# Chest pain call turns into a code...



## para_god (May 21, 2010)

So, I'm sitting here, working on the never ending mass of paperwork, and I can't help but to think that I could've done something differently...

Here's what happened...

Got a call at 6am for chest pain. Arrived onscene to find a 50 year old female sitting on the sofa, awake, alert, and oriented. She's c/o sternal c/p, rates 8/10, described as "dull" and "constant". She's also co/o  n/v which started before the c/p Currently not vomiting, still feels nauseated. The c/p is non radiating, no diaphoresis, no SOB, and is mildly tender to palpation right above the zyphoid process. Only hx is HTN, takes antihypertensives. Checked a set of vitals...pressure was 150/98, HR 92 and regular, RR 18 and regular, SPO2 98% on RA. Put her on the monitor, SR w/out ectopy. Put her on O2, and loaded her up. 

We've got ridiculously short transport times to the ED...this one was around 5 min. I rechecked vital signs, gave her ASA, started a saline lock, considered doing a quick 12 lead but her outfit would have required me to completely undress her in order to perform a 12 lead, and we were only a min away from the ED at this point (any longer, and I'd have rigged up some sort of privacy screen out of a sheet or something creative like that, but were were almost at the ED). I verified no allergies, and was about to give her some nitro...when damn! She did a sort of tonic seizure thing for about 30 secs, then became unresponsive. I suctioned her airway, put her on a  NRB. She still had gasping respirations at about 10-12 a min. I noticed she was in a SB rhythm at this point, at a rate of about 45. Still had a pulse...

We were pulling  up at the ED at this point, so I elected to just throw the monitor on the stretcher and roll with it, instead of trying to work this mess in the back of an ambulance sitting at the ED parking lot....

Anyways, she coded and died, probably a massive MI.

So, I'm sitting here, wondering if there's anything I could've done differently....I care deeply about every single one of my patients, and the thought that I missed something that could've saved her life just eats me up inside....

What do y'all think?


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## rhan101277 (May 21, 2010)

I would have done a 12 lead on scene, just to rule in or rule out something.  You might would have detected it then, women have strange MI symptoms and don't always follow the books.  Just remember sometimes if you do everything right it still isn't enough.  If it is someone's time to go then its their time to go.


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## 8jimi8 (May 21, 2010)

para_god said:


> So, I'm sitting here, working on the never ending mass of paperwork, and I can't help but to think that I could've done something differently...
> 
> Here's what happened...
> 
> ...



Thank you for graciously ushering someone else on to the next level man.  The fact that you care about your patients leads me to believe that you did everything that you thought you could.  

I would have done a 12 lead on scene, but it sounds like she still would have coded in your box.  You just might have known that it was about to happen.  Do you all have any thrombolytic protocols?


All we can do is be compassionate ushers, into the next existence, or to the hospital.

When people die in front of you it leaves a mark.  Make sure you take care of yourself.  If your supervisor hasn't come in to chastise you, you probably didn't leave anything out.  Make sure you take care of yourself.





Make sure you take care of yourself.  Hope that you will! and feel free to pm me or continue blowing off steam here.


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## Veneficus (May 21, 2010)

> What do y'all think?


I think it went rather well from the best care perspective. 

Sudden death from major MI, nothing in the kit for that. You didn't waste anytime getting to the hospital. Which is what she needed. With a 5 minute transport, if you suspect your patient is serious, it is a fair judgement to not perform a 12 lead or a host of onscene interventions is the best choice. ASA, Nitro, and be on the way.

Since you were already following an ACS algorythm, anything more probably would have delayed transport. Performing interventions or working a code in a rig in the parking lot is wrong when there are expert minds, treatments, and more than enough hands only feet away. You didn't make that mistake.

The only intervention I think would have been worth stopping for was defib if indicated. (sounds like it was not)

It sounds as if you wanted an IV before nitro, which is often taught in medic schools. (I don't agree, I have no issue giving nitro w/o a line, but it is what it is) By using the "safe" logic for the decision I don't think anyone can find fault in it.

As for the 12 lead, they can do it in the ED along with a host of other things simultaneously. I don't see any significant changes its findings would have led to. By the time you got a doc on the phone and said you had or didn't have a STEMI but suspected an infarct all the same, you could be talking to her face to face.

I think you demonstrated extremely good judgement. Outstanding work on the part of a provider does not equate to a positive outcome for the patient.


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## Lt.Col.Warren (Jul 7, 2010)

It sounds like you did everying that you should have done. Unfortunately, at the end of the day we are just Paramedics and EMT's, and we don't get to decide who stays and who goes, but you did your best and that's all that you can do.


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## zmedic (Jul 7, 2010)

I know you didn't give nitro, but sounds like you were thinking about it. Just as a teaching point I wouldn't give nitro without a 12 lead. If she was having a big inferior MI/right sided MI you run the risk of bottoming out her pressure. Again, not the case here but the last thing you would want to face is someone in court saying "autopsy showed a right sided MI, you gave nitro without a 12 lead and then the patient coded and died, can you show that giving her nitro did not contribute to deceasing her coronary perfusion and hastening her death?" 

