Stutter Steps

Attack One responds to a midday call for a man with difficulty breathing. His concerned wife meets the crew at the door and asks them to accompany her to the basement. She reports her husband is doing well at the moment, but when she called he was having jaw pain and had become short of breath. The crew finds the man in a basement bathroom, where he is changing out of his exercise clothes. He is in no distress.

They converse as he finishes cleaning himself up. He is 47 years old, in good health, and had some pain in the left side of his jaw while doing his daily exercise routine. He quit exercising, and the pain stopped. He got back on the treadmill and began running again, and the pain returned, and he got unusually short of breath. When he stopped his pain lessened, but he was still short of breath. His wife was concerned and called 9-1-1.

At this point the man says he is completely pain free and not short of breath at all. He wants to know if he and his wife can go to the hospital on their own.

The paramedic asks to check his vital signs and get some more details of his history before answering. Placing a pulse oximeter on the man’s finger, the crew checks a quick blood pressure. His oxygen saturation is in the high 90% range, and his pulse rate is regular and rapid. The paramedic asks about prior medical problems and any history of cardiac risk factors. The man and his wife say he is healthy and on no medicines, but he has an extensive family history of heart disease and strokes, and that is why his wife is so concerned. He has never had chest pain or heart palpitations or exercise problems. His last EKG was a year ago during a physical, and he was told it was normal. He has had no other heart testing. He has also had no injury to his jaw or recent dental problems.

Asked specifically about the episode of shortness of breath, the patient says it was fairly sudden in onset, just as his jaw started hurting again on the treadmill.

“Sir, if there is no other reason for your jaw to hurt and you suddenly got short of breath, we are concerned about you,” the medic tells him. “Even if you feel fine now, we all know those symptoms could be associated with heart problems. Would you please let us do a simple heart test and watch you on the monitor and take you to the hospital?”

The patient and his wife exchange uncertain glances, and the paramedic is concerned the man will refuse treatment. Making firm eye contact, he pushes a bit.

“Sir, that episode must have been pretty bad at the time, or you wouldn’t have said anything to your wife and had her call 9-1-1. I am glad you are feeling better now, but we would suggest you let us do an EKG and give you some aspirin and transport you to the hospital. We will monitor you, and you will both feel better after a thorough exam and testing in the emergency department.” That’s enough for the wife, who expresses her support, and the man concedes.

The patient has no history of aspirin allergy and so is given a dose, and his 12-lead EKG shows a normal sinus rhythm and no acute changes of any type. He is placed on the EMS cot. The patient and his wife request that he be transported to the community hospital a short distance away, although he has no local physician and has had no prior hospital treatment of any type. His wife starts closing up the house and will follow the ambulance to that hospital.

The patient is smiling as he’s loaded in the ambulance. But about five minutes into the transport, he tells the paramedic, “You know, that pain in my jaw has come back.”

The paramedic looks at the three-lead cardiac monitor and pulse oximeter. They show normal values and a regular pulse. The paramedic tries to check the man’s blood pressure but has trouble because the ambulance is bouncing quite a bit. He asks the driver to pull over. “We’re going to stop for a moment and get a good blood pressure and another 12-lead EKG to see if anything has changed,” he tells the patient. “I can’t do either well while the ambulance is moving.” The patient’s wife is in the car behind them and stops also.

As the paramedic connects the lead wires back onto the patient’s 12-lead patches, the patient says, “The pain is getting worse, and I feel a little short of breath again!”

The 12-lead spits out a piece of paper, and the paramedic interprets the results. He looks up and speaks calmly to avoid alarming the patient.

“Sir, this EKG looks very different than the one at the house, and indicates you are having a blockage in one of your arteries,” he says. “Your blood pressure and heart rhythm are fine, so I’m going to give you some medicine for your pain, and instead of going to the community hospital, we’re going to proceed very safely to a different hospital that has special services available for heart problems. It is a few minutes farther but has the specialists and facilities you might need. I’ll have our EMT tell your wife what we are doing and why, and that you’re still stable. We’ll ask her not to follow us, because we’ll be using our lights and siren to make sure we don’t get caught in this traffic, but we’ll proceed safely and comfortably for you.”

The EMT and paramedic confer, and they notify the wife and share the destination change with the dispatch center. The dispatcher alerts the hospital that a patient will be arriving in about 15 minutes who meets criteria for a cardiac alert.

The patient receives two nitroglycerin, and his discomfort decreases. The monitor shows an ongoing sinus rhythm, and his blood pressure is stable. En route to the hospital, the paramedic gives a report directly to the ED.

Hospital Management

The ED is prepared for the patient’s arrival. The paramedic gives the emergency physician the history, introduces the patient and shares the two 12-lead EKGs. The physician asks if the crew will keep the patient on their stretcher and monitor.

Quickly nurses apply an armband, draw some tubes of blood for lab tests, and lead the patient and EMS crew to the hospital’s cardiac intervention lab. That lab has been prepared for the patient, and he is immediately loaded onto its table. The cardiologist introduces himself, and the entire lab crew goes to work.

The Attack One crew returns to the ED to prepare their patient care report and clean their equipment. As they finish the ED charge nurse comes into the EMS room and says, “Great news. The cardiac lab called and said that man had a very high-grade blockage in one of his coronary arteries, which they have opened. They have some more work to do but think he’s going to do well. They are all grateful for your work.”

The patient in fact does well in the cardiac lab. He had only the one blockage and is admitted for a short observation period before being released home.

Case Discussion

This case demonstrates the unusual presentations that are becoming common in patients suffering from acute ST segment-elevation myocardial infarctions (STEMIs). The occlusion of coronary arteries can come on suddenly or occur on and off for some time. This is sometimes called a “stuttering” onset of symptoms. It also happens frequently with patients having strokes, occlusions of blood vessels in the abdomen, and in some other, less common diseases. EMS personnel may encounter these patients during these periods and must rely on descriptions of patients’ symptoms when they were at their worst for an idea of how serious they may be. It can also be hard to determine the exact time of onset of the disease if the patient has alternating periods of being ill and not ill. In trying to time the therapy for STEMIs or strokes, this uncertainty can be difficult. Time of onset is usually easier to specify for trauma, burns, childbirth and other medical issues.

This patient was taken to a hospital that had an interventional cardiac lab with which EMS personnel were familiar. The protocol at the hospital allowed for rapid movement through the ED and, as was demonstrated in this case, an opportunity to do a couple of key items before the EMS stretcher and personnel delivered the patient to the cath lab. A protocol like this must be approved in advance to be effective for the patient.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.