I wish I could say that I spotted it right off the bat. That I stood up and said to the firefighters crowded into the small room, “Hey guys, somethin’ ain’t right. Let’s get a medic here now!”
We marked on scene. I knew we were in the area. The fire apparatus parked on the street corner was a dead giveaway, but I couldn’t find the house. I double checked the address on the MDT. It should be right here.
“Where is this damn place,”‘ I muttered to my partner as I checked house numbers with my flashlight, walking from mailbox to mailbox.
A little kid with no shoes ran out to the street to wave us in. The small house was tucked behind a chain link fence and a stand of trees at the end of the dead end street.
When Mark and I walked in, we found the tiny house was packed with furniture and relatives and a steaming rice cooker. It smelled like a luau and felt like a sauna. A crowded sauna. Tropical music was blaring from a radio as I walked toward the pile of BLS gear in the hallway.
The guy was 350 pounds if he was an ounce. The guy was sprawled on the queen sized bed, looking like he had the flu. The guy had said he’d been ill for the past week and now he felt weak and crummy and wanted to get checked out. The guy wanted to know if he could just skip this “ambulance stuff” and get a ride to the hospital from his wife.
“I started feeling really lousy about 5 hours ago,” he said. “My wife made me call.”
“Any pain in your chest?”
“Nope.”
We went down the list, asking the questions. Abdomen? Nope. Short of breath? Nope. We were looking for anything that might suggest this was more than a guy who simply didn’t feel well.
Yeah, his BP was high, but it was always high. He wasn’t compliant with his meds, he said. He couldn’t remember the last time he took his Lisinopril or HCTZ.
“Yes,” he said when we asked him about other medical issues. “I have diabetes. I take Glipizide and I just had some juice. I thought that my sugar was low and that’s why I felt crappy.” His BGL was 110.
His O2 sat was about 92% on room air. We got him on the cot, and I put him on 3lpm on a nasal and his sat went up to 96. It was a big effort getting the guy into the truck. It took 4 firefighters to help load him. They handed me a SOAP, and off we went.
As we were en route, I was doing another exam in the truck. I noticed his pulse was kind of thready, but rapid. His BP was 200 palp and he was diaphoretic and cool to the touch. In clinical terms, he was looking like crap.
“Shit.”
I told my partner to put his foot down and get us to the ER. I swapped the guy over to a NRB at 15.
We rolled in to the ER and the RN said, “Is this the ‘been ill for a week’ guy?” I nodded and said, “Yeah, but I think it’s an MI.”
Zip! Off to a Cardiac Room, quick 12 lead and yep, it was an MI. “Wow,” the doc said. “Look at that ST elevation .”
I had guessed right, but felt like shit.
We were so focused on the fact that he was denying chest pain and any of the other typical MI symptoms that we didn’t even consider that it might be cardiac.
Now I agree with the guys that say every patient deserves an ALS evaluation. Some Nitro for vasodilation was defiantly in order. Aspirin? Yeah, that would have been nice too.
Am I going to look at every “sick/unwell” patient a little closer? You’re damn right.
I’m not a medic yet. I have a lot to learn. And I don’t know about you guys, but I use almost every call as a learning experience.
Man the learning experiences in EMS is awesome. This is a very cool post M22!
Looks like you got caught by a silent MI.
“Silent MI’s” affect people, like diabetics, who have varying degrees of neuropathy that effect their ability to feel the ischemic chest pain. Diabetics are notorious for having these silent MI’s due to their roller coaster blood sugar levels playing havok with their nerves.
In these cases, MIs present as nonspecific weird general malaise cases. The kind of cases where people “Just weren’t feeling well” and then drop dead. A good and thorough physical assessment is always your best friend to guard against being pinched by these.
Oh, and always a 12 lead. If you don’t know what you’re looking at and nothing else fits… get a 12 lead
Great post!
Yeah, a 12 lead would have found it. However, there were no medics on this call. We were called for transport because fire decided that it was a BLS call.
This call makes a perfect argument for a medic on every call.
But, that’ll never happen here. Maybe at my next job.
This call does not make the perfect argument for ALS providers being sent to every call. The proposed solution doesn’t improve the crappy BLS service and would damage one of the world’s best ALS systems. Improve BLS. Don’t screw up ALS.
Every so often I have one of those calls that makes me think “Damn, I really should have [insert intervention/assessment here]…” just like you did. It’s true, you do learn a little bit each time it happens; it feels crappy, but it makes you a better provider, little by little.
In my perfect world: Every 911 Ambulance has at least one paramedic on board.
This has nothing to do with “crappy” BLS or “diluting” ALS. It’s all about raising the standard of care for every patient.
Let’s be honest, does every 911 call need a medic? No. Does every patient deserve a medic? Absolutely.
