Routine

Most of EMS is routine. You punch in. You check your vehicle and equipment. You respond to calls. You drive cautiously, look both ways at the intersections. When you get to your patient, you ask the same questions. How are you feeling? When did it start? Have you ever felt this way before? What kind of medical problems do you have? You take vitals. You do your head to toe. Your IV, 02, monitor. At the hospital you give your report. Write your paperwork, and get ready to do it all again.

“Any good calls lately?” others ask.

“No, just routine,” you answer.

But every once in a while, you have a story.

So the other day about noon time we get a call for a stroke. Woman with right sided weakness. The first question I always try to answer is when did it start. If it started within the last three hours, we go lights and sirens to the hospital and call in a Stroke alert. If it started longer than three hours ago, we go speed of traffic. Less than 3 hours the hospital can give thrombolyitics to try to bust up the clot causing the CVA if they determine the cause of the stroke is a clot and the patient meets a host of other criteria. If it is over three hours, they generally cannot. (I realize there are some regional variations on the three hour time, but three seems to be the most commonly used.)

I find the woman sitting in a chair leaning against the wall. She has clear right-sided facial droop, but her speech is still understandable. She says she had a bad headache last night, and woke up weak this morning, and this weakness has been progressive. She had to use her husband’s walker to go to the bathroom. Her grip strengths aren’t too bad, and there is no pronator drift. Her BP is 130/70. Her heart rate is 56 and a little irregular. No prior CVA history. She has Hypertension and has had a cardiac stent placed. She is in no pain.

I reconfirm that she woke up this morning with the facial droop and weakness. We’re talking six hours ago. So we get her on the stretcher and start to the hospital, routine post-clock CVA going with flow of traffic. Unless I need to, I usually do most of my care in the ambulance. En route to the hospital, I put the woman on a cannula, pop in an IV, put her on the monitor. I apply electrodes to the chest leads and then put them on the patient’s chest. Every CVA gets a 12-lead. Routine. I ask her age – 75, and then hit the button.

What I see catches my attention. That can’t be right. Maybe we hit a bump at just the right moment.

I repeat the 12-lead. I repeat it again just to be sure.

I stare at it. Elevation in I, V5 and V6 with reciprocal changes in V2 and V3. It looks like the patient is having a STEMI – a ST-Elevation MI – a heart attack.

“You sure you are not having any chest pain?” I ask the patient.

“Well, I am having some,” she says, “but it’s not too bad.”

“Jim,” I call up to my partner. “You can hit the lights on.”

I call the hospital and ask for medical control. “I have a bit of an odd call here,” I say. “I have a STEMI/STROKE Alert. Patient woke up with right sided weakness. While her grips are strong and equal, she has clear new onset facial droop. I also just did a 12-lead that looks as if the patient is having a STEMI. She is now admitting some chest pain.” I describe the patient presentation in more detail as well as history and a more specific description of the 12-lead. “I have withheld the aspirin unless you want to go ahead and give it.”

In the ED, they have a team waiting for us.

“What do you have?” a nurse asks.

“A STEMI and a CVA?” I say. “Looks like it anyway.”

They repeat their own 12-lead (as well as a neuro exam). The MI takes the priority and they send the patient right up to the cath lab where they find a blockage in the Right Coronary Artery and place a stent. Next stop CAT scan confirms an embolic CVA as well.

While the patient faces recovery from the CVA, at least she didn’t arrest waiting in the triage line. The speedy trip to the cath lab no doubt saved some heart muscle.*

Once again routine earns its pay.

*I am confident the hospital would have eventually done a 12-lead as well because they have their routines, too.

10 Comments

  • CBEMT says:

    Good catch. Our stroke center has the relatively new invasive catheterization technique (the actual name always escapes me), which they tell us can increase the window for effective treatment to as much as eight hours.

  • Jess says:

    I did a similar job recently. I also do my 12 leads on ?CVAs en route, and was rather surprised to have an antero-lateral STEMI appear.

