It is a busy Friday night at the rural EMS service where you work as a paramedic. You’re dropping off a patient at the local level IV hospital but before you can even finish your hand-off report dispatch pages you again. “Please respond to a 58 year old male that is conscious and breathing, complaining of severe chest pain, no other information is available.”
Its been eight hours since you last got some food and you’d really like to hit the EMS lounge on the way out the door. You start to wonder, how likely is this to be a myocardial infarction just based on the dispatch info?
On scene the patient is an overweight, 58-year old male sitting in a recliner. He looks like shit. He is profoundly diaphoretic, has Levine’s sign when showing you where his chest pain is, describing it as “crushing,” rating it at 8/10. When you ask if the pain goes anywhere he says it travels to both arms. He denies any trouble breathing or shortness of breath, but he does tell you that he feels more tired than usual after walking up a flight of stairs.
His chest pain started 12 hours ago when he was at work. He was hoping it was GERD but Zantac and tums did nothing for his pain and he thinks it probably isn’t GERD at this point. He tells you that he had an MI in 2014 and that this feels just like that one did. He got one stent placed in 2014 but can’t remember which artery it was in, he thinks he has some paperwork on it in a drawer on it somewhere.
You give him 162mg of ASA and obtain his vital signs. He has a heart rate of 88 beats per minute, manual blood pressures are done in both arms, 142/94 in the R arm and 140/92 in the L arm. He is breathing 18 times per minute and his room air oxygen saturation is 95% with a great “pleth” wave and he is afebrile at 98.4 degrees. Both lung sounds are clear to auscultation. When you palpate his chest wall and ask if that changes the pain he replies, “I’m not sure.”
He has a history of coronary artery disease, peripheral artery disease, hypertension, hypercholesterolemia and benign prostate hyperplasia. He takes 81mg of aspirin every day, atorvastatin, flomax, lisinopril, and some vitamins. He used to have some nitro but it expired and he never bothered with refilling it. He has no allergies. He is supposed to schedule a stress test with his doctor next month as part of a routine follow-up but hasn’t done it yet.
You establish an IV and as your partner gets the 12-lead ecg set up you begin to contemplate where to take this patient. You have two choices; there is a level IV hospital twelve minutes away and a level II hospital fifty eight minutes away. They are in opposite directions.
The level IV hospital has board certified EM physicians but there is no cath lab there, they do have TNKase available and can consult with cardiology at the level II. Due to thunderstorms in the area flights are grounded for the next few hours so they are not an option. If you bring this patient to the level IV and it turns out he is having an MI, you will have to transfer him to the level II which is an hour and ten minutes away.
The level II hospital really likes to work with EMS and they came and did an in-service for your EMS agency last month about their cardiac alert protocol – they have started to perform urgent PCI on some NSTEMI patients in addition to the regular STEMI patients. You can activate a “cardiac alert” there with nothing more than a gut feeling if you like. When you activate the “cardiac alert” a cardiologist or PA from cardiology meets you at the door, performs an I-stat troponin, gets a hand-off report and decides if the patient goes straight to the cath lab or they stay in the ED for more of a work-up.
The twelve lead comes back as a textbook normal sinus rhythm with no other changes noted – no subtle ST segment depression, no T wave inversion, no De Winter’s T waves, no hemi-blocks or anything else is noted, this is just a normal ecg. This is surprising as you were pretty certain you would see a STEMI on there. Just to be sure, you do a V4R and V7, V8, and V9 and still see no signs of infarct or ischemia on the ecg.
You get the patient loaded up in your ambulance and give him a quick squirt of nitro under the tongue. You set out the fentanyl because you rarely get patients down pain to a comfortable level with just nitro.
Your partner yells from the front, “which hospital are we going to?”
This is part one of this article. Part two will be coming out next week and will look at the answers to these questions as well as look at the results from the dozens of readers of this blog.