We were dispatched for a generic “Cardiac Problem” call. As in the 9-1-1 operator just picked the first likely complaint off of the Wheel of Misfortune that passes for our phone triage system and sent ALS. Which I guess puts us up one on Sweden, sort of.
The call was just minutes, like two, from our station and we beat both the fire department and the BLS ambulance to the call. My partner rang the door bell, but nothing happened. As in no one buzzed us in and there was no intercom so no one asked who was ringing their door bell in the middle of the night. We called dispatch and asked for a call back to confirm the address and make sure we could get in. Before they could do that a lot came on in the stair well and we saw a person roughly the age of our patient making his way down the stairs. Which was made difficult by the arm full of clothes he was carrying and one of his underlying which made walking difficult. We saw the clothes, but didn’t know about his history at this point.
The man, who turned out to be the patient, opened the door and walked out to meet us. I had already gone back to the ambulance to get our stretcher and he continued the three or four steps down so he could get onto it. Nothing like a cooperative patient, I always say. We put him in the back of the ambulance and started interviewing him.
“What’s going on this morning, sir?”
“I missed my last dialysis appointment, I’m due this morning, and I feel bad.”
“Are you having chest pain?”
“No sir.”
“Trouble breathing?”
“No, I just feel bad.
No chest pain, no trouble breathing, needs emergency dialysis. OK, got it. A check of the vital signs revealed a pulse of 78, a BP of 120/P, respiratory rate of about 20. A quick 12 Lead ECG was in order to rule out anything else and then off to the hospital for dialysis. If only it were so easy, but it never is, the EMS gods won’t allow it to be so easy.
Well, that didn’t look too bad, other than the prolonged QT interval. Still, with dialysis patients Potassium levels are a concern, especially if they have missed a session. Which of course our patient had. So, on to the 12 Lead ECG.
This of course is why we do 12 Lead ECGs. Not visible at all in the limb leads, but clearly visible in the chest leads were those extremely peaked T waves. That’s a sure sign of Hyperkalemia, which can go from serious to fatal in relatively short time. It certainly explained why the patient “felt bad”. What it didn’t explain was how he was compensating so well, well enough to walk down a flight of stairs.
“I think we’ll have to treat that.”, I commented to my partner. “Yes, we will.”, was his reply.
So, we replaced the nasal cannula with a little Oxygen with an Albuterol nebulizer with as much Albuterol as we could fit into the little cup as possible.
Then my partner started an IV, amazingly finding a vein that he could use. Amazing because this patient had used his veins for a lot of things over his 50 odd years and had pretty much worn them out. While he was doing that, I drew up some Calcium and Sodium Bicarbonate so we could inject those. The goal of these treatments is to bind the Potassium or counter it’s effects on the heart. It’s all just temporizing because the definitive treatment is the aforementioned dialysis.
All was going well, all things considered, when the patient decided he wasn’t sick enough already. So, he started to have chest pain. Which was really concerning, all things considered. Another 12 lead was in order, to make sure he wasn’t also having a MI in addition to everything else. Well, Aspirin and Nitroglycerin were in order as well, since we wanted to treat his chest pain.
No real difference between the first and the third. The second was also the same, so I didn’t include it here. What’s interesting to note here is that while the prolonged QT interval is there, the algorithm the monitor is built around doesn’t note it. Nor does it note the peaked T waves, because it’s not programmed to do that either. It does seem to be programmed to hedge it’s bets by addding “Cannot rule out ________ Infact, Age age undetermined”, because it seems like just about every 12 lead print out has that. Which is why the interpretations are sometimes helpful, but certainly not a replacement for a well educated paramedic. Despite what some medical directors might think. I could go all Rogue Medic on lazy medical directors, but he’s done the heavy lifting on that, so go read his blog if you want to know his (and my) opinion.
Back to our patient. The Calcium and Bicarb were administered, the Albuterol was hissing away, the aspirin was chewed and swalloed, and the Nitroglycerin was sprayed under his tongue. None of which seemed to be helping the patient.
Time to get on the radio and call the ER do let them know we were coming in with a patient who was much sicker than he looked. Fortunately for him, he goes to one of the better hospitals in the area. I called on the radio and one of the nurses (I presumed) answered the radio. I proceeded to give the report and asked the nurse if she copied all of it and had any questions. My answer was silence. Class? Class? Anyone? Bueller? So I called back and got… no answer. I looked at my partner and said, “I guess we’ll just surprise them.”. At which point a different voice, one that I recognized answered and told me that they would be expecting us.
Which they were.
So, we moved the patient into one of their handy dandy resuscitation rooms and I started to give my report. At which point I remembered it was July. You know what happens in July, right? Medical school graduates who can now write “MD” after their name are unleashed on an unsuspecting public. So, I slowed down my report to make things really clear. At least I thought that they were really clear, I hope that they were really clear, because this was no time for confusion on the part of the people who are going to continue treating this man. They seemed to have a good handle on what I told them, so I left him in their care and went off to write my report.
Probably the best part of this call was that he made it down those stairs. It very easily could have been that he’d lose consciousness or go into cardiac arrest while trying to make that trip. That would have been a disaster.
