Posted by: medicblog999 | August 9, 2009

Jumping to conclusions – Part 2

jack in the boxSo, here is the second job I had in my run of two recently that reminded me not to pre-judge my patients.

I had just cleared from lesson number one, when I was assigned to a further emergency.

This time, it was to a 45 yr old man who had a “pain in his neck and arm – cervical spondylosis – waiting for physio”

Ok, I know this can be a painful condition, but does it require a paramedic at ungodly O’clock in the morning?

I head off and within 15 minutes, I’m at the door step. I consider taking just my first response bag in, as it seems like a straightforward muscle,nerve,bone type pain, but as I have been burned in the past, I do the normal thing of lugging all of the bags and the Lifepack 12 monitor in as well.

The one time I did get caught out, for a fall/arm injury, which turned out to be a cardiac arrest, taught me the career long lesson of ‘expect the worst’. I never want to have to run out of a house, back to my car to get some kit, whilst a family watches you disappear out of the front door, ever again!

As I walk into the house I am met by his wife, she is in her pyjamas and appears to be a little annoyed at being up at 3am in the morning. She raises her eyebrows and points in the direction of the bathroom.

“Hes in there, said he felt sick or something”

I place my bags in the hallway and walk the few short steps to the bathroom door.

M999: “Whats his name please?”

Wife: “Its Frank”

M999: “Frank?, its Mark from the ambulance service, are you decent in there? Can I come in and check you over?”

Frank: ” Yes, come in, I don’t feel too good”

As I walk in, I see Frank sitting on the edge of the bath. He has a small amount of vomit down his front and looks white as a sheet. Im getting a little worried about him now, but some people do go white when they feel poorly, its not necessarily a sign of something terrible all of the time.

As is my want, I get close up to him and reach out and check his pulse. I stop and reposition my index and middle finger to check what I was feeling was correct…. His pulse was fairly strong to palpate, but his rate was going very slow (about 30 beats per minute). It very quickly becomes apparent that this is not just a cervical pain job and as I lay Frank on the floor of the bathroom, I press my radio button and ask for backup as a Category A response.

Control : ” Sorry, did you say you wanted that as a Cat Alpha Response?? ”

M999: (nice and calmly!) “That’s affirmative control, Cat A, A for Alpha, please”

Control : “That’s received, we will have a crew with you as soon as possible”

Right, now I know that my backup is on its way, I get back to concentrating on Frank. Further investigation tells me the following facts.

  • Frank goes to his GP the day before to be seen with a chief complaint of intermittent pains in the neck and left shoulder/axilla.
  • GP diagnoses early cervical spondylosis and arranges and appointment for physio, which Frank is due to attend the next week.
  • Frank comes home from the GP and the pain goes for a few hours, but comes back during the late evening.
  • The pain is located in his ‘neck’ but he actually rubs his throat when he describes it. The pain is also in his left shoulder but this time it is also in his axilla.
  • He describes the pain as a ‘horrible ache’
  • He has NO central or left sided chest pain.
  • He is not diabetic (who have a high incidence of silent heart attacks i.e. no chest pain)
  • Since the pain came on at 01.00 it has remained without any relief

Its easy to look back with hindsight and think the GP has made a monumental mis-diagnosis, but we were not there at the time of assessment and for all we know Frank may have told the Gp that the pain was sharp and stabbing and running down the path that a trapped nerve may display etc etc. However, I am now dealing with the hear and now.

His radial pulse is still strong and slow, but he says he feels light headed and dizzy. He is now supine on the floor, with a 100% O2 mask on. I decide to cannulate before anything else in case I need to do something about his bradycardia, or in case he arrests. Once the cannula is in, I get his wife, who know looks alot more concerned than before, to get me a small glass of water so that I can give him some aspirin whilst I am waiting for the crew to arrive.

Time for the 12 Lead:

ECG Geek 3 crop

Again, I didn’t think I would be dealing with that when I walked into the patients house. His pulse had now returned to a more stable rate, but he still looked obviously very unwell. The ECG shows a significant Infero-Posterior MI (a heart attack that is affecting both the bottom of his heart and the back of his heart. Not good news for anyone!

