Changing Cardiac Care – Being Suspicious

Want another reason to lug the EKG machine out of the ambulance on your next call? A study recently published in the Journal of the American Medical Association and reported on by many national news outlets has found some information that may change EMS care.

From CBSnews.com:

“The study looked at 1.4 million patients who had experienced a heart attack between 1994 and 2006 to investigate the relationship between age and gender and heart attacks, specifically symptoms and death rates. Data revealed that 14.6 percent of women hospitalized with a heart attack died, compared with 10.3 percent of men.

Women were also much more likely to have a heart attack without any chest pain – 42 percent, compared with 30.7 percent of men.”

http://www.cbsnews.com/8301-504763_162-57382624-10391704/heart-attacks-in-women-greater-death-risk-fewer-feel-chest-pain/

Think about how the media represents heart attack symptoms to the public and about how we educate the public to recognize heart attack symptoms. Think about how even our EMS training has prepared us to recognize the signs and symptoms of a heart attack. We all pretty much look for the same thing, chest pain or pressure with radiation down the left arm. However, this study shows that a staggering 42% of women don’t have that symptom and that 30.7% of men don’t either. It tells us that nearly half of the patients who have this deadly condition don’t present with the symptoms we’re classically trained to recognize.

The study’s other finding that more men than women who had myocardial infarctions died after having the condition help illustrate another point: When looking for heart attacks, we all tend to assess everyone like they’re a 45 year-old white male. It is important to remember that age, gender, ethnicity, and culture play a role in how symptoms present. Comorbid conditions such as diabetes can change the way a heart attack presents as well.

This study helps confirm what we pretty much all know, that no two heart attacks are alike. When the heart doesn’t get blood flow to a part of it, it doesn’t work well, and it sends signals to our bodies that we may misinterpret. The classic “Chest Pain” symptom of a heart attack may well present as Jaw Pain, arm pain, weakness, diaphoresis, back or abdominal pain, or even making the patient feel like they have to burp. Unexplained fatigue with exertion, the inability to lie flat, or even dizziness and/or fainting may point to a heart attack.

EMS plays an extremely important role in cardiac care. It could be one of the biggest areas where the appropriate field assessment, working diagnosis, treatment, and transport decisions made by EMS improve the quality of life for the population as a whole. The proper assessment and working diagnosis by EMS can set the patient on the proper path through the healthcare system and make a huge difference in their quality of life.

What does this mean for your care today? It means that should you suspect that a patient has a possibility of having cardiac ischemia or is otherwise presenting with a cluster of symptoms you can’t pin down you should try to perform a 12-lead EKG with your first set of vital signs. While delaying treatment to perform a 12-lead is not anyone’s goal, emerging evidence is suggesting that significant ST elevation can normalize within as little as 4 minutes of common EMS care, including just the placement of a patient on oxygen. If we capture a symptomatic 12-lead at the point where the patient’s symptoms are most acute we can properly make the diagnosis and save the patient precious minutes, hours, and days of diagnostics to pin down the cause. Serial 12-leads, taking multiple 12-lead EKGs at various time intervals can prove beneficial as well. Remember that one 12-lead is a reference, two are a trend.

Gathering the best information we can on all patients in order to help guide their treatment through the healthcare system is one of the most powerful benefits of EMS care. Let’s help all of our patients get the care they need.

  • Danny

    Our local hospital has been doing a bunch of public service announcements about heart attack symptoms, including handing out refrigerator magnets with the following information, in an attempt to redefine the public’s awareness of how heart attacks actually present: †”1. Symptoms can occur in the center of the chest from the bottom of the ribs to the neck, and may also involve the throat, arms, jaw, and back. 2. The sensation can feel like pressure, heaviness, burning (similar to indigestion), an ache, or a feeling of tightness. 3. Patients often describe these symptoms as discomfort, rather than severe pain. 4. The symptoms don’t go away, they are constant. 5. The symptoms may be accompanied by shortness of breath, nausea, vomiting, and sweating.”

  • Too Old To Work

    Think about how the media represents heart attack symptoms to the public
    and†about how we educate the public to recognize heart attack symptoms.
    Think about how even our EMS training has prepared us to recognize the
    signs and symptoms of a heart attack. We all pretty much look for the
    same thing, chest pain or pressure with radiation down the left arm.
    However, this study shows that a staggering 42% of women donít have that
    symptom and that 30.7% of men donít either. It tells us that nearly
    half of the patients who have this deadly condition donít present with
    the symptoms weíre classically trained to recognize.

    I think that it’s more negligent that EMS does a bad job of educating us to recognize non classic signs and symptoms than that the media does a bad job of teaching the public to recognize non classic signs and symptoms.

    EMS education is mired in the easy to teach “classic” signs and symptoms, even though medicine in general has advanced over the past 20 or so years. It takes a long time to teach an new EMT or paramedic to look beyond the obvious and we shouldn’t be taking our cues from the popular media be it CBS or USA Today. That we do is all the condemnation of EMS education that I need.

    My anecdotal experience is that contrary to what we’re taught women often have their first MI at a younger age then men. I’m always leery of women in their early 40s who complain of left sided (not mid sternal) sharp (not dull) pain that they can localize to under their left breast. I’ve learned the hard way not to dismiss that type of complaint.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.

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