Due to reader demand, I thought I would join two of my most popular types of post. My ‘what would you do?’ and my ‘ECG Geek’ series.
This one is going to come in three parts, with three distinct points for intervention and/or actions. I wanted to share it with you because it was a fairly rare occurrence, and you all seemed to enjoy my last ‘what would you do?’ post.
So without further ado, let me set the stage for you.
You are working on the Rapid response car, and you are sent to an elderly male (72 yrs old) called Jim. He has had a fall and now has a head injury. You proceed as normal with blue lights and sirens for the 6 minute drive to a local ‘sheltered housing’ scheme (for those not familiar with this phrase, it is a collection of small flats or bungalows which whilst not having direct access to carers 24 hours a day, has a ‘warden’ who is responsible for assisting the residents in times of need etc)
Once on scene you take all of your equipment in (because you have been caught out before when going in for a simple fall, and of course you have learned from your mistakes in the past!)
On gaining entry to the flat you find Jim, sitting on the floor in the kitchen, fully conscious and alert. He appears to have a good colour, is not short of breath, has no evidence of diaphoresis (posh word for sweating) and seems able to support himself in his sitting position without any real problems what so ever.
A quick initial history reveals that Jim was standing in the kitchen, just about to make his morning cup of tea (the time is approximately 09:30). Whilst he was standing there he felt a little dizzy..
“although I get dizzy all of the time you know son”
This appeared to have come on fairly suddenly and wasn’t preceded by a sudden change in posture such as standing from a sitting position. As he felt dizzy, he thought he may be about to faint, so placed himself on the floor where he pulled on his call button around his neck, which placed him into contact with a call centre somewhere who ultimately called me to the scene. Jim denied losing consciousness at any time.
He didn’t have any apparent injuries from the fall other than a small bump to the back of the head (which went against his history of not ‘falling’ and also led me to believe that he did actually have a period of LOC) He had no neck pain or back pain and no new pains which where different from his usual aches and pains in his knees.
He now did not feel dizzy in any way..
“I feel fine now son, just get me off the floor will you? These damned knees wont do anything I want them to these days”
“No problem Jim, just let me check you blood pressure and everything else out before I get you off the floor ok?”
I had already had a feel of his radial pulse as I first knelt down next to him when I entered his flat. At that time it was strong but a slow, but then you tend to assume most patients his age with a slowish pulse is down to them taking a beta blocker, so I was not too concerned by it at that time, judging by his physical appearance and lack of symptoms for hypo perfusion.
His blood pressure, oxygen saturations and blood sugar were all within normal limits.
Pulse: 45, strong and regular
SaO2 on air: 97%
BM: 4.9 mmol
He had no chest pain at present and did not have any prior to the fall.
His medical history was pretty unremarkable too. He seemed fairly fit and well other than hypertension and hypercholesterolaemia which he was on a statin for.
All in all, everything seemed ok, with nothing pointing to anything too worrying (although that pulse rate would need checking again after he is back up off the floor). I got him off the floor with the assistance of the warden and started to complete my patient report form.
“Jim, I know everything seems alright now, but you have had a bit of a funny turn, and the fact that you have bumped your head makes me think that maybe you did black out and you just dont know. Your heart rate is quite slow too, which may be what caused you to feel dizzy for a while. All of this means that you should go up to the hospital and get checked out ok?”
“No, Im not going up there, Im ok! I dont need to be wasting anyones time by taking up a hospital bed. No, dont worry son I will be fine, you just get yourself away and help someone else”
This went on for about the next five minutes. Eventually I pulled out my normal ‘deal maker’.
“Right Jim, Ill tell you what. I will do an ECG, a heart tracing, and if that is ok, then we can talk about leaving you at home and getting your GP out. If there is anything abnormal, then you have to agree to come in then ok?”
(If I am concerned about a patient and want them to go in, I can always find something abnormal on an ECG, no matter how small!)
He agreed to this and I hooked up the Lifepak 12.
Now unfortunately, the 12 lead went with the crew who came and I didnt get a copy off the archives. What I do have though is a photocopy of the initial rhythm strip that I took whilst I was putting his chest leads on:
So, there you go. I at appears that Jim was one of these remarkable patients who can tolerate a large cardiovascular insult to his health without being symptomatic.
This is your first decision point.
What rhythm abnormality does this show and what are you going to do about it. I know this copy is a bit of a nightmare for looking at the big squares and small squares as it was reduced down to fit a good length of trace onto an A4 piece of paper, however I can tell you that the heart rate based on the R-R method is approximately 34 beats per minute.
I will not go into details about treatment options open to me as a UK paramedic yet because I am more interested in reading what you would do using what ever protocols and guidelines you have available to you.
Right then……Off you go, leave a comment and tell me how you would treat this patient.
Next part comes in two days time.