Hello to all,
I work at factory that has a sickbay (occupied by RN's and paramedics, and during morning shifts we also have a family doctor), when we have serious calls then we evacuate with our ALS ambulance (MICU).
A 56 year old man walks in 5 minutes before the shift ends, his complaint – "a strange feeling in his left upper shoulder", the way he stood and pointed at his shoulder resembled Levin sign.
The discomfort started half an hour ago and hasn't changed, he tried to sit and drink some tea waiting for the discomfort to pass, yet the discomfort remained and he decided to come to sick bay "just that he'll feel calm".
The feeling appeared suddenly and wasn’t provoked by anything, it doesn't radiate, and it doesn't heart, and doesn't have postural change.
Breathing – 16/min, lungs bi-latterly clean, SP02 – 98 RA, HR – 80/min, NSR, LOC – A and oriented, PERLLA, he's not diaphoretic or pale, except his complaint he looks fine, yet he's got that distressed gaze in his eyes, as if something is really wrong.
His history – during 1998 he had a PCI which was followed by a CABG, he hasn’t had any problems since then, he takes his aspirin once a day.
One month ago he was treated by our MICU and taken to the ER because he started vomiting blood (the aspirin caused a peptic ulcer, he was put on Omepradex).
We preformed a 12 lead and this is what we found:
I, AVL, V3, V4 – slight ST depression about 0.5-1mm (the T wave was slightly biphasic)
II, III, AVF, AVR, V1-2, V5-6- normal.
We didn’t have any old ECG to compare it to.
Because of his cardiac history we deiced to evacuate him to an ER, he wanted to go to a hospital half an hour away drive.
And this is when the argument began; one guy claimed its nothing, lets evacuate just for being on the safe side.
I was more worried and wanted to start an IV, MONA and Heparin.
The discussion was – should we give him the MI package? (1) The ECG findings and the clinical presentation aren't substantial and even rather ambiguous; (2) he had a recent peptic ulcer, that's a relative contraindication.
On the other hand he had that impending doom look in his eyes.
What would you have done?
How did the case end up? – We started an IV, put him on a non-rebreather mask, gave him 300 mg aspirin PO (chewing) and Heparin 5000 IU IV.
We convinced him to be evacuated to a nearer better hospital.
During the drive he mentioned the drugs made him feel better (that made us feel better – it indicated something is actually wrong with him).
When we arrived to the ED another ECG was preformed, this is what was found:
I, AVL –ST depression about 2-4mm and the T wave was biphasic.
II, III, AVF – ST elevation 4-5mm.
V1-2 – normal.
V3-6- ST depression 2-3mm.
The door to PTCA time was approximately 30 minutes.
The message of this case – sometimes you got to just trust your gut feelings
nussy