82 y/o chest pain

[EMTRaven]

You're a BLS unit dispatched to a local rehabilitation facility for the back pain. ALS not dispatched as per EMD. You arrive to find 82 year old female sitting on a stationary bicycle with a rehabilitation staff person on scene. Patient is alert and oriented, complaining of sudden onset 15 minutes prior of upper back pain radiating into the shoulder and arm, and pain to the mouth. Patient denies chest pain. Patient is dry heaving and complains of feeling nauseous and weak. Patient's breathing is labored, pale sweaty and warm. Patient's son is on phone with staff, states patient has had a cold the past few days and he doesn't think she needs to go to the hospital. He states he is only a few minutes away and en route to scene. Staff says patient was on the stationary bicycle and begin to complain of back pain and shortness of breath. Patient takes Furosemide, Famotidine, and Losartan. History of Hypertension, COPD and surgery two weeks prior on the leg. Vitals 112/82 BP, 60 HR, 20 R. Son arrives on scene and is adamant that patient does not need to seek further medical attention. Due to configuration of building you will need a stair chair to go all the way outside to ambulance if patient is to be transported, definitely will be a project to move this patient. What do you do next?

Here are your closest resources:
- ALS Unit 10 minutes away
- Heart & Stroke Center 12-15 minutes away
- Trauma Center 17-20 minutes away

I've been an EMT for three years now and this was an actual call of mine. I want to see what other's would have done and then I'll say what happened after this

 

[MonkeyArrow]

What is the pt's mental status? Why is the son making decisions for her?

 

[Gurby]

Is the son the healthcare proxy? Is patient able to make their own decisions, and how does the patient feel about going to the hospital?

Obviously the story is pretty good for an MI, and PE is a concern due to the recent surgery. Let's call for an ALS unit (to rule out/in STEMI), and in the mean time get on the phone with medical control and have the son speak directly to a doctor who might better be able to convince him to allow transport.

 

[EMTRaven]

What is the pt's mental status? Why is the son making decisions for her?

Patient is alert and oriented, is capable of making her own decisions. Son is just very outspoken and adamant about her not going, he in no way has decision over patient, however she is definitely being swayed by the son. Patient is not convinced either way, but she trusts her son's judgement.

 

[Tigger]

I'd have my partner speak to the son elsewhere, and then ask the patient what she wants. If ALS has a decent ETA they should come, otherwise we'll just go to the hospital. The patient probably needs to be seen given risk factors, regardless of symptoms now. Give some aspirin, oxygen if needed, and figure out a way to extricate the patient from the facility.

 

[Akulahawk]

As soon as I heard the actual complaint and pain character, I'd have called for ALS to come. While the ETA to get her to the hospital is around 12 minutes after extrication, ALS can be there in 10 minutes and is capable of initiating cardiac care while on scene. Given that the son is being a bit of a pain and probably getting very close to interfering with my scene, the fact that I'm BLS, and there's a complicated extrication process going on, I would suggest that calling ALS would be the right thing to do.

Also, given that the patient is fully capable of making her own decisions, I would have my partner "talk" with the son away from the patient for a few minutes while I ask her what she really wants along with a very strong suggestion that her symptoms very easily could be cardiac. and that I have a very strong suspicion of that. If she decides to be transported and the son interferes, then I will have the son removed from my scene, up to and including, calling law enforcement.

 

[EMTRaven]

With this patient I ended up doing the following, I dispatched ALS to start heading towards the scene, and began talking with the son while my partner stayed with the patient. I brought him out to the hallway and explained her symptoms concerned me and explained that I had a paramedic unit coming to the scene that could put her on an EKG and see what her heart is doing. I explained to the son that I would like to take her outside to the ambulance, and that we would wait for the paramedics to come and assess her, and then we can go from there whether it be a refusal or transport. The son reluctantly backed down, and I went back to the patient and my partner and explained to her what we were going to do next. By the time we stair chaired her outside and started loading into rig, ALS arrived on scene. Son came in the back with us and EKG showed STEMI. Medics explained to son, and he turned as white as a sheet of paper. Patient, just being told she's having a heart attack, looks at her son and goes "I know you want my inheritance and all, but thank god I didn't listen to you!". Patient transported to the cath lab.

 

[Martyn]

"I know you want my inheritance and all, but thank god I didn't listen to you!".