Also as to the argument about if you needed to do a 12 lead before transporting, it depends on your ED situation. If the closer ED didn't have a cath lab and there was a cath lab 10 minutes further away, having a confirmed MI could let you go directly to the cath lab ED (if your protocols allow.) In this case it didn't matter but if they had gotten a pulse back in the ED and there was no cath lab sorta an unfortunate situation.


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## WolfmanHarris (Jul 7, 2010)

Ya it doesn't seem like she was pre-arrest from the presentation. Have you considered PE? A saddle embolism might account for the instant decline and PE presentation is famously atypical.

Anything else would be very system dependent. Here we would 100% do a 12 lead on scene, since our ACP's can thrombolyze and then follow that up with a bypass to a direct admit into the regional cath lab. This would save tonnes of time in ED for them to do their own work-up. (Feather in my service's cap: Our Pt. contact to balloon time averages 84 minutes across the whole Region we serve. Beating the ED just downstairs from the cath lab.  )


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## skivail (Jul 7, 2010)

Looks to me like you made all the right moves given the situation.


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## jjesusfreak01 (Jul 7, 2010)

8jimi8 said:


> Do you all have any thrombolytic protocols?



Do they give thrombolytics in the ambulance in your area? Just a basic (student), but my instructors give me the impression that those should only be given after an exhaustive screen (for stroke patients at least) in the hospital. Not saying I would disagree (you cant kill a dead person), but it seems like something that the medical establishment wouldn't want medics doing in the field. Lets just say I would call it a progressive treatment, like induced hypothermia (my county does it post resuscitation for arrests, but not spinal injuries...yet).


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## WolfmanHarris (Jul 7, 2010)

jjesusfreak01 said:


> Do they give thrombolytics in the ambulance in your area? Just a basic (student), but my instructors give me the impression that those should only be given after an exhaustive screen (for stroke patients at least) in the hospital. Not saying I would disagree (you cant kill a dead person), but it seems like something that the medical establishment wouldn't want medics doing in the field. Lets just say I would call it a progressive treatment, like induced hypothermia (my county does it post resuscitation for arrests, but not spinal injuries...yet).



Big difference in thrombolytics for MI vs. CVA. For one, the research pretty clearly supports thrombolytics for MI, whereas for CVA it's contentious at best. Even though it's a standard of care, the research doesn't really conclusively support it. The reason a stat CT is needed for CVA is clot busting makes sense for ischemic strokes and not for hemmorhagic strokes.


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## 8jimi8 (Jul 7, 2010)

jjesusfreak01 said:


> Do they give thrombolytics in the ambulance in your area? Just a basic (student), but my instructors give me the impression that those should only be given after an exhaustive screen (for stroke patients at least) in the hospital. Not saying I would disagree (you cant kill a dead person), but it seems like something that the medical establishment wouldn't want medics doing in the field. Lets just say I would call it a progressive treatment, like induced hypothermia (my county does it post resuscitation for arrests, but not spinal injuries...yet).



I'm not sure about Austin treavis county, but I know San marcos / hays county does administer thromblytics. Their stemis often by pass the Ed as well


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## jjesusfreak01 (Jul 8, 2010)

WolfmanHarris said:


> Big difference in thrombolytics for MI vs. CVA. For one, the research pretty clearly supports thrombolytics for MI, whereas for CVA it's contentious at best. Even though it's a standard of care, the research doesn't really conclusively support it. The reason a stat CT is needed for CVA is clot busting makes sense for ischemic strokes and not for hemmorhagic strokes.



Ahh, right...you don't really see hemmorhagic MIs (what would that be, like a pulmonary vein rupture). I suppose they would probably be DOA. Im going to recheck the stemi protocol for my county. Thanks!


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## Smash (Jul 12, 2010)

jjesusfreak01 said:


> Ahh, right...you don't really see hemmorhagic MIs (what would that be, like a pulmonary vein rupture). I suppose they would probably be DOA. Im going to recheck the stemi protocol for my county. Thanks!



Spontaneous coronary artery dissection can occur but it is quite a rare beast (as opposed to having a wire poked through and perforation during PCI). They do have a high mortality rate but are survivable. I think they are more common peri-partum for some reason. The likelihood of dissection being the cause of ACS as opposed to thrombus means that thrombolytics for MI still make sense: it is highly unlikely that the cause will be dissection, and if it is, chances are they would die anyway regardless of thrombolysis making things worse. The same can't be said for stroke. 

I agree with rhan that women can have "strange" symptoms, but this is a textbook example of AMI, nothing subtle about it at all. It sounds like the actions taken were appropriate. Sometimes people die anyway...


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## FlightMedicHunter (Jul 12, 2010)

Sounds like you did well...........

Sounds to me like she had an upper aortic dissection.  Could have had the aneurysm right next to her heart which put mild pressure on the pericardium causing mild chest pain.  The fact that she brady'd down so quickly and went unresponsive so quickly tells me the dissection was most likely very close to the heart and probably superior to the heart as well.  

Not a thing in the world you can do about stuff like this.  I have been there a time or two.  Just learn from the situation and move on....


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## firetender (Jul 13, 2010)

What I appreciated most was that you were a highly competent mechanic while remaining an aware, sensitive human being. Good role-modeling!


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