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A lesson in cardiology

This post arises from a call I ran yesterday with a relatively new medic. Those of you in EMS know that new medics are pretty timid, and tend to have problems with calls that require them to think outside of the box we call protocol. This was one of those times that it is obvious that we need to do so. I hope any new medics that read this will learn an important lesson.

Our patient was a 58 year old man who was working at some light gardening when he began having pain between his shoulder blades, and began loudly burping, which relieved the pain. He went inside and took some gas medicine. His obviously intelligent wife called 911 and got him to take 2 baby aspirin.

When we arrived, we found him seated on his couch, he was cool and covered in sweat. He states he has a history of hypertension, for which he takes no medicine. He states that his doctor feels like his blood sugar is too high, and wanted him tested for diabetes, but that was 6 months ago, and he hasn’t been back since. When we stand him up to plpace him on the stretcher, his pulse becomes irregular. His vitals are: P- 88, BP 138/86, RR 20. In the truck, we start an IV, and find him to be in a normal sinus rhythm, his SaO2 is 99% on room air, blood sugar is 170. His 12 lead EKG is as follows:

(Click for a larger picture)

There are a few things that jump out at you here.

  1. The 12mm height of the QRS in lead aVL indicates “voltage criteria” for left ventricular hypertrophy. This is likely caused by his history of uncontrolled high blood pressure.
  2. The length of his QRS (0.122 sec) could be considered a left bundle branch block, but I think this is probably due to the QRS widening caused by the LVH, since the EKG doesn’t have that “LBBB look” to it.
  3. The poor R wave progression in leads V1 through V6
  4. The ST segment depression in Leads V3 and V4

I pointed out to New Medic Partner (NMP) that nitroglycerin was probably a good idea here. NMP didn’t want to give it because the patient “didn’t have chest pain.”

Sigh. This is one of my pet peeves. This man has risk factors- possible untreated diabetes AND high blood pressure. He is complaining of anginal equivalents- indigestion, and back pain. His irregular pulse on standing MAY be PVC’s, and his 12 lead confirms a cardiac event.

I finally prevailed, and we alerted the hospital. The doctor sent him to the cath lab, and it turns out that he had a complete blockage of the distal end of the left anterior descending coronary artery. He was having a hearta ttack, but we caught it early, and he is now recovering.

Please, medics. Learn how to read the signs your patient is giving you, and learn to read and interpret the 12 lead EKG. Cardiology, diabetes, and drug overdoses are the three areas where medics save the most lives. Be the best you can be at this, lives depend on it.