Effing diabetics...

[Asysin2leads]

Ready for this one?

61 year old female, called for 'cardiac'. Pt reports having severe epigastric pain for the past 2 days, has not been eating well. When asked about the cardiac call, patient son states she was having chest pain, but is quickly corrected by his wife (okay, not really his wife, more his baby's momma) that it wasn't chest pain it was pain in her abdomen, but lower. Pt. denies chest pain, only pain in periembilical area, severe,sharp pain occasionally radiating to back, 10/10. Negative nausea/vomiting, negative blood in stool, normal bowel movements. Negative SOB, Negative dizziness. Speaks no english, son is used to translate.

PMH: Diabetes type II controlled by medication, HTN, high cholesterol, ulcers, negative cardiac history

NKA

Meds: Norvasc, Zocor, Simvastatin

Vitals: BP 110/80, RR 14, GCS 15, Pulse: 54, SP02: 97% on room air, skin warm, dry, unremarkable

PE: perrl, negative cyanosis, negative JVD, trachea midline, negative accessory muscle use, equal chest expansion, lungs clear bilaterally, abdomen soft, non-tender, negative pulsating masses, negative incontinence, PMS present x 4 in extremities, negative edema.

EKG: Sinus Bradycardia, rate 54

12 lead: Isoelectric, minor T wave abnormality noted in V1, nothing I haven't seen before in a normal healthy adult

TxN: Administered 02 10lpm v/NRB, obtained IV access 20 gauge in L AC with 250 cc bag @ KVO.

Okay, so pretty straight forward, right? History of ulcers, reported severe pain in abdomen, but does not show physical signs of extreme pain, history of ulcers. Her rate is the only thing concerning me, there is absolutely no evidence of her being on a beta blocker, so her rate really doesn't fit. However, she is asymptomatic, with a stable BP, clear EKG, resting comfortably on the stretcher. Perhaps shes just one of those members of the population with a lower heart rate, but it still raises the index of suspicion. We start taking a slow easy ride to the hospital, no lights or siren at this point. Upon applying the NRB, I notice she is starting to cry. When I ask her through her son what's the matter, she states that she is afraid that because I am giving her the NRB that something is seriously wrong with her. I tell her not to worry, she'll be fine, that she was doing fine and everything so far was checking out. But honestly, I could see she was really scared, and it bothered me, raised my medic-spidey sense to think there was something else going on.

At the next stop light I do another quick 12 lead. What the hell, why not. This one is so drastically different than the one I did three minutes before that I couldn't believe I was looking at the same person. Major ST depressions in Leads V5, V6, and II, III, and aVF. I tell my partner what is going on, ASA, NTG, notification to the hospital, vitals held all the way. 15 minutes after arriving at the ED, she was being prepped and on her way up to the cath lab.

One of these days, I tell you, one of these days, I will have the 64 year old overweight chain smoker who is pale, cool, and diaphoretic breathing 40 times a minute and clutching his chest, who's family all died at age 35 of cardiac problems. Until then, I'm never going to catch a break with presentations. Effing diabetics, don't they ever read cardiology primers?

[Dustdevil]

One of these days, I tell you, one of these days, I will have the 64 year old overweight chain smoker who is pale, cool, and diaphoretic breathing 40 times a minute and clutching his chest, who's family all died at age 35 of cardiac problems.

Word!

Sometimes I genuinely wonder why we even bother to teach the "classic" presentation to our students anymore. It almost seems to be an extinct animal these days. I've had two AMI patients out here so far. One presented with a toothache. The other presented only with nausea and vomiting. And both were very young too. On the other hand, I have had two middle-aged patients here who presented with "classic" AMI signs and symptoms who turned out to be nothing but GERD. So much for the classics!

[medic001918]

Great pick up. Glad you trusted that something wasn't right and thoroughly worked up your patient. This makes a great case for doing repeat 12-leads during transport.

Few patients read the book of presentations...

Shane

NREMT-P

[Ridryder 911]

New text:

Presentation of an AMI: Chest pain or may be described as chest pressure. The potential pain may be described as radiating into left arm, back, jaw. Diaphoresis may or not be present with episodes of nausea and vomiting. Pain may or not be present nor the patient may have any of descriptions or symptoms as noted above; especially if female, or known diabetic. Treat accordingly

[medic429]

Good job Asys!!!

:wink:

[AZCEP]

Didn't your dad teach you not to trust what women tell you?

Over 40, +/- female, diabetic, complaint from the waist to the ears is a cardiac event until proven otherwise.

[hammerpcp]

Didn't your dad teach you not to trust what women tell you?

Hey now. I think its rather a problem with interpretation, either that or you just weren't listening.

[fiznat]

Over 40, +/- female, diabetic, complaint from the waist to the ears is a cardiac event until proven otherwise.

haha I like that!

Man, scary case though. As I was reading, I have to admit my eyebows were raising a little bit with your choice of the NRB. I probably would have just given her a cannula at 3-4lpm. ...Mostly cause of the restrictive/stressful nature of the NRB and the apparant lack of necessity here. Big surpise to find out this one was actually something real-- very nice catch. Kinda scary to see that. I know LOTS of medics who would have jumped at the chance to downgrade this one.

By the way. I'll add this in cause I'm still a medic student and I like asking questions. Is this a true case of "treat the monitor, not the patient?" ...Cause while the EKG obviously did change drastically enroute, it seems that the patient's complaints and presentation did not.

[ncmedic309]

Keep in mind, most cardiac patients present initially with normal EKGs (over 50% of them)...

If it sounds like it's cardiac, then it's probably cardiac...

[Asysin2leads]

The old adage is "treat the patient, not the monitor", and yes, if this was simply a case of a completely asymptomatic patient who all of a sudden showed EKG changes, I'd probably rap the monitor a few times and try again. However, it was more that the EKG changes were the final piece of the puzzle that fell into place. Before the EKG changes, I wasn't 100% sure of what was going on, but was leaning towards GI distress, but after the EKG changes, I was 100% certain of what was going on. As for the NRB, I always use an NRB. I usually only use the nasal for either someone who can't tolerate the mask or to hold a broken tech bag closed.