Again, it’ll never happen here. Not worth arguing about.
This type of thing will happen again, and again, and again…All through your career!!
There is absolutely no such thing as a ‘typical patient’. I have been caught with MIs before who really didnt present as such. I have wrote more than a couple of posts sharing these ‘learning opportunities’, just like you have.
I always go with my gut instinct. If I am thinking about leaving someone at home as I feel they dont need to go to A&E, then they get the works, just in case something crops up that I didnt expect. If all of that is fine too, but I am still not 100% happy then they are going to hospital.
I am sure I will be caught out again in the future, as we all will at some point, but I will do everything I can to make sure it happens as infrequently as possible!!
Interesting comments here.
“Don’t screw up ALS, improve BLS” – Timothy Clemans
“Let’s be honest, does every 911 call need a medic? No. Does every patient deserve a medic? Absolutely” – Medic 22
“Again, it will never happen here” – Medic 22
And you’re right about every patient DESERVING a medic, Medic22. They do.
Years ago, I lobbied pretty hard on some EMS message boards for all ALS ambulance services. I believed then that every ambulances should be staffed by Paramedic/Basic crews. The reasons for this were that “prioritizing” emergency calls at the dispatch center never works. It does on some levels, but invariably it will have severe consequences for outliers on both the very severe and less severe of the mistakenly “Phone diagnosed” conditions.
Some of that has to do with cynicism on the part of the EMS proividers. Most of it has to do with the limitations of the system design.
Here I am on one blog commenting that we should have more than one option to send to an emergency response, and on this one I’m lobbying for the opposite. Here’s why. In the current incarnation of EMS, a “prioritized” response is woefully inadequate and has the potential to hurt people based simply upon their understanding and ability to describe a medical condition over the phone to a minimally medically trained and overworked dispatcher. In the future of EMS 2.0 this will change, it hasn’t yet.
While BLS should very well improve, and I support the use of BLS units having the ability to obtain 12-lead EKGs and use other diagnostic tools (With minimal impact upon their treatment pathways), I also think that BLS only (and this is not a crack at their personal dedication) should not be sent to 911 calls without at least an ALS QRV responding to back them up. Every patient DESERVES a paramedic. We should not let the individual calling suffer because of our lack of ability to design a system.
“Again, it will never happen here” – That’s where you’re wrong my friend. Things are constantly changing and steadily improving. We will change the world
CK, I agree with most of what you said.
I like the idea of “EMS 2.0″ raising the standard of care. I like the idea that, at minimum, every truck that responds to a 911 call should have at least one paramedic on board. I also agree that a prioritized or tired response is inadequate, simply due to the fact that dispatchers and call takers get limited information from that 911 call.
Seems like we’re on the same page, doesn’t it?
But, when I say “it’ll never happen here,” I mean it.
See, I live in King County Washington. Do I need to say anything else?
The Paramedics in Seattle are members of the Seattle Fire Department. All of the other King County paramedics, with the exception of one agency, are also fire medics. All of the medics in King County are trained at Harborview Medical Center, in one of the most rigorous Paramedic education programs in the world. (I’m sure you know about the Medic One System.)
Well trained. Highly educated. Able to respond quickly.
So far, so good. Where’s the problem?
Well, in King County Dr. Copass runs the show. And here, the EMS model doesn’t include a medic on every rig. Sure there are Paramedics available, but they’re not on scene first, to make the determination if the patient is an ALS or BLS patient. It’s a fire fighter that makes that call. Not knocking the fireguys, because most of the time they’re on point with getting medics en route when they need them. It’s the situation like the call above.
I won’t back down on this: Every patient deserves an ALS evaluation. Even if it’s NOT an ALS transport, a paramedic should make that decision, and not have to be “summoned to the scene.”
When I suggest more paramedics, or (gasp!) Private Ambulance paramedics to respond with fire, I’m met with stony silence. People look at me like I have two heads when I suggest medics should be on EVERY call.
Sorry y’all. It’s the way I feel.
And that’s one of the big reasons I’m moving as soon as I finish medic school.
Heh, one of my buddies at the (SuperSecretJob) I have works and lives up there. He’s an EMT-B and the last time we met up we discussed it.
Did you get a chance to see my posts on the CCR stuff that we do here in Rural Wisconsin? I had a talk with my medical director about how our save rates are higher than King County’s. They are. *We* send a paramedic to every call.
You hit a point on there that I’m reluctant to harp on… However, I will. Firefighters are not EMS providers by definition. ALS/BLS determination systems only function properly when driven by proper and thorough assessment, not by cynicism. I’m not sayin, I’m just sayin’
However, I do respect the King County system. Don’t get me wrong. However… has it been too taken over by the interests of the FD?