other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Tuesday, April 28, 2009

A Call That Went Right

At first, it didn't sound like much of an emergency. Someone had passed out, the dispatcher told us. She was awake now, but because of her age, the call had been classified as a cardiac problem.

We arrived to find the woman on the floor, right where she'd collapsed. According to another woman present, she'd been unconscious for about three minutes. When I asked if she felt any pain, she replied with a grin. "Why, no. In fact, I feel pretty good."

She hadn't been injured in the fall, but something still wasn't right. Her face was quite pale, and her clothing felt moist. As every health care provider knows, these can be ominous signs, indicating shock of some kind.

An EMT took her blood pressure. It was normal at first, but when he took it again a couple of minutes later, it had dropped to just seventy. My partner connected her to a cardiac monitor, and that's when we discovered the problem. She was indeed having a heart attack, without even feeling it. The evidence was right there on the paper.

We carried her out the door to the ambulance. I gave her some aspirin while my partner started an IV. We would have liked to given her some nitroglycerine, to open up her coronary arteries, but her blood pressure was too low for that.

On the way to the hospital, my partner started a second IV. A patient needs two IVs before undergoing cardiac catheterization. If our diagnosis was correct, and the woman was having a heart attack, the second IV would reduce the delay in going up to the cath lab.

Meanwhile, I was talking by radio to the emergency department. We wanted the staff to be ready when we arrived.

And so they were. The triage nurse looked up from her desk as we wheeled the woman into the emergency department. She didn't bother with any paperwork. "Go right in," she said. 'They're waiting for you."

Another nurse welcomed us into the treatment room. A moment later, we were joined by a pair of doctors. Having heard my report on the radio, they asked no questions. Instead, they asked to see the EKG we'd taken.

Taking it from my pocket, I handed it to one of the physicians. He was a cardiologist, I noticed. "Inferior MI," he said. "We'll go upstairs as soon as she has two IVs."

"She's already got two IVs," my partner said.

The cardiologist looked over at the patient and saw the twin plastic bags hanging from the ceiling. "Oh, good," he said. "I'll call them, to let them know we're coming, and we'll go right up."

Many things could have gone wrong on this call. Triaging the situation as a cardiac emergency was more a matter of luck than anything else, but it worked to the patient's benefit, because paramedics were dispatched immediately. We diagnosed the heart attack immediately. Both IVs went in on the first try, and the patient was totally cooperative. Triage nurses sometimes insist on taking vital signs at the door, even when the patient is dying, but this nurse had the good sense to dispense with such formalities. And the doctors actually believed us. That doesn't always happen. It's frustrating to watch the seconds tick by, as a doctor repeats all the questions and procedures we've already performed in the field. This time, though, that didn't happen. The patient went upstairs for her catheterization within thirty minutes of being wheeled into the ED.

While the cardiologist was on the phone to the cath lab, I stepped back into the patient's room to say goodbye. She was partially upright in her bed, looking perfectly healthy, and again she smiled when I wished her well.

"This is the most remarkable thing," she told me in a cheerful voice. "They tell me I'm having a heart attack. But to be honest, I feel just fine."

"This wasn't what you had in mind when you woke up today," I said.

"No," she replied, laughing a little bit. "Not at all."

14 Comments:

Blogger Norma said...

It's also fortunate that the other woman present when the patient lost consciousness called for an ambulance rather than taking the patient's "I feel fine" at face value. Nice work as usual, TS!

7:47 AM  
Blogger Renee said...

When things go off without a hitch, its always good. Especially when it is during such as serious call. Doesn't happen often enough, huh?

10:06 AM  
Blogger TS said...

Norma:

That's a great point--one I'd overlooked entirely. Thanks!

10:25 AM  
Blogger TS said...

Renee:

That's so true. When you think about it, there are so many different layers of problems that something is almost bound to go wrong. Diagnosing a heart attack in the field does no good if the hospital staff wastes time in treating it. Conversely, if we miss the diagnosis, the patient will suffer, no matter how good the hospital care might be. From the 911 call to the recovery room, every element of care has to go right for the patient to do well.

