You respond to a 65 y/o Male at his residence. His daughter, on scene, called 911 because she is worried about her father’s health. She states that he just hasn’t been acting right. “He is weaker than normal, and becomes short of breath very easily”. The patient himself is not thrilled about your presence. He is a rather obese man (about 400 lbs), and he is sitting in his recliner sans shirt or pants. His immediate area provides evidence that he doesn’t move
S – The patient states that he is always weak and it is normal for him to get short of breath when he gets up.
A – NKDA
M – Glucophage, Gabapentin, Albuterol, Singulair, Prevacid, Carevedilol, Enalapril, Digoxin, Aspirin, Oxygen
P – AMI, CHF, Asthma, Non-insulin dependent diabetes, AICD
L – Oreos and Orange Juice
E – Sitting in his chair
B/P: 61/37, Left Arm
SpO2: 83, on 2 lpm O2,
Pulse: 40 & regular
Resp: 30 & regular
Skin: Pale, cool, & clammy
You place your patient on the monitor and obtain the following 12-lead. What would you immediately ask your patient? What is your interpretation of the ECG? What treatments would you provide?
Also Posted over at ECG Experts
Submission thanks to Tim Waters, CCEMTP of Lee County Medstar
40 yo female, thin build with no history/meds/allergies. + smoker. Works as painter outside and was painting when developed pain in her upper chest/left arm which is the same she uses to paint. Also adds that she has been moving and lifting numerous heavy objects over the past week and since then has been having these episodes of shoulder discomfort. Pain is non-radiating with moderate reproducibility with movement and inspiration. I forget what severity scale she gave it but was definitely uncomfortable. Onset was about 3 ½ hours prior to presentation while painting with her trying to work through the pain until it became to unbearable.. Denies nausea, is diaphoretic but has been working outside.
I posted this article over at http://www.lifeunderthelights.com/ a few days ago and I thought it would good for here as well. I’m sorry that I’ve only rarely posted here, but I read this blog quite often and recommend it to all of my peers. Enjoy
A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.
On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.
It’s amazing when I have my maul how every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.
Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to reasons of wanting to remain employed.
And, like a lot of posts I write, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.
For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.
As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed, I must say) IV stick into an impossibly small and crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy and obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.
The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.
But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.
I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.
We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.
This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.
Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.
It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.
The original post has some pictures of the fire and of the doggies that my wife and I saved on our first “Fire Date” – It can be seen HERE
A 67 y/o male has fallen to the ground at his residence. His “partner” called 911 after seeing that he was unconscious. Upon your arrival the patient is alert and requesting that you pick him up because he really needs to make a bowel movement. The patient denies syncope but states that he does not remember falling.
His Vital Signs
HR correlates with monitor, pulse not palpable at radial.
Initial BP 78/60
AAOx3, normal mental status, just wants to make a bowel movement.
Skin – Pale, more pronounced and white from the waste down. Skin was relatively dry.
First Possibility: Right-sided infarct with hemodynamic compromise leading to a syncopal episode. The syncope caused a secondary head injury which cerebrally herniated during transport. I would like to note that this is highly unlikely. Also, the patient did not improve with fluids, which would have happened with a traditional RV infarct.Second Possibility: It is much more likely that the patient had an atypical hemorrhagic stroke that presented with the first symptom of syncope. The changes on the 12-lead ECG could just be concurrent with cerebral ischemia. This is not completely understood, but theories involving nerve endings in the myocardium are abundant. The patient’s ICP would have increased during transport with the final result being cardiac arrest.Third Possibility: Abdominal aortic aneurism with severe secondary cerebral ischemia due to hemodynamic instability. I’m not fond of this idea even though the AAA fit the picture in the beginning, it does not explain the decorticate posturing.
Upon arrival the patient was laying on the walkway to the beach. FD stated that she was AAOx3. Her husband stated that she had a brief loss of consciousness. The patient denied any pain, but felt weak and short of breath. During transport the Zoll pacemaker was not functioning, it read “poor pad contact”. A new set of pads was tried without success. The patient’s perfusion status was rapidly declining, and we became unable to obtain a BP. Her ventricular rate slowed to about 10 BPM, and Epinephrine was given. The Epinephrine brought the HR up, Dopamine was then started. With the 3rd set of pacer pads the pacemaker began to get capture. The Dopamine was stopped after 1min. of administration. The patient’s perfusion status improved. Versed was administered for conscious sedation. Verbal report was given to the ER physician and care was transferred.
Prehospital 12 Lead:
PT STATES HE WAS ASLEEP AND WAS WOKE OUT OF A SLEEP BY SEVERE SUBSTERNAL CHEST PAIN, 10/10 ON PAIN SCALE. PT STATES HE TOOK THREE OF HIS OWN NITROGLYCERIN AND CALLED 911. PT STATES AT TIME OF INITIAL EMS ASSESSMENT PATIENT’S PAIN WAS A 2/10 ON PAIN SCALE. PT DENIES NAUSEA, DIAPHORESIS, VOMITING, OR SHORTNESS OF BREATH. PT IS ALERT AND ORIENTATED. PT ADMITS TO DRINKING APPROX 5 ALCOHOLIC DRINKS THIS EVENING, AND STATES HE DID TAKE A VIAGRA THIS EVENING SEVERAL HOURS BEFORE BEDTIME. DURING INITIAL ASSESSMENT PATIENT STATES PAIN DID RE-OCCUR AND WAS NOW A 10/10, WITH RADIATION TO THE NECK AND JAW. PT IS STILL DENYING NAUSEA OR SHORTNESS OF BREATH.
Mental Status: Normal Mental Status for Patient, Oriented-Person, Oriented-Place, Oriented-Time, Oriented-Events, ; Neuro: Normal, ; Eyes: R: Reactive,; L: Reactive, ; Skin: Normal, ; Head/Face: Normal, ; Neck: Normal, ; LUQ: Normal (Soft, Non-Tender), ; LLQ: Normal (Soft, Non-Tender), ; RUQ: Normal (Soft, Non-Tender), ; RLQ: Normal (Soft, Non-Tender), ; GU: Normal, ; Cervical: Normal (No Pain or Deformities), ; Thoracic(back): Normal (No Pain or Deformities), ; Lumbar: Normal (No Pain or Deformities), ; Extremities: Upper R: Normal, ; Upper L: Normal, ; Lower R: Normal, ; Lower L: Normal, ;
Chest/Lungs: Chest Pain/Pressure (Non-reproducable), SEVERE PAIN 10/10 RADIATING TO NECK, AND JAW;
01:02 92/60 80 RR 20 Normal 97 Low O2 2/10 Right Arm (Supine)
01:12 88/60 78 RR 20 Normal 100 High O2 10/10 Right Arm (Semi-Fowlers)
01:24 86/56 72 RR 22 Normal 100 High O2 10/10 Right Arm (Supine)
01:31 118/63 72 RR 20 Normal 100 High O2 10/10 Right Arm (Trendelenburg)
01:38 108/60 68 RR 20 Normal 100 High O2 8/10 Right Arm (Trendelenburg)
Medic 15 respond to 1212 Statin rd for a welfare check.