like ALS rarely gets there because they are cancelled most of the time. In this case, we arrived just before the BLS crew who must have pushed their ambulance considering how much closer they were to the call than were we. Otherwise we wouldn’t have met out patient is my guess.
Even the fire fighters were rolling their eyes as we walked upstairs to the apartment. There on his bed was our patient. Mid 60s, with the emaciated look that only a person who loves alcohol more than food can have.
“What’s wrong today, sir?”, my partner asked.
“He always has chest pain.” one of the BLS crew informed us.
My partner went on to ask a series of questions about the pain including the inevitable “What did they tell you at the hospital?”. The answer was nothing because he had left without being treated because they wouldn’t let him smoke in the hospital. As if that’s a new rule or something.
“BP is 118/70, pulse is 130.” , from the EMT.
A bit fast. Plus he had the aforementioned more or less permanent chest pain which is why he calls 9-1-1. Which meant that some ECG monitoring was in order.
First the “Rhythm Strip”, which is the initial view we more or less always get.
Umm, yeah. Pulse of 130, not so much. I averaged this out to about 180, which is well into the range where we want to treat the rhythm, especially if the patient has chest pain with it. Rate related chest pain was our diagnosis, so Nitroglycerin was definitely not in order. Good thing we kind of ignored the BLS commentary that “He always has chest pain.”, and looked beyond the obvious.
Being diligent paramedics and since the patient had chest pain, we did a 12 Lead ECG.
Not much there.
We asked about his medications, but since he didn’t take any of them it didn’t matter a whole lot. No allergies, either. It appears that he mostly drank cheap beer and smoked cigarettes. Which would explain his appearance.
So, what to do? Actually, we knew what to do, but we had a choice of medications. Choosing which one would have been a lot easier if the patient took medications, but since he didn’t we decided to go with Diltiazem. Which has to be mixed and then given in a nice, slow, bolus. All of this takes a few minutes and we decided to move to the ambulance before continuing treatment since we could treat and transport simultaneously.
All of which was done in due course and without any excitement. Also, without any effect other than to slightly decrease the patient’s blood pressure. Still fast and the patient still had chest pain.
If anything, it’s a bit faster. So, more Diltiazem was in order. The second dose is always a bit higher than the first with this drug, so more drawing up of medications and slow injection into the IV line. We also gave him some baby aspirin to chew and swallow, just because.
There was a bit of improvement in the rate, but the chest pain and hypotension stayed.
We arrived at the hospital and my partner gave report. Or, he tried to in any case.
He started out like this,
“This is Bill, he’s 64 and says that he has chest pain -”
“Did you give him nitro?”, the first genius medical resident asked.
“No, can I continue?” answered my partner. More patiently than I might have.
“Bill is non compliant with his medications, so he’s not taking anyt-”
“Did you give him nitro?”, another resident asked.
“Uh, no, as I said. His vital signs are BP 110/p, Heart rate of 180, respiratory rate of 20. His BP was higher in the field initially, but we’ve given him two doses of Diltiazem and four baby aspirin.”
“Did you give him nitro?”, someone else asked. Apparently listening is not something that is taught in medical school these days.
At which point I answered no, we don’t give nitroglycerin to people in atrial fibrillation who are hypotensive, we give medications to correct the dysrhythmia.
“Sir, have you ever had nitroglycerin for your chest pain?”
Like talking to a fucking wall.
I hate July.
Fortunately the nurse, well experienced, demurred when the resident ordered nitroglycerin. The resident backed down and they still hadn’t given any when we left.
In any event, the hospital didn’t kill him because units were sent to his address yet again this morning.