A Tip

Instead of writing about one of my calls – I haven’t had much to write about lately — I’m going to write about a call a medic I know did a few weeks ago. In addition to being a good story, it is instructive.

The call comes in as a syncope. A basic crew responds along with the first responders. They find a fifty-year old woman who passed out while running on the treadmill. She has no medical history. She insists she is in good shape and refuses transport. Her vitals are BP 118/70, P-64, RR-18. A medic has been drifiting toward the location in case the basic crew needs ALS. The dispatcher checks with the basic crew, who relays what the first responders told them — that the patient is refusing so they won’t need the medic.

The medic, even though she has been told she is not needed, goes anyway (keeping herself available) — call it a sixth sense or whatever. She finds a woman who is pale and clammy, whose skin the medic says feels like a cold fish. The woman repeats she has no medical problems. No history, no meds, not even an allergy. But the medic will not take no for an answer. The patient finally agrees to let the medic do a 12-Lead ECG.

Even with the poor quality of the copy, you can see the tombstone ST segments in the inferior leads — the hallmark of an acute life-threatening heart attack.

Can we say on our way to the hospital? The medic gives the patient some aspirin and due to the possible right-sided MI, withholds nitro.

The hospital, notified over the radio by the medic, is getting the cath lab ready.

The medic drops the patient off, and then goes to write her paperwork. A few minutes later, her partner comes into the EMS room and tells her the woman just coded. The medic goes back down to check and sees the MD shocking the patient. The patient’s eyes open suddenly, she sits up, sees the medic and says “You again? What you’ve come back for a tip?”

Even the medic is speechless.

The patient then apologizes for going to sleep. The doctor has to explain that they were actually doing CPR on her, and they need to get her up to the cath lab right now.


You can talk all you want about medics with great intubation or IV skills, medics who get blood pressures back from dead people in arrest, but this medic saved this woman’s life simply by deciding to go on in and check her out. She knew that syncope is not something to trifle with and then seeing the woman, and knowing that a workout isn’t going to leave a healthy person that cold and clammy, refused to settle for a refusal.

The woman is lucky to be alive and people of her fair city are lucky to have a great paramedic riding their streets.

Well done.


  • Anonymous says:

    Good catch by the medic.That ekg is actually fairly good for showing not only the possible inferior wall MI in leads II, III and aVF but the reciprocal changes in the lateral I and aVL leads and also STEMI in V3 and V4.Why withold the ntg? There is the risk of drastically reducing preload, but if you have an IV in place, this is somewhat mitigated. I know some systems and physicians who suggest 250 cc NS bolus and then ntg in possible RVMI to maintain preload.Did the medic attempt a right sided ECG (at least V4R)?I’d probably consult with the base physician in this case.Regardless, kudos to the medic…

  • Stacey says:

    I was impressed to read that the medic didnt allow them to cancel her. That would have sucked if they signed the patient off. On a seperate note.Do you know how to get activated charcoal out of a white uniform shirt? I have already tried bleach, peroxide, and stain stick. Do you have any ideas?

  • PC says:

    You are right the ECG shows a much bigger infarct than simply inferior. My read on the shape in V2 (inverted ST) particuarly is that the posterior side may also be involved. She did two other serial ECGs which show the MI evolving and worsening. The medic didn’t do the right-sided ECG because she said the transport was so short and she had more immediate priorities, including getting the IV line and the radio patch to the hospital all while en route.One reason key reason she withheld the nitro which I wasn’t thinking about when I wrote the post is remember that the patient wasn’t in any pain. But also from what I have read and been told nitro in an AMI, despite its properties, hasn’t really proven to improve morbidity or mortality; its use is primarily to make the patient feel more comfortable. ASA and the cath lab are the real lifesavers. Studies are also showing by the way that Morphine actually appears to worse morbidity and mortality in MI, and it may not be too many years before it is removed from chest pain protocols across the country, if further studies confirm this.Our protocols for the right-sided MI say the following : “If 12 lead shows inferior infarct, consider right sided ECG. If right side leads reveal possible right ventricular infarct, establish a large bore IV, use NTG and MS with caution. Be ready for fluid infusion, monitor lung sounds.”My field guide, Emeregency & Critical Care Pocket Guide ACLS, as well as other texts, lists a right sided MI as a contraindication for NTG.I used to just put in large bore IVs and as you suggest give the patient a bolus and then NTG, but I had several episodes where despite the bolus the NTG dropped the pressure to the 70-90 range and I couldn’t get it back, so I pretty much avoid it now if I have a confirmed right-sided MI.And stacey, I have no idea how to get activated charcol out. That stuff is nasty.Thanks for the comments.

  • Anonymous says:

    Very true, neither ntg or morphine have been proven to improve pt outcomes in blinded, prospective studies. Most of the information against them however comes from uncontrolled retrospective studies where pts are not compared with similar cohorts, just their final outcomes of a large group. So the jury is still out. I wouldn’t be surprised however if there is a paradigm shift in care in the future when it comes to field ACS care.It really touches on the large subject of how much in medicine is based on anecdotal cases and tradition as opposed to science. Perhaps we’ll look at ntg in the future as we look at trepanning or leeches today…

  • Anonymous says:

    I found this blog while looking for info on RMI. We just ran one. Out PT was only complaining of being ” weak” she was cool and moist skin and first be was 60 sys. Of course nitro was out. 12-lead showed classic lateral with 2 3 and avf. V4R was unremarkable from what I could tell. Anyways by the time we got in the truck BP was down to 50 after 500ml of fluid. I ended up starting 5 of dope for inotrope only effects. We dont carry doubutimine. BP came up to 100/70 and no change in 12 lead. I was worrried about increasing the MI. Pt made it up to cath lab and is going to make a full recovery. Thanks for the blog. PS – there is no way getting charcoal out of a white shirt.

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