    I wasn’t heading for a PPCI centre, and the patient had multilevel other problems, so I called our clinical advice line. They told me to carry on to the local hospital as CVAs can sometimes produce ST elevation without an MI.

    The doctor at the receiving hospital hadn’t heard of this and was less than impressed with my not having taken the patient for PPCI. However, I expect the PPCI centre would have turned me away.

  • medicscribe says:

    While waiting to get follow up on this case, a doctor mentioned to me what you also heard that CVAs can produce ST elevation. That was new information to me, too. This lady turned out to be a true MI. In my area the three hospitals I transport to all do emergency caths.

  • Jess says:

    Did the doctor explain the pathophys behind that? I looked, but failed to find, anything in the literature.

    As it was explained to me, it’s not a STEMI, rather the stroke causes ST elevation without myocardial damage.

    It’s presumably possible for someone to have a thrombotic stroke and an MI at the same time if they’re very unlucky though!

    We have not long stopped thrombolysing (UK) and several of our cath labs don’t have any ED facilities, so making the right call in the field becomes especially important.

  • EZIO says:

    I had the same call a couple of days ago Pete lady found unresponsive by family with unknown downtime, no response to verbal or painful stimuli. Her mouth was completely clenched so to protect her airway she bought an NPA which she didn’t react to either. I was thinking CVA because she had a right sided gaze with intermittent periods of nystagmus. Unfortunately we were BLS and reallllly close to the ED so we took her in with no intercept and sure enough we we got to the ED and they did their routine 12 lead they found a STEMI. Later I found out he was also having an ischemic stroke (I think he said posterior circulation infarct.)

  • Renee says:

    Actually, some of the current thinking is that more patients are actually having a CVA at the same time as an MI, and this might be the cause of the “cardiac fog” that some people appear to be in during the weeks and months after an MI.

    Over the past few years, I’ve had a few patients who had CVAs at the same time as an MI. Usually, they reported mild to moderate chest pain up to 24 hours prior to the CVA symptoms, and then the onset of more moderate chest pain. I did have one gentleman who started with the MI and then had the CVA… his outcome was surprisingly good, since he had thrombolytic therapy very quickly, and got stented in the cath lab w/in 1 hour of onset. Heart muscle and brain preserved (with minor left side deficit – unless you saw him tired, you’d never know he’d had a stroke).

  • Ben says:

    Ok,
    This is too weird. Up to this point in my career I had never seen this phenominon. Just this past week I had a similar case. All S/S pointed toward CVA. As we were headed into the ER we placed the pt. on a 12-lead and both my partner and I were floored at what we saw. STEMI! CVA and STEMI simultaniously? And now I find this article? Is this coincidense or what? Thanks for the article!

  • Brian says:

    A few article abstracts… a little dated but…

    http://journals.lww.com/neurosurgery/Abstract/1986/01000/Subarachnoid_Hemorrhage_and_the_Heart.19.aspx

    http://content.onlinejacc.org/cgi/content/abstract/24/3/636?ijkey=5db9c4ba66dd73ae36c725b879ac5db165e00f1f&keytype2=tf_ipsecsha

    But after scanning through some articles it become apparent that medicscribe’s patient is a true rarity; her CVA was due to a clot, not a bleed so the ST-segment changes demonstrated in these abstracts doesn’t necessarily apply here. I couldn’t find any articles relating to a thrombotic CVA being the cause of ST elevation on EKGs. And, as Medic states, his patient was found to be having two separate medical events confirmed with CT and Cath. Interesting case indeed…

    Medic, love your blog and your books, keep up the good work!

  • Tom B. says:

    Wow! Really interesting. Aortic dissection would have definitely been on my list of possible causes (the only diagnosis I can think of that could explain both the stroke symptoms and ECG signs of STEMI). Fascinating that the patient had both! I wonder if she had a clotting disorder.

    Tom

  • medicscribe says:

    Thanks for all the great comments. Sorry for the delay in approving them.

    Peter C

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