I am not trying to MMQB this medic, but a lot can be learned from this case. So please see my reply as an effort to point things out, not stand in judgment. The news article is poorly written as well. I didn’t realize there were EMS agencies performing heart echos and “heart attack” is a phrase of laypersons.
This case demonstrates exactly why more education is needed in EMS. There are several subtle signs here that point to a serious underlying problem which probably a large percentage EMS providers may not even know about.
Dehydration among athletes is a serious and complex issue, particularly in fluid and electrolyte balance. During recovery, it is important that pts be “watched.” Probably hooked up to some monitors too. Sports medicine and excercise physiology are their own disciplines and with good reason.
The fact the pt requested an IV shows that this is a recurrent issue. By itself it suggests that either this patient doesn’t properly pace his workouts in a healthy way or may demonstrate his inability to compensate in a normal physiological way to the intensity. Because of fluid and electrolyte shifts, adding IV fluid as a routine field treatment, especially in endurance athletes is not a good idea unless they are going to be transported to a hospital.
Epidemiology counts. The number one way that congenital heart defects, particularly long QT syndrome, DXed in males is in teenage athletes. This is not part of a normal physical and even if a 12 lead were made part of one, because there is a natural range it is very difficult for even experienced physicians to detect. Long QT generally progresses to torsades and obviously if untreated, death. (according to my personal research as part of a recent presentation in the matter, available on request, I am not posting my PPTs here)
The patient "paced around" is a subtle anxiety response. Which can be looked at as a slightly altered mentation. It is certainly a sign of shock.
Cramping is a sign of elevated uncompensated lactate levels. We all know lactic acidosis is bad, but not everyone knows what it can look like clinically.
When you take it as a whole, the physiology of fluid/electrolyte imbalance in athletes, history of dehydration requiring invasive care, subtle signs of shock, lactic acidosis which is a sure sign of inadequate tissue metabolism, and the number one circumstance leading to the detection of occult genetic heart defects, transport to a higher level of care would be a good idea. Placing the pt on a monitor would have been a very good idea, considering fluid/electrolyte imbalance may (but not always) show up. A 12 lead may demonstrate exactly the electrolyte imbalances. A simple pulse check may not reveal weak ectopic beats and certainly not the difference in high rate sinus tachycardia and a low rate V-tach.
Unless a minor in the country is not permitted to refuse, as stated could be the case here, I don’t really see any fault, just lack of knowledge which is not part of the current EMS curriculum and not noticing some very subtle signs of a potential serious problem. Perhaps if tachycardia and hypotension were present it would have been more obvious from the EMS standpoint but that is not stipulated here, not to mention if this was a conditioned athlete it most likely would still be within normal limits or even acceptable parameters.
The whole event seems very unfortunate for all involved.
