Posted by: medicblog999 | May 27, 2009

ECG Geek – Part 3

heart-angiogram-sd3453-gaIt frustrates me greatly when I look after a patient who has had warning signs of significant cardiac problems for a few months then sits with severe chest pain for a number of hours before calling for help.

It amazes me that following all of the publicity over the last couple of years in the Uk regarding heart disease, and specifically heart attacks, that some people still worry about calling us and causing us trouble (yes, there are some out there, usually the genuine patients with the life threatening conditions).

I know that this is not a UK only phenomenon, and I am sure that all those readers who are in the job will most definitely relate to the details below.

I was recently sent to attend to a male patient in his early 40`s who works as a carer in a local nursing home. His manager phoned 999 after noticing that he didn’t seem himself to day and after questioning him, he admitted to having central chest pain.

On arrival, I walked in, introduced myself and my partner and began our assessment. I could see that he was a good colour, conscious alert and orientated, not sweating or short of breath and seemed in good spirits. He quickly apologised for us being called for and said that everyone was just fussing over nothing.

His pain remained, described as an ache in his left upper chest which radiated around to his back and his left arm. This pain had been there for the last 8 hours and hadn’t eased at any time. He stated that his current pain score was 8 on a 0-10 scale.

100% Oxygen on, a quick set of primary obs, all of which were within normal limits and onto the 12 lead lead ECG, which was as follows:

ECG Geek 3

For the non-medical among the readers this shows that it is highly likely that he has had a very recent lateral MI (a heart attack which affects the side of his heart muscle of the lower left chamber of the heart). It is likely that this occurred shortly after his pain started 8 hours earlier.

Further examination and history taking gave up the following details:

  • He admitted to having episodes of central chest pain on minor exertion when walking to work, which eased on resting, for the last 6 MONTHS!
  • He informed us that his mother and father both died of heart attacks before the age of 60.
  • He informed me that his sister is currently under investigations for angina and is aged only 44.
  • He has developed significant oedema to both lower legs over the last week.

He got his aspirin, buccal GTN, cannula and morphine. The ECG was sent to the local coronary care unit who accepted him directly to the ward, and we transported him directly to the unit for further care.

I checked up on him later in the day to see the outcome of his assessments. His Troponin levels were raised which confirmed the ECG findings of a recent resolving lateral MI and he was on his way for an angiogram and a MIBI scan to assess the damage done to his myocardium (which looks like it may be a problem for him due to the oedematus legs). He was smiling and chatty and again, apologetic for causing us trouble, however, I checked with him to ensure that he had gotten a sufficiently stern lecture from the nurses on the ward for not acting sooner, which he had!

He is a very lucky man, for many others this would have resulted in their very premature deaths. We all know about the risk factors for heart disease and heart attacks. The vast majority of adults should know about the warning signs and when to call for an ambulance, but as I stated earlier, Its always the genuine patients who dont want to bother us.

If only we could turn that on its head and make the inappropriate callers think about bothering us, then we could have so much more resources to look after the proper patients.

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Responses

  1. Mark,
    Great trace, as usual. I know a great many Paramedics who would have scanned this 12 lead and seen nothing at all. I see a possible T change medial, but still, the symptoms were my worry. I’d be curious to see if this man’s heart was young and “healthy” enough to build another pathway around the blockage.

    Welcome back from holiday by the way.
    Any plans for next summer yet?

  2. Hello from Canada!

    You might be interested in some recent research from Oregon about six identified behaviour patterns that are typical of people suffering heart attack symptoms that may explain treatment-seeking delays.

    This particular study deals with women (notoriously slow to seek medical help during a heart attack) but I suspect that men can also see themselves in one or more of the six behaviours.

    I’m a heart attack survivor and a 2008 graduate of the Mayo Clinic Science & Leadership Symposium for Women With Heart Disease. I was misdiagnosed in Emergency with acid reflux – ECG and troponin levels normal – but finally admitted two weeks later after suffering increasingly debilitating attack symptoms like crushing chest pain, pain radiating down my left arm, sweating and nausea. Two weeks of talking myself out of seeking help. Definitely a #5 or #6 on the Oregon list!

    More at: http://myheartsisters.org/2009/05/22/know-and-go-during-heart-attack/

    cheers,
    Carolyn

  3. It is good to see that there are experienced people all over the globe. Here in the USA the ‘standard of care’ can fluctuate from one ‘parish/county/shire’ to another. You can cross one busy state such as New York and and find great care across the state and drive out to Ohio heading west (toward CA) and find spotty care along I-70. It is so great that you can bring them right up to CCU. I don’t know how you have the manpower to do that! GREAT!

  4. I agree 100% with Carolyn. I had a heart attack last summer after about 6 very similar incidents (they could have been heart attacks too). I thought I was having a panic attack. My symptoms were crushing chest pain, severe pain in my arms, drenching sweat, nausea and denial. Even after my son told me (he is a 2nd year nursing student) that my symptoms appeared to be cardiac in nature, I still didn’t do anything until I finally asked a co-worker to call 911.


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