Posted by: medicblog999 | March 20, 2009

ECG Geek – Part 2, The conclusion

heart-angiogram-sd3453-gaSo, where were we?
Click here if you need to read what happened up to this point.
So I’m standing in the back of the ambulance, just about to move the patient into the A&E department. I have seen the ECG which now shows definite inferior involvement and ST elevation.

I ask my partner to stay with the patient whilst I quickly run into the department where I ask one of the nurses if I can speak to a senior doc. I am shown to the consultant and I quickly say:
“I have a patient outside who has been having cardiac chest pain along with ECG changes suggestive of unstable angina. I now believe that she is starting to infarct. Do you have any objections to me not bringing her in and just heading off to the PPCI centre instead?”

” Does she need resuscitating?, is she stable?”

” At the present time she is okay, her pain is a 4 on a 0-10 scale and all her other obs are stable and within normal limits ”

” Sounds good, I’m happy for you to go”

As I was walking away I heard her say

“Who was that? Can we have more like him please!!”

Now I know this was not a compliment on my diagnostic abilities and choice of treatment, but was more likely the appreciation for not bringing a critical patient into an already heaving A&E department!

Back on the ambulance and I try to transmit the ECG to the PPCI centre, however the transmission keeps failing, so I phone them up and speak to the senior nurse on duty. We discuss the case and she accepts the patient for PPCI based on my interpretation of the ECG:

” If you are sure he is infarcting then you can bring him here……if you are sure”

Yes, I’m sure and we are now on our way, travelling with lights and sirens. I give some Morphine, titrated to effect, to ease some of his pain on the way and manage to keep the pain score down to a 4. We arrive at the PPCI centre approximately 20mins later and move him straight into the cath lab where the team attack him from all sides!! We say our goodbyes, handover and move back to the ambulance where we reflect on the job that we have just done.

I took one final ECG on arrival at the PPCI centre which looked like this:

ecg4-full-inf-mi

I phoned the coronary care department a few hours later to enquire how he got on and was told that they had stented his circumflex artery, and he was looking really well. The team complimented us on our decision and suggested that the time from infarct to stent was less than an hour and is likely to have a really positive effect on his heart function following this MI.

Reading through the comments you all left after the original post, most of you would have done the same thing, which is reassuring for me. I was very happy with what I decided to do, but there is always that worry……what if he arrested on the way?

Would both hospitals have been so supportive of my decision then? I`ll leave that one up in the air I think.

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Responses

  1. Elevation now clear in lead II and now new changes in V3 and V4. That ischemia is on the move. You made the right decision.

    As far as being able to run in and get a quick answer from a Doc about a patient, you lucky dog, you. I once asked a doctor for advice over the radio and he asked, “Are you on hospital property?” I relied in the negative and he replied “Not my patient.”
    Wonderful to get honest advice.

    And also, why ask “What if he had coded?” he wasn’t going to. If he was your super spider sense would have told you to get him into the first A&E without delay.
    Your experience and training allowed you to manage a patient to proper definitive care.

    Great scenario. And nice EKG traces also, mine look all v-fibby all the time.

    HM

  2. Great result; good choice. Bit concerned that tenecteplase withdrawn in some areas with long journeys to PCI. I had a similar situation with a 55yr old male, woke with chest pain, luckily his wife made him call us straight away. O/a pain 6, not pale or sweaty, thin chap didn’t look cardiac. spidey sense made us insist on chair to vehicle. No history of health problems but smoker since age 10 at 40/day. ECG showed massive septal infarct; tried to fax to CCU but line down; rang and confirmed that cath lab not open till two hours later. Another paramedic on scene unable to autonomously thrombolyse; luckily I could as I’d done an extra two day course in my own time with a really good trainer and was able to give tenecteplase 80 mins after pain started. 15 minutes later all pain gone, all ST elevation gone, ECG normal (Woo hoo!) Transported him to CCU where patient later stented twice in cath lab. Patient went home on his birthday, with next to no lasting heart muscle damage; hasn’t smoked since. Glad we still had TNK tho cath lab first choice if available. I often think about him; he hadn’t answered our question about family history; later learned his dad died at 56 from an MI…

  3. Firstly, fab name!
    Parabnormal sounds much better than Medicblog. Wish I had thought of that first!
    As for TNK, I was fortunate enough to thrombolyse 17 patients whilst we had it, all did well, but a few needed stenting as well!There is still ongoing discussion somewhere in the cardiac networks regarding us thrombolysing as well as direct PPCI, but I can’t see that happening.
    Just have to wait and see!