As I am helping him take his aspirin, the crew arrive and walk into the bedroom, with a quizical look on their faces which I know means ‘youve upgraded a shoulder pain to a Cat A??’

M999: “Morning Guys! M.I….Chair please”

I hope that they understand the urgent tone in my voice as I have this feeling that Frank may well ‘go off’ and arrest soon.

One of the crew returns with the chair whilst the other assists me to package Frank and get him ready to move to the ambulance.

Wife :”Whats going on?”

M999: “If you give me a couple of minutes to get Frank on the ambulance, I will come back and tell you everything that is happening whilst the lads are sorting him out in the back of the ambulance. Is that OK?”

Wife: “Ok….”

Whilst the crew move Frank out to the vehicle to continue the treatment and get him ready for transport, I send the 12 lead ECG to the PPCI centre, who rapidly accept him and ask for our ETA.

M999: “About 15-20 minutes”

We were quite far away, and I actually estimated it to be about 25 minutes with getting him loaded and the travel time, but at least they will all be ready for him on his arrival.

I quickly jump onto the ambulance and explain everything to Frank, I tell him his diagnosis and what the treatment is, which he accepts with a simple

“Oh Shit!”

M999: “Frank, I really need to let your wife know what is going on too. Whats her name?”

Frank: “Sarah”

With that I leave the ambulance and go back into the house where Sarah is frantically packing bags and starting to hyperventilate a bit. Again, I quickly and as gently as possible explain what is happening to Frank. She doesn’t take it so well. I spend a couple of minutes telling her what we are planning to do then usher her to the ambulance so that the crew can get away.

We say our goodbyes and I inform the crew that the PPCI will accept him and I have given their ETA. As I am packing my bags into the back of the car, the crew turn the vehicle around. As it passes the car, the driver slows down and winds the window down.

“What do we do, if he arrests on the way? Do we continue to the PPCI centre or divert to A&E?”

M999: “If you are closer to the PPCI centre then just continue there. They will accept patients in cardiac arrest”

And off they go.

I never managed to see them before the end of my shift, so i dont know if he made it or not. Hopefully he did, but even if he did, he is likely to have some problems after damaging so much of his heart.

Its all just another reason for me to keep lugging those bags into the patients houses for most, if not all jobs I get sent to.

Atypical acute cardiac chest pain! – You gotta respect it!!

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Responses

  1. Good call. Yes those bags are bloody heavy but like you would rather be over prepared.

    It always suprises me that some crews luckily not from our station attend chest pain calls without the Lifepac 12 and urgent calls without even a response bag!!

  2. Mark, you did the right thing so you know he did well.
    That 12lead is remarkable, is it not? Even with leads I II III we know this fellow is in trouble, but now they can trend it at the cath lab.

    I always assume the chief complaint was lost in translation between patient, caller, call taker and dispatcher. Like that telephone game we all used to play.
    I just start from scratch every time.

    Unless it is another regular lying on a blanket in the middle of the park (twice between 2 and 3 this morning.

    Well done again, mark.

  3. Hey Happy. Just so you know, I got to sleep all night. I feel GREAT 🙂

    Mark, I assume that you carry Atropine for bradycardia over there, do you not? I have Atropine, Dopamine (chronotropic and Inotropic properties), and external cardiac pacing. What’s in your tool bag?

  4. Great call Mark. I always take all the bags in because like you have been caught out with the fall with head injury end up being a cardiac arrest. Luckily we could see the heads of people going up and down rhythmically in the window so we kinda figured the worst.

  5. wow thats pretty intense! i’m glad you carried everything in there with you because those precious seconds could mean trouble.

  6. What was his pressure like? I can imagine “not good,” but I’m curious.

  7. Good on you for catching this. I have a bad feeling that in some places in the States, this poor would have been walked to the truck and hauled in BLS.

  8. Mark.
    I’ve just come across your blogs. Great stuff!
    Reading with interest as We’ve just initiated a CFR scheme in our area and it’s good to get a PM’s view on what happens during your shifts.
    So far we have been very lucky and have had a good reception from PM’s and they appear to value our (minor but useful) input into the 999 response.
    We are an very isolated rural community served by a cracking, but limited in numbers, ambulance team.
    I look forward to reading through the blog history and your updates.
    Martin.


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