Well, this is a interesting one!
Called to a 82 yr old man who had a fall at home and couldn’t get off the floor. This came through as a ‘Cat C’ response, so off I tootled without any lights or sirens. The address was local so it didn’t really make a difference with the travel time anyway.
When I got on scene, I was met by a carer who comes in each morning and evening to help Joe, get dressed and undressed as required. The carer told me that Joe had slipped off the chair when he went to sit down, but due to the fact that he had a ‘dodgy ankle’, he couldn’t get back off the floor and into his chair.
All seems pretty straight forward, yes?
Whenever I attend to this type of patient, I always have a quick feel for the radial pulse as I am having a quick initial chat about what went on. As I was asking the usual questions :
- Can you remember falling?
- Did you feel dizzy or faint before you fell?
- Do you fall often?
- Do you have any new pain that wasn’t there before you had your fall?
- What is stoppping you from getting up?
As I felt his pulse, it was strong and regular but was a little slow at about 50 beats per minute. I asked to see his medication list and low and behold he was on a beta blocker which I assumed was responsible for his slow heart rate. It was still a little low for my liking, but as was asymptomatic (i.e. had no symptoms from the slow heart rate), I thought that with the help of the carer I would get him off the floor and back into his chair. This was achieved without any problems and all appeared tickety boo!
I started to formulate a treatment plan for Joe, based around him staying at home and getting a GP referral to check to see if his dosage of Beta Blockers needed adjusting. Before I placed the call, I completed the rest of my secondary vital signs.
I rechecked his pulse……………surely that’s not right?
I check again, then move to his other arm and check again.
Its slow……REALLY slow……..how is he sitting up talking to me?
M999: “Are you okay Joe, do you feel dizzy?”
Joe : “No son, I’m alright thanks”
His pulse was hovering around the 28 – 30 beats per minute mark!!
M999: ” Joe, I’m just going to do a quick heart tracing because your heart seems to be going a little slow. It may be just the medication, but I need to have a quick look see, is that Ok?”
I attached the four limb leads from the 12 LifePak 12. This is what I get :
He has no pain what so ever, he doesn’t feel dizzy or light headed. He looks a little pallid, but is undergoing treatment for anaemia, so is that poor perfusion or just anaemia?
I request a Category A ambulance backup and explain what is happening, to which he shrugs his shoulders and says
“Right then, oh well…”
As I wait for the crew, I cannulate Joe and place him on some O2. He is saturating at 94% on air, so a little more wouldn’t go a miss in this case. I stop and think about a little atropine, but the guideline is a little vague on when to give as it is based on the patient being symptomatic, however, I decide that there is no way I can send a patient to hospital with a pulse less than 30 beats per minute without trying to do something about it, and as I have already said, maybe his pallor is due to poor perfusion rather than his anaemia. I give 500mcg Atropine which stimulates a few extra beats for a couple of minutes, but he then settles down back to his 30 beats per minute.
By now the crew arrive and take over care of the patient who is then whisked off to hospital.
Now for the big question?
What is your diagnosis of the rhythm strip? I had to really look at this one to get my diagnosis and even then I wasn’t sure if I was right or not. I am an ECG Geek. Ive said it in the past, and if I don’t know or am not sure what I am looking at then I have to find out. A quick trip to the coronary care ward and a discussion with the Cardiologist proved my initial provisional diagnosis right.
What do you think?