    • Thanks, really enjoying yr blog. Think PCI will soon be available here 24/7 but not yet. Re stent plus TNK; guess if you’ve one narrowed area with plaque you’re likely to have others – and i can see why the risks are greater if they’re not clotting. But some of our transfers are 60 mins plus to PCI so it will be good to get the stats in and maybe keep TNK for long delays – and maybe recent pain (<3hr)? STREAM is clinical trial in Bristol for comparing results of PCI vs thrombolysis; not sure if it looks at risks/benefits of TNK + PCI for cases like this. BTW, this last TNK beat my first thrombolysis; one of those jobs where you think why oh why did I say that? (along with ‘are you the mother’ – ‘no that’s my husband’; MUST remember to ask ‘what relation’ instead..). Anyway sent on an emergency call to a ‘panic attack’, arrived to find thin fit-looking man in his 40s writhing on his living room floor, overbreathing, slight left shoulder pain, no chest pain, resps 30, sats 99%, tingling in his fingers and toes… Relaxed and world-weary wife tells me he’s a hypochondriac, often has panic attacks. Think i may then have asked if he ever got ‘man flu’… Well b***r me if he didn’t turn out to be having a massive MI as well, on the ECG. Oops! Luckily, he cheered right up when my colleague told him (Spike Millligan’s ‘see, told you I was ill’ principle) and got quite interested in the treatment. Thank god we always do a 12-lead, especially as we later found out he was diabetic (some always tell you they’re fit and well don’t they, until later on when they mention the diabetes, the car accident, the aneurysm; the head bolts – usually in front of the A&E staff at handover….). Unrelated thought, tho same job: how often do you ask if pt is taking viagra before giving GTN? I rely on them telling me their list of meds but then i wonder if they might leave it out… Bound to catch me out some day but then it’s awkward to suggest; ‘hey not only are you poorly, but you look like the sort of chap who can’t get it up, care to confirm this in front of the bus queue/office/supermarket voyeurs-R-us?’ 🙂

  4. hi parabnormal,

    As far as the GTN/Viagra question. I always ask it!! As well as the standard reasons (i.e. the contraindication of GTN), it always lightens the mood for a moment, especially if your asking a 75 yr old.
    One memorable time though, I asked if the gentleman had taken viagra in the last 24hrs. He looked a bit sheepish then said he had taken it last night. His wife (who was with him in the back of the ambulance) went ballistic. I’m now immediately thinking that he has been a naughty boy with someone else, however it turned out that he had taken it to try and improve their love life, but he had failed to inform her about it.
    Oh, how we all laughed!!

  5. Hello again – Sorry I was so slow to reply to this. Definately a good call in what you did.

    I was going to give you a bit more info on STREAM but Parabnormal has kinda beaten me to it.

    It isn’t a trial in Bristol though, it is actually a world wide trial sponsored by the company that make TNK Broheim Inger (very not sure I’ve spelt that right!!) EMAS are taking part, as are WMAS (I think) and ambulances across europe and Canada. I think they are aiming to get 2000 patients in the trial.

    STREAM stands for STrategic Reperfussion Early After Mi and is basically asking the question – which is better Thrombolysis at say 1 hour after onset of pain or PCI at say 2-3 hours after onset.

    The theory being that thrombolysis will always be quicker to give than PCI – especially if out of hours – even 24/7 cath labs have to bleep their oncall staff etc etc and the patient has to get to the lab first!

    I will try and dig out some ‘proper’ information for you that isn’t paraphrased in my usual confusing manor!!

    Keep up the Blog Mark – I am really enjoying reading it – nice to see someone with some passion for the job amoungst all the moaners in the world!!

  6. ha – how wrong did I spell the drugs company?!!?

    Boehringer Ingelheim (No wonder people refer to them as ‘B.I’ lol)

    Have dug out my paper work on it the clinical trial protocol is a 70 page document so I won’t go there, but the actual title is

    “Comparison of the efficacy and safety of pre-hospital fibrinolytic treatment with Tenecteplase and additional antiplatelet and antithrombin therapy followed by catheterisation within 6-24 hours or rescue coronary intervention versus a strategy of standard PCI in patients with acute myocardial infarction within 3 hours of onset of symptoms”


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