What would you do

[nussy]

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

[AZCEP]

Remember this for the next time.

Good job treating the patient and not the ECG! Excellent work staying ahead of the problem, as well.

What type of industry is this in? Rather unusual to have that degree of medical staff onsite, that close to a receiving hospital.

The progression of the twelve lead's would be interesting to see.

[nussy]

We've got lots of chemical substances.

So there's an MICU and sickbay at all times.

nussy

[Ace844]

We've got lots of chemical substances.

So there's an MICU and sickbay at all times.

nussy

"nussy,"

Great job, and good work all around. I think what "AZCEP," was tryingt to ask you is the following:

A.) WHAT/WHICH Company is smart enough and cares enough about it's employees to devote both this kind of capital and extensive resources for their Employees..? {They should be commended}

B.) What Industry are you providing coverage for?

Hope this Helps,

ACE844

[nussy]

It’s a large company that provides maintenance to different kinds of vehicles.

I don’t think the company cares all that much. The countries law requires that if you use cretin substances than you must have a medical team; and it's more costly effective to treat them at work than to send them home to see the doctor…

[Just Plain Ruff]

Great job trusting your instincts Nussy

I had a similar patient a while ago - but their ecg was wierder

When they had pain their ST Elevation was incredible but when the pain subsided then the ecg returned to normal. The cardiologist who did the PCTA said that there was a large clot that was not too large to cause complete occlusion and it sort of just fluttered around the narrowing of the artery but when it got lodged at the narrowing the elevation recurred and then when we gave MS and the pain went away so did the pressure in the artery allowing the clot to float again.

It was really incredible hearing how this happened to the patient. They then delivered the clot busting drug directly to the clot itself and it dissolved and the patient has had no recurrence of this problem ever since.

[chbare]

Nussy, good call. I would bet the inferior wall of his heart was thanking you all the way to the cath lab.

Take care,

chbare.

[Eromitlab]

as others have said ALWAYS TREAT YOUR PATIENT NOT YOUR MONITOR!

ALWAYS watch for that impending doom look in their eyes! Good judgement and persistance!

[angelbaby1414]

[/font:579af26a4a] My rule of thumb-If a patient says he is gonna die or looks like he is gonna die...BELIEVE IT! GOOD JOB!!