Old woman has a syncopal episode at the dinning room table. No prior history. The family says she was out 1-2 minutes. Her eyes rolled back into her head and she vomited. Can’t determine whether she vomited and then passed out or passed out and vomited.
She looks terrible, although she is alert. She says she feels weak, but she doesn’t want to go to the hospital. Despite her age she had no significant medical history and lives independently. Her pressure is 120/70. Here is her strip:
I tell them in any unexplained syncope, it is important to go to the hospital. I can understand how given the dinner occasion, she might not want to go. I am thinking this is a vasol vagal episode. I want to do orthostatics, just to see what happens, but she says she is too weak to stand. And then she is unresponsive and vomits again. Unfortunately the leads have come off due to her sweaty skin, but I manage to get new leads on all the while supporting her airway, and hoping she doesn’t code. Here is what I capture:
She wakes up and her rythm goes back to this:
We still insist she go to the hospital. With the help of her granddaughters, I get her out of her vomit drenched blouse and into a hospital gown, which I carry on the stretcher with the sheets.
We go on a non-priority. I put her on some 02 and put in an IV as we drive. Her color is much better. I get her demographic information, and then go to call the hospital. Right when I get ready to patch, I glance at her and she is vomitting again. I give a quick patch, “Sorry, my patient just started vomiting and is bradying down. Bottom line syncope at the dinner table. Be there in 5 minutes.”
I hit print on the monitor while I try to keep the vomit in the small garbadge pail I grabbed and off her face. The episode isn’t as long as the others and I can’t say she is unresponsive during it. We are already at the hospital now. I have her cleaned off, and we take her in.
I give the report, and then write my run form. When I see the doctor, he shows me her 12 lead. The computer printout says possible posterior MI, although it doesn’t jump out at me, and I’m not certain I agree. I show him my strips, and tell him this is what she was doing when vomitting, although she appeared normal at other times.
And then I look closely at the strip I recorded during the last vomiting episode. Here the ST is clearly elevated, but only for a few beats.
Its odd, but maybe what happens to her is similar to what happens when someone gets ST elevation during a stress test. She has a near blockage perhaps, which occludes during the stress of vomiting or is spasming. I’m not really sure.
I was surprised afterward that I didn’t do a 12 lead myself and wish I had. I normally always do. I was just sort of busy, and I guess I was just thinking it was all a vagal episode and/or an upset stomach, but maybe it was an MI, and so was lower on my priority list. I think I might have done one in the house if there hadn’t been so many firefighters and police offiders standing around the patient. I could have asked them to leave. Not that as health care providers, they shouldn’t be involved, just having so many people — firefighters, cops or medics makes it more awkward for the patient.
I’ll post more later on this case when I next see the doctor and I can get more information.
I have also noticed that it is easier to study a strip after a call, than during one. It is hard to pick out subtleties unless you really study the strip. I think I should also have said to myself — the irregular beats while she was vomiting are not typical of vagal episodes, at least in my experience.
I had another interesting call the same day, which I write about in my November log on my Capnography for Paramedics web site. It is another call where things aren’t always what they may appear at first glance.