#8147 - 12/06/05 02:49 PM
your call
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Bryan Green
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Registered: 05/11/03
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You are called to the residence of a 51 y/o M. Pt stated he has had GI upset for several hours and chest Pressure across his chest moving from left to the right and is unsure if both have lasted for same period of time. Pt stated that he wanted EMS to give him something for the GI upset and that he has felt this before and contributes it to food poisoning. The patient is not direct on a timeline of events but he gives you the following information: 24hrs ago he had dinner with his girlfriend at a restaurant out of town and shortly (his answer is 2 to 20 hrs) after began to feel “bad” with the GI upset characterized by nausea without vomiting, diarrhea, feeling bloated, and excessive gas.
Assessment:
Pt abd is distended however not tender; Pt is pink, warm, and dry, V/S: bp130/80, hr68, SPO2 100%, RR 18-20, no urologic deficiencies as noted by a brief basic exam, BBS CTA X4, stated he has felt chills, denies cough, denies urinary problems, 1 time diarrhea brown without blood indicated as per the Pt description. Medical history: not remarkable, denies HIV or HEP-C (see social HX). Meds: none NKDA. Social history: recently won the lottery and has used a portion of that money to fund an iv drug habit that he stopped without assistance 3 wks ago, he does smoke, does drink however denies ETOH abuse (house and pt do not indicate any current use), house is kept in moderate shape, lives alone, has a long distance relationship.
After the above assessment the Pt refuses transport to the ER
What would you do for this patient? What further evaluations do you think are warranted? Would you insist transport?
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#8148 - 12/06/05 06:43 PM
Re: your call
[Re: Bryan Green]
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George Gibbons
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Registered: 05/20/03
Posts: 287
Loc: State of Confusion...
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Run a 12-lead. What specifically was the IV drug of choice and how did he "quit w/o assistance?" Need some more info before commiting to an answer...
Edited by George Gibbons (12/06/05 06:44 PM)
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#8149 - 12/06/05 09:24 PM
Re: your call
[Re: George Gibbons]
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Bryan Green
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Loc: austin
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IV drug of choice is heroin, he quit without social assistance from a formal program or medical (methadone) assistance (basically cold turkey). Also to note that I did not mention the Pt is approximately 20-30lb overweight.
12 lead: This is actually one of the reasons I bring Pt X up! How many medics would do a 12lead? I have a new partner who came out of the last academy. I am attempting to show him a need to do more 12lead’s in the field. One of the things I have noticed is that the statement “this dos not sound like your heart” will come out of someone’s mouth (not just my partners) on patients that a 12lead was indicated but not run and the statement was not followed by the “we need more test that can not be performed in the field to verify my clinical impression” statement. I know those are just statements but the thought process behind them is what I question. What I find is more distressing is the thought that a 12lead is invasive and is not indicated on people because you must expose them coupled with the above.
After stating the above the 12 is as follows: Lead 2 showing a NSR a rate of 68 with upright P waves, WNL PRI, QRS of normal duration. No Q waves, flipped T waves, or ST segment change noted in the limb leads, QTC is .404, Axes is 17. Lead V1 1mm of ST segment elevation no Q wave, no flipped T. Lead V2-V3 2mm of ST segment elevation no Q wave, no flipped T. Lead V4-V5 1mm of ST segment elevation no Q wave, no flipped T. Lead V6 1mm of ST segment elevation no Q wave, no flipped T. Pericardial leads are discordant, and suggestive of borderline LVH and ST elevation may be “strain”. Initial 12lead is non conclusive. The LP12 stated 1st degree AV block, cannot rule out inferior infarct, and cannot rule out anterior infarct. NOTE: no AV block just the damn LP12!
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#8150 - 12/06/05 11:16 PM
Re: your call
[Re: Bryan Green]
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David Beckerley
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Registered: 09/22/03
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Loc: Parhelion
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Generally speaking, I do a 12 lead on 99% of everybody over the age of 40 AND complaining of chest pain, especially non-specific chest pain. Also, I will do a 12-lead on anyone over the age of 50 with a complaint of nausea and/or vomiting without a prior dr.'s dx and even then. I've had the "yeah yeah, it's food poisoning and I just need something for the nausea", just to find they are bradycardic (60) with tombstones. So with that said, your pt has two reason why I would do a 12-lead. I, and I hope everyone, would always suggest transport and include the need for more tests in your reason. Remember, a refusal is fine as long as it is an INFORMED refusal.
As for a 12-lead being invasive, if they consent to it and it's neccesary, it's not invasive....They're stickers. Now a female at work needing a 12-lead with the whole office watching, that's invasive. But a 50ish man at home complaining of chest pain is not. An IV, intubation, medication (PO, IM, IV, SL, TD), a cric, those are invasive. Anything that cause a possible adverse reaction or undue pain is invasive. A 12-lead is not.
Invasive defined:
Merriam-Webster Online Dictionary
in·va·sive
Pronunciation: -siv, -ziv
Function: adjective
1 : of, relating to, or characterized by military aggression
2 : tending to spread; especially : tending to invade healthy tissue <invasive cancer cells>
3 : tending to infringe
4 : involving entry into the living body (as by incision or by insertion of an instrument) <invasive diagnostic techniques>
- in·va·sive·ness noun
_________________________
"Hooray beer!", says the beautiful man.
