If you havenít been to www.EMS12Lead.com, Tom Bouthilletís wonderful EMS educational blogÖ well then Iím going to just come out and say this:
What are you doing here when you should be over there reading his stuff??
Considering how Tom dwarfs my humble traffic numbers (which is something I always kind of knew he did, but didnít really know how much until I had a few drinks with him at EMS Today and weaseled his numbers out of him) Iíve figured that Iím going to have to do something. Iím going to straight up steal his shtick and write an ďeducationalĒ EMS 12-lead EKG post of my very own for your reading enjoyment and educational purposes. Heck, I might even be able to make a point or two. Letís find out.
I keep an archive of interesting tidbits from my EMS career locked up in a vault in my basement and among the oddities and whatnot I have a binder full of 12-leads. I blew the dust off of the old tome and pulled the EKG that Iím using for this story out of the archives. Oh my, this was a doozy. As always with my stories about patients, I may not have ran this one myself and even if I did, I donít remember where it was that I ran it nor do I remember the age, location, or even the gender of the patient in question. I also have taken the liberty of lying about all of that stuff just to make it even more confusing and difficult for me to write. So, if you think Iím violating the female Hippo, youíre mistaken.
As I recall, the call was toned out with the dispatch information of a ď64yo M Pt unable to breatheĒ. It wasnít a long distance away and Our Intrepid Paramedic (OIP) responded in a response vehicle being followed up by an ambulance which arrived shortly after He did. It was a nice, well kept residence and the wife of the Pt let OIP in the door as he entered the home. She indicated that the Pt was in a back bedroom of the house and motioned down the hallway. OIP made the trek and found the Pt sitting upright on his bed, Conscious, Alert, and Oriented times 3 (CAOx3) with somewhat increased work of breathing. The patient stated that he had been experiencing pain that he indicated began at the level of his mandible and continued to his epigastrum (his Jaw to his Gut). He stated that the pain had simply become too much for him this evening and that it became very hard to breathe when he laid down for bed. A good look at him was all it really took for OIP to make a working diagnosis after feeling the patentís weak and irregular radial pulse and pale, cool, and moist skin. OIP placed the patient on 6-LPM oxygen via Nasal Cannula and told the ambulance medic to break out a 12-lead. The initial rhythm strip showed a sinus bradycardia with an IVCD and lots of multifocal ectopy, including multifocal couplets and triplets. The 12-lead was no better. It showed bad, bad mojo. This poor guy was sick.
As the ambulance crew was packaging up on the stretcher to take the Patient to the ambulance, OIP had a few moments to speak with the patientís wife. She told OIP that the patient had been experiencing pain in his jaw for the last week. She also told OIP that the patient had gone to see his Primary Care physician two days prior and had been told to take advil for the pain in his jaw. She told OIP about how the patient had been very lethargic lately and about how he would become winded when taking out the garbage and walking even shorter distances. She told OIP about how the pain had been getting steadily worseÖ and also how the doctor said he was fine.
And with a symptom profile of exertional fatigue, difficult breathing, jaw pain,† substernal chest pain, and diaphoresisÖ what doctor wouldnít say thatÖ right? Oh waitÖ hopefully most of them.
The patient wasnít having a heart attackÖ he had been having a heart attack for days and now the damage had been done. This was a clear case of the patient not being educated to the symptoms of a heart attackÖ or of ignoring them in the hopes that theyíd just go away. The physician did not obtain a 12-lead nor do lab work and did not diagnose the problem as being cardiac ischemia (Heart attack) when the patient presented for care.
But OIP didÖ about 2 minutes after meeting the patient he woke up the cardiologist and the cath lab team at a hospital a half-hourís drive away to help take care of the man. Youíve seen the 12-lead above. It indicates a heart that is in serious trouble. The patient was treated per protocol, which included high-flow o2, bilateral IVs, NTG tablets and paste, and Iím not sure what else the ambulance paramedic did because OIP didnít accompany the patient to the hospital. That,† and it was too long ago for me to remember what happenedÖ I just know the patient made it there alive to find out whatever his prognosis was going to be from the cardiology team at the ER.
Hereís the deal, once this patient called the ambulance, his care was stellar. OIP and the other EMTs did a fantastic job at rapid recognition, appropriate stabilizing care, and swift transport to an appropriate care facility as none of the local hospitals had the capacity to care for this guy. The EMS people did what they were trained, equipped, and supposed to do. The problem is they were called way too late to make much of a difference in the patientís continuing quality of life.
I can understand that patients donít necessarily know when theyíre having a heart attack. To a layperson, jaw pain and fatigue could just be the flu. Chest pain could just be heartburn, and exertional dyspnea could just mean that a person has been ďpushing themselves too hard latelyĒ. All of those symptom profiles could mean any number of thingsÖ but they could also be a heart attack. I can understand how people want to think that theyíre not having a heart attack. I get that no one wants to have one. Theyíre not fun and we as a society may hype them up too much so that people think there is a stigma to the diagnosis. I donít know if that statement is true, but it sure seems that way sometimes to me.
What I canít understand is how a patient can present for treatment at a physicianís office with clear symptoms of cardiac ischemia (heart attack) and not be checked for it. Iíd like to think that a paramedic would rule it out first and foremostÖ and I donít understand why someone wouldnít.
Then again, I donít know the information the physician was working with. Perhaps the patient wasnít honest with his symptoms and tried to minimize what was going on. Thatís possible too, as this patient was a proud man who has lived his life like he could handle anything. People do that. Nobody wants to be sick.
The lesson here is to have a high index of suspicion. Patients sometimes minimize their symptoms, and sometimes they over-dramatize them. Some people donít want to be sickÖ and some people want to be sicker than they are. I personally will buy into false drama from someone whoís not as sick as they want to be than chance missing the minimized symptoms of someone whoís sicker. I tell my patients that as a paramedic my job is to ďTreat for the Worst, and hope for the best.Ē
But for this guy, OIP never got the chance. This was too late for that. The damage had been done.
This patientís quality of life was greatly impacted by the fact that he didnít call 911 at the first signs of his illness. Had he done so, his prognosis would be much different. A quick exam, 12-lead, and appropriate care would have made this guyís story quite a bit different. Where was the failure? Was it the patientís fault for not recognizing and/or minimizing his symptoms? Was it the fault of ďhealth educationĒ in general for not reaching the patient in a manner in which he could understand? Does the fault lie with OIP for not spending enough time educating the public about the symptoms and danger of heart attacks? Does the fault lie with this patientís doctor for missing the diagnosis and/or not providing proper education beforehand?
I donít know the answer to the above question either. I just know that OIP and the EMS team treated him well once the call came in. I just wish that something different would have happened in the chance of events that lead up to all of this. It would have made the above 12-lead a lot different.
Be vigilant out there.