Monday, November 29, 2010

Go with your gut!

It was the first call of the day on the week of Thanksgiving. It was cool and blustery outside, raining on and off. The leaves, which had made their final curtain call, were ablaze in yellow, orange, and red; contrasting the dull, gray, overcast skies that threatened us ominously. Many of the leaves had already made the leap to the ground creating colorful, yet slimy masses waiting for an ambulance to try and take a corner too quickly.

My partner and I were wearing our rain gear, which is too hot for sitting in an ambulance, but too difficult to deal with taking on and off each time we get in and out. Besides, our seats were already wet from our clothing, so we would have to deal with it.

The call was in a more upscale part of Oakland. This particular part is walking distance from a quaint section of downtown that has a Main Street feel to it. The patient had already been walked down to the portico and was sitting on the front steps, protected from the rain. He was wearing a T-shirt, jeans, and sneakers and was not looking like today was his best day.

Using and umbrella in the 911 system is not an option. Not only does it limit where you go, it also takes away a valuable hand that you need to do the job correctly. We put up our hoods and made the dash from the ambulance to the doorway without the gurney. It was raining hard enough that taking the gurney out would be a bad idea unless it is absolutely necessary.

“So what do we have?” I asked the Lieutenant.

“Looks like abdominal pain” he responded.

“Might be cardiac” the medic said and raised up the sublingual nitroglycerin spray pump to the patient’s mouth.

“Hold on…” I tried to stop him from delivering the spray. It was no use. He was on it.

When nitroglycerin is delivered for a suspected cardiac event, most notably indicated by chest pain, it causes vaso-dilation of the coronary arteries and often relieves the pain. This is good. The problem is, it often can hide the indicators of a heart attack from the EKG until the medicine wears off. Time we don’t have to waste.

“OK, let’s just get him in the ambulance.” I said wanting to get things moving along.

We loaded the patient up and I got to work assessing him.

“Any chest pain sir?”

“Nope. Where is my newspaper?” he asked. Really odd question given his situation. Where were his priorities? I thought.

“Any shortness of breath?”

“Nope” he was however breathing faster than normal and appeared anxious. I put him on oxygen anyway.

His behavior had me a bit confused. Where was this call going? He was sweaty and it was cold out, but it was possible he could have been in the rain this morning or could still be damp from a shower. I asked and both of these answers came back negative.

“Where exactly does it hurt?”

It’s like heartburn, right here” he said pointing to his upper stomach, right where you would expect acid reflux or a hiatal hernia to hurt. “My wallet is in my back left pocket in case I die.” He added nonchalantly.

I started to wonder about this talk we were having.

“Any medical history?”


“Allergies, medications, eat anything unusual? Acid reflux? Nausea, vomiting, diarrhea, blood in stools or urine? Any cardiac history? Diabetes? Ulcers?”

The answers were “no” to all of those questions.

While I was asking these questions I was taking vital signs and hooking him up to the monitor for a 12 lead electro-cardiogram. I shot the EKG and it came back negative for clear signs of a heart attack, but did show some depression in the ST segment; this was a possible harbinger of impending doom.

My partner was standing in the rain at the end of the bench by the open doors typing the info into the computer as I spit it out to her.

“So, what do you think?” she asked quietly. I leaned into her to talk, out of earshot of the patient.

“I’m not sure. My gut is saying cardiac, but I have nothing showing. Maybe it’s just anxiety or psych?” I half-asked, half-stated.

“Is that dynamite?” The patient loudly asked pointing to our road flares with an anxious look on his face.

“Yeah, we carry dynamite on all emergency rigs in this county. You never know when you are going to need to blow something up” I replied sarcastically.

He took the answer at face value and didn’t question it.

I looked at my partner with a look that said “See what I mean?”

“Let’s just roll to Summit” she said. “They are a cardiac center anyway, best place for him either way."