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#8151 - 12/07/05 02:33 AM
Re: your call
[Re: Bryan Green]
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Patrick Murphy
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Registered: 03/09/03
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Pericardial = precordial:-) Is he febrile? Any PR segment depression?
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#8152 - 12/07/05 10:55 AM
Re: your call
[Re: Patrick Murphy]
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Matt Schickel
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Registered: 06/22/03
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Loc: Troublemakersville
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uhhh, 50 year old, 20-30lbs overweight, complaints noted, but with "chest pressure", who just quit banging heroin? Nevermind complaints, risk factors alone would indicate a 12 lead. I agree with the statement of "this doesn't sound like your heart", however that statement should be followed with "but we're still going to perform a more comprehensive look of your heart just to cover all our bases". Not only is it OUR FREAKIN JOB, it make one sound like they are going the extra mile for the patient, and patients like to feel special. Everybody likes to feel special.
It seems like your partner was on the right diagnosis, but he missed some subtle nuances.
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People are a lot like Slinkys. They are not good for much but are a lot of fun to push down a flight of stairs.
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#8153 - 12/07/05 12:08 PM
Re: your call
[Re: Matt Schickel]
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Bryan Green
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Registered: 05/11/03
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Loc: austin
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Patrick,
Thanks for the spelling lesson you know I suck at it! No PR depression that I can remember.
David and Matt,
I do not consider a 12lead to be invasive at all. We can easily make a room private or find one to make private. Heck the back of the unit will work to. I agree with you that this patient has a lot of risk factors and a 12lead even without chest pressure is more then warranted. This particular call was actually mine and one earlier in the day with odd symptoms and chest pain x2 weeks was mine as well. I have on other calls with other “new” medics noted the probable fear of EKGs. I wonder how well our 12lead classes are being received by the cadets. I am not bashing my new partner or by no means think he is deficient. I wonder how well he was taught or how well he received his 12lead interpretation and when and when not to use it.
In the case listed on my first post I spent some time convincing him to go to the ER and started ASA, NTG for the chest pressure. Initially the pressure and other symptoms subsided. During transport he became diaphoretic and pale (he stated this was the hot and cold flash he was talking about). With repeated 12leads it was noted that he now had flipped T waves in V1 to V4 that subsided before arrival at the ED but still remained subtly. The ER MD ordered a cardio consult and a cathlab visit based on our 12lead EKGs alone. Before exiting the ER I checked his labs: Traponin 8.29 and CK/CKMB 73.2. Both this call and the other were good lessons.
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#8154 - 12/07/05 01:02 PM
Re: your call
[Re: Bryan Green]
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Wes Ogilvie
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Registered: 03/14/03
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Loc: Baja Westlake (Ce-Bar)/North A...
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Bryan -- great work! I'm "just a basic," but I really can't see how the (minimally) additional work of obtaining a 12-lead is not dramatically outweighed by the potential benefits of a 12-lead's diagnostic capabilities. Some of these calls of generalized sickness, unspecified respiratory difficulties, abdominal pain, and complaints that don't match with the assessment challenge each of our abilities.
I've got only a few basic tools in my EMS arsenal, but I've found that a thorough assessment and visual inspection of the patient (and their surroundings) goes a long ways.
Regarding Matt's comment about making a patient feel special, I've often done the same thing. I take an oral temperature on patients when I can't find anything else to do. It does two things. First, it makes the patient feel like we're "doing something." Second, since the patient's temperature is usually taken when they go to the doctor and/or hospital, it cofnrims their experience with other health care providers and shows that we are health care providers too (in other words, we're not just ambulance drivers...).
Edited by Wes Ogilvie (12/07/05 01:08 PM)
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#8155 - 12/07/05 10:16 PM
Re: your call
[Re: Wes Ogilvie]
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Corey Ricketson
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Registered: 03/05/03
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Loc: Round Rock
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Bryan,
Thanks for posting the case. I just now got to read it and am glad a lot of people have replied.
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#8156 - 12/08/05 04:26 PM
Re: your call
[Re: Bryan Green]
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Laurie Emmer
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Registered: 11/19/03
Posts: 133
Loc: Bastrop, Texas
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Quote:
The LP12 stated 1st degree AV block, cannot rule out inferior infarct, and cannot rule out anterior infarct. NOTE: no AV block just the damn LP12!
Bryan,
I NEVER EVER read the LP12's assessment of what the rhythm or diagnosis is until I have covered it up and evaluated the 12 lead with my own brain. There are many, many times when the machine is WRONG. Now I know that if the LP12 states 'acute MI suspected', I should be suspicious. But if the machine could see it, I should be able to see it too. As far as when to 12 lead and when not to, I am like you. I would rather have the information for the patient's peace of mind AND mine. Especially considering the history. I also often take the time (when appropriate) to talk to the patient about what I am looking at. Think about this scenario: I don't know anything about medicine. Someone hooks me up to a machine by means of putting stickers all over me. A piece of paper spits out, and the someone looks at it and sets it aside, and says, 'I don't see anything that makes me think it's your heart.' Maybe I am assuming here, but if I was the patient, I want to know what in the hell you were looking at  .
I like to think that this is an agency in which we do things thoroughly and effectively. Getting the quick refusal isn't always what's most efficient or effective if you spend seven days (or longer!) in court explaining your methodology when the patient turns up dead.
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