We were dispatched to an unfamiliar address for an elderly man complaining of chest pain. Unfamiliar in the sense that it wasn’t one of the many elderly housing complexes that we seem to spend much of our shift in, it was in fact a three story multi family house, known in these parts as a “Three Decker”. Only unlike real Three Deckers, this one was made of brick, which makes it a townhouse. Got that?
None of it matters because the patient met us in the front lobby, after which he turned around and sat down on the stairs.
“What’s the problem, sir?”
“My chest hurts.”
From there I proceeded to ask him the rest of the questions that we use to try to get an idea of what’s going on.
His story was that he had been in bed not sleeping and had a sudden onset of chest pain in the middle of his sternum, without radiation, without shortness of breath, but with diaphoresis. All of which, along with is crappy appearance, lead us to put the ECG machine on right there in the lobby. That’s odd, but not that odd. The patient didn’t want us to go up to his apartment to get him anything, which was also odd as usually they want keys, shoes, something from the apartment. No, he’d prefer it if no one went up to his apartment. That was odd, but again, not that odd.
Well, this was not encouraging, but the 12 Lead is the proof we need because a rhythm strip is not considered diagnostic. In this case, it came close, but still no cigar.
Ooo. Not good. Diagnostic, but not good. Folks, this is not an ECG you want to have. 100/60 is not a blood pressure you want to have if you do have an ECG like this. That gave us no working room for Nitroglycerin, so that was out of the mix. An IV and fluid were certainly in the mix as long as the patient didn’t have fluid in his lungs, which fortunately for him he didn’t.
Out to the ambulance where my partner started an IV and gave some fluid while I broke out the Fentanyl. The patient was complaining of a lot of pain and I couldn’t blame him one bit. He was having a pretty significant cardiac event and it and it hurt like hell.
In the meantime my partner did another 12 Lead ECG with a right sided chest lead. We were looking for, but hoping not to find, was evidence of a Right Ventricular Infarct.
No such luck. Our patient was having a really bad morning. The problem, for my non medical readers is that a Right Ventricular Infarct (RVI) impedes the hearts ability to pump blood into itself and since output is dependent on input, blood pressure drops. It’s what we call a “pump” problem. Generally the two ways to fix this are to correct the pump problem or assist the pump by putting in more fluid. Since neither of us are cardiologists, we can’t fix the pump, so we opted to put in more fluid. Which isn’t without it’s own risks, but is better than the alternative.
I called the hospital ahead of time so they could wake up their cath lab team and have them start in to get the equipment ready. The longer a heart attack goes on, the worse it gets, so getting to a cath lab fast is important.
While we were transporting I asked a few more questions of the patient. The first of which was if his pain was any better. It wasn’t so we gave more Fentanyl, which helped a bit. The other question is one that normally we ask early on, but since we weren’t giving Nitroglycerin it wasn’t a priority.
“Sir, do you ever take Viagra or other similar drugs?”
“Did you take any within the last 24 hours?”
Suddenly, meeting us in the lobby and not wanting us to go up stairs to his apartment fell into perspective. This elderly gentleman had been entertaining someone in his apartment. Which was nothing to be ashamed of. In fact, if I make it to his age, I hope to be able to entertain a lady in MY apartment.
I hope he does well, but as with most of my patients, I’ll probably never know.