10:29 AM  
Blogger Renee said...

And compounding that is that the people we treat tend to be sicker, due to conditions that previously would have killed them years before, but through modern medicine, are treatable. Mimickers and distractors can make our work that much harder. Congrats again on "The perfect call" (Or near-perfect)!

11:41 AM  
OpenID medicblog999 said...

Good job, good outcome!
It doesn't always have to be the big trauma jobs that bring the job satisfaction, it's often the times when things just go smooth and efficiently. I had a similar one just the other day which I wrote about - which brought me tithe same sort of conclusion - if it handnt been for you and your partner being thorough, it would have got missed. I bet you can team off the name of quite a few paramedics who wouldn't have done the 12 lead etc and would have taken the "I feel fine" comment at face value.
Well done!

12:54 PM  
OpenID medicblog999 said...

Sorry for the terrible spelling! I blame my iPhones predictive text!

12:55 PM  
Blogger TS said...

While I appreciate the kind words from all of you, I feel a bit uncomfortable accepting congratulations.

We didn't do anything extraordinary on this call. As public servants so often say, we were simply doing our job. A number of factors worked in this patient's favor, and we were just a small part of that.

I hope this doesn't sound ungrateful. But, please, no more congratulations, okay? Comments on the call in general, and on the writing, are always welcome, of course--as usual.

Thanks!

3:23 PM  
Blogger Last Angry Man said...

Medicblog999, I have seen exactly that - a patient's claims of feeling fine being taken at face value.

TS, as a former medical professional (among other things, I was an EKG Analyst) what were your indications of an infarct?

I am Curious. I try to keep up with the former profession(s) to this day.

5:16 PM  
Blogger TS said...

Last Angry Man:

2 mm ST segment elevation in leads II, III, and aVF, with unexplained bradycardia (the patient did not have a history of bradycardia, and was not taking beta-blockers or other medications that would have slowed her heart rate).

Aside from the absence of chest pain, it was a classic inferior-wall MI presentation. This is precisely why I didn't feel that congratulations were in order--it didn't exactly take a Rhodes Scholar to make the diagnosis!

5:43 PM  
Anonymous Anonymous said...

I attended a seminar recently that discussed our local hospital's plans to give EMS more responsibility in diagnosing MIs. Outlined were plans to speak directly to staff from the cath lab via radio and bypass the "formalities" at the door you were speaking of. The dept. head said if he has it his way, we will skip the ER entirely. There was even some discussion about starting fibrinolytic therapy in the field (beyond asa), and some liability issues were brought up. It would be interesting to hear some thoughts about that from experienced medics like you and other readers. I'll be testing in august for medic, so I might never know the frustration you're describing with which to develop an opinion.

Btw- thanks for the great blog. I might not have dared to take the first step into EMS without it!

7:07 PM  
Anonymous JAM said...

I understand the rational for no ntg. Was there any reason that another analgesic medication couldn't have been used? (Fentanyl?)

Also in the original post you say that the cardiologist remarked "anterion mi". However when you describe the ekg to Last Angry Man, you describe an inferior wall mi. Typo?

8:59 PM  
Blogger TS said...

JAM:

The reason for no analgesic? There wasn't any need for it. She didn't have any pain.

And, yes, I meant to type "inferior" in the original story. I've changed it. Thanks!

9:29 AM  
Blogger TS said...

Anonymous:

In theory, we have that same kind of plan in place already. Unfortunately, like so many aspects of medicine, how well this works depends on the personality of the attending physician. Some favor aggressive treatment, and they trust the opinions of the paramedics. These doctors direct us straight to the cath lab. Others want to look at the patient themselves. Those are the cases that get delayed.

And by the way, these doctors have every reason to trust our diagnostic skills. Boston EMS physicians recently published a study in which Boston paramedics diagnosed MIs with greater than 90%accuracy--better than many categories of physicians.

9:35 AM  

Post a Comment

<< Home

[ View Guestbook ] [ Sign Guestbook ]
Get a FREE guestbook here!