I’m still a student, but this was my first ALS call where I acted as the “paramedic” start to finish.
Obviously, all the details have been changed to make sure I don’t get stepped on by a HIPAApotamous.
Medic 22 was dispatched priority to a private residence for a 56 year old male C/O low blood pressure and feeling dizzy with a slight SOB. PT states he had been feeling unwell, with some chest pain and fatigue since yesterday afternoon following power washing his deck. The pain yesterday was described as a sub-sternal burning pain rated as “13 out of 10”. Believing this pain to be heartburn, the PT took OTC antacid and received no relief. This evening he was still feeling dizzy with some CP, and took his BP with a home machine. His BP was 84/52, so he summoned 911. The PT has a history of hypertension and takes Metoprolol 50mg, Amlodipine 5mg, Clonidine 0.2mg and HCTZ. There have been no recent medication changes and he has been compliant with his meds and is positive he has not taken any more than usual. The patient is also a smoker and has recently reduced his consumption to a half pack a day. PT denies any diaphoresis or nausea or vomiting. PT has no other complaints aside from the chest tightness, dizzyness and slight SOB. PT’s last meal was a turkey sandwich about 90 minutes prior to our arrival. PT is allergic to codine.
Upon our arrival, PT was found sitting on the edge of his bed. He had just extinguished a cigarette as we arrived. He was CAOx3, GC15. His skin was cool and dry and pulse was slow and weak. BP: 90/62 HR: 52 RESPIR: 16 SpO2: 96% on RA. The monitor showed Sinus Brady with a rate of 54 with no ectopy. 12 lead was unremarkable with no noted ST elevation. HEENT: No trauma noted, Pupils PERRL. CHEST: Lung sounds were clear and equal bilaterally. PT says his chest “feels tight. About a 4/10.” No radiation. No palliation. He states he has felt this way all day. ABD: Soft and non-tender in 4 quadrants. PELVIS: Intact. EXTREMITIES: No edema noted. His extremities were cold to the touch, with slow capillary refill.
PT to be transported to XXXXX ER ALS to R/O MI.
BSI, PT contact followed by interview questions and exam. PT placed on 2 LPM of O2 via NC. SpO2 to 99% with Oxygen. Vitals obtained. PT placed on monitor and 12 lead obtained. The patient was able to stand and ambulate without difficulty. He was assisted in walking approximately 10 feet from his bedroom to the front door where he sat on the stretcher and was placed in a semi-fowler’s position, covered with blankets and moved to the ambulance. PT was assisted into a hospital gown. IV access was established in the Right AC with an 18ga angiocath and a 500ml fluid bolus of NS was started. PT was administered 324mg of ASA and 0.5mg of Atropine IVP. Following the fluid bolus and Atropine, vital signs were reassessed. BP: 106/88, HR: 72, RESPIR: 16 Lungs remained clear bilaterally. IV drip rate adjusted to TKO. PT was administered 0.4mg Nitro SL. PT states chest discomfort is gone.Telephone report to ED was made. A second 12 lead showed NSR at a rate of 72 with no ectopy or ST elevation noted. On arrival at ED, PT was transferred to bed 8 via 3-man draw sheet lift and report given to Jane Doe, RN. PT care and transport occurred without complication or incident. Signatures obtained and Medic 22 returned to service.
Not an earth shattering call, by any means… but the first one I ran soup to nuts. And what I did made a difference.
It was pretty cool. I copied my SOAP here so I never forget how jazzed I was about this first call.
Cool! I’ll always remember my first too. Sounds like you’re having fun. Enjoy and take care!
Symptomatic bradyardia on your first ALS Tech call? Sweet. It doesn’t happen that way as often as you think.
I worry about the Atropine on this… a HR in the 50s isn’t terrible, although it sounds like the patient tolerated it well and improved with the dosage. I would have been curious to see what his right sided EKG looked like with the hypotension and slight bradycardia. Did you attempt a fluid bolus?
I’m just doing what I do to my students, btw. My advice to them is always this: “Know WHY you’re doing what you’re doing. Have a GOOD REASON to do EVERYTHING.” Simple is almost always better.
Good job though, this Medic stuff is fun.
Yes, fluid bolus in first, before the Atropine. He wound up getting 500ml and his pressure came up to 106/88, but his rate was still slow. (I grabbed for the Atropine when I looked at the monitor and his rate was 47.) My first though was that he had overdosed himself on the metoprolol. We did not run a right sided 12.
And thanks Chris…this is the kind of feedback I want. My preceptor was watching and helping, doing what I asked him to do, and nothing more. He told me the treatment was excellent and he was playing little tricks to see if I’d take the bait. For example, he grabbed the ASA and the nitro at the same time. I told him to hold on the nitro til I ran in some fluid and he smiled. You’re right… this Medic stuff is fun…and I really like being able to get from point A to point B on my own. This call ran just like a class scenario, but it’s so much more rewarding doing it for real.
Congrats. Ran my first ALS solo about 6 months ago and spent the next 3 days telling anybody who would listen. 6 months as a medic I still get the butterflies in my stomach when a “good” run comes in
Not sure what your protocols say but if he overdosed on metoprolol.. just saying… then perhaps maybe 1mg glucagon would help in this case…i dont recall the antidote for norvasc/clonidine but a beta blocker od would be glucagon…
Yeah… Great point. I was on the edge with the beta blocker overdose, but he was adamant that he hadn’t taken too much and that he hadn’t done anything outside the norm. So, in this case, I feel the fluid bolus and atropine, followed by nitrates and ASA was the prudent choice. (I’m still not convinced he didn’t take a few more Metoprolol than he should have…)
Nice job – good documentation, too. And it sounds like you’re off to a good start. I’m with Chris, BTW – a right-sided 12 lead would have been good to have, but it does take a little bit of time simply because you’re duplicating what you did on the left.
That said, I would likely have done the same as you with respect to the Atropine and the NTG afterward so long as he was able to hold his pressure. Curious – did you grab a BP after the NTG? And if you did was there any significant change?
No reason – just asking…
Walt, As I mentioned, my original thought was a beta blocker overdose. But since I was unable to ascertain if he did or did not take more than he claimed and I don’t carry enough Glucagon to make a difference, I was going down the symptomatic bradycardia route. Thinking his pressure was the culprit, he got a fluid bolus first, and there was no rate change. The atropine quickly brought him up to 70 (from 47) and he became pain free with one SL nitro. There was no appreciable pressure change after the nitro. Following the Atropine and fluid, he just looked better and and his mentation was a bit more crisp that it had been on arrival.
I’m just an EMT but am starting medic school in September. Did the atropine raise the bp up enough for the atropine? I know it has to be over 100 and was just wondering if that was what did it or did it just happen? Thanks!
I meant nitro for the second atropine. My bad!