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.