We were literally blocks from the hospital so I had my partner go ahead and go code 2, but alert them that we are suspecting a cardiac patient, but we don’t have the proof.

In route I took another couple of EKGs. They were all still negative, but it was progressing.

“I can’t get this guy to shoot an MI, but he totally looks like one” I yelled up to my partner.

“Maybe try a right sided EKG?” she suggested. It’s nice to have a smart partner.

“Good idea.” I tried it, but still no indication clearly pointing to the heart attack I new this guy was heading for.

This is when the fear and doubt sets in for paramedics. We are alone out there and have to follow three simple steps: Assess, Decide, and Act. Assessing is easy. So is acting. It’s the deciding to act that is the problem in these borderline cases. Do I act conservatively and go full cardiac? What if this guy is just a psych case and has us fooled? What if he is just an odd-ball with an ulcer starting? What if his references to his own death are his sense of impending doom that sets in prior to cardiac arrest? Do I want to give four aspirin to a guy with a stomach acid problem? Why is he sweating? Am I so sure that I am willing to risk the trust and reputation I have built with the Emergency Room staff on a gamble? All of these thoughts and many others immediately swirled in my head.

Assess. Decide…

Assess. Decide…

Assess. Decide…

I kept stalling out.

I closed my eyes for a second and blanked my mind. I decided to open them and go with the kind of patient I saw when I opened them.

Eyes open:

CARDIAC. It was clear as a bell.

This entire evolution in my mind took about 15 seconds but felt like an hour.

I quickly fell into the routine of treating a cardiac patient. All doubt was gone. My sense of calm had returned and I was working through a familiar protocol in my mind. Oxygen, Nitro, Aspirin, IV, vital signs, backup EKGs, blood sugar. The next two blocks we drove were like clockwork.

I could hear the familiar beeping of the ambulance backing up into the bay. I thought to myself, what musical note is that? Enough of that nonsense, we were here and it was time to switch everything over.

I was met by the triage nurse in the doorway. He was a bit confused as to what we were bringing in.

“So what is this now?” he asked.

“ABD pain, epigastric, feels like heartburn. It looks cardiac to me. Can’t get the EKG to back me up though. Good depression in the ST segment.” I said with confidence.

“Put him in X” the nurse said indicating the room for the stat patients.

I gave my turn over and got to work on my paperwork. The nurse walked out of the room telling me that they were getting a “positive” for an MI. A heart attack. The Nitro had finally worn off and the heart attack was showing through on the diagnostic equipment. It got really busy in there. Chest X-rays, preparations were made for the cath-lab and the patient was whisked away.

An hour later we were back at the hospital and I was told that the patient had suffered a massive heart attack. His lateral anterior descending coronary artery was 100% occluded; it needed to be cleaned out and stented in order to restore adequate blood flow to the muscle of the heart before the tissue dies. I looked at my partner and she at I. We were right. Dangerously close to not being right. If we had brought him to another hospital that say was not suited for cardiac care there would have been valuable time wasted in transferring him to a cardiac center. This delay could potentially result in unrecoverable cardiac muscle tissue that would significantly reduce output.

The cardiologist and nurses all echoed my sentiments that this particular patient was a peculiar one. He was very anxious, kept asking odd questions, and needed to be given ativan to control his anxiety. The odd things is that his anxiety was not directed at the fact that he was suffering a heart attack, or at least he didn’t point to that. He was more worried about his clothing, the time, his newspaper and other seemingly insignificant worries.

In my younger days, (without dating myself too much) REO Speedwagon, a Canadian rock band had a hit called “Should I Follow my head or follow my heart” that while they applied it to relationship choices, still rings true. Your mind can talk your “gut” out of making decisions that at a base level you know are correct, perhaps you just can’t articulate why in a manner suitable to satisfy your intellect. I thought about this and decided from here on out, I am going to follow my gut more. I’ll see how it goes.

copyright 2010 Jon Kuppinger