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In disguise

Posted Mar 07 2010 8:28am
He is sat on the edge of his bed puffing through the pain. He has a bright red face and is holding his lower chest.

"Hello, my name is Louise, whats been happening?"

Between the patient and his wife I get a story of central chest pain and upper epigastric pain for half an hour. He has had a similar pain before but not as bad as this. He has had some recent blood tests and is waiting for other investigations into pain, the doctor has told him he maybe has ulcers.

While we've been talking his vitals have been popping up on the screen one by one. Oxygen saturation 99%, pulse 112, blood pressure 154/87. Nothing popping up as completely out of the ordinary, its not unusual for people to be tachy with raised BP when they are in pain.

We hook him up to the ECG. His appearance and history points towards the epigastric pain he has been getting but something doesn't fit. He doubles up with spasms of pain every so often. He is adopting the classic see-it-on-casualty* 'I'm having a heart attack' pose.

But he has a flushed face, his vitals including his 12 lead ECG are within normal limits, no radiating of the pain and no nausea or vomiting.

We decide to go with caution and treat him as having a cardiac episode. Aspirin and GTN are administered and an oxygen mask is attached to his face on high flow. I offer him entonox for the pain but he declines, he had it before for a fractured ankle and it made him feel sick. We're a double technician crew so didn't have the option of morphine for pain relief.

As we pull him into a majors bay in Holy Hospital he begins to vomit violently. On the way in all his vitals had been stable, not changes to the ECG even with the spasms of pain. I give my handover to Nigel*, one of the A&E doctors who is very pro ambulance service and a pleasure to work with. He agrees the ECG and presentation suggest an epigastric episode but that something isn't right about it.

A couple of hours later we're back at A&E and able to check on how our patient is doing.

"The first ECG we did was normal. Did a second as his pain was worsening and it showed a massive anterior MI**. He got sent to Central Hospital"

Central is the main centre for PPCI (primary percutaneous coronary intervention). This where a patient having a heart attack can go straight to the catheterisation lab to get the coronary artery unblocked. Its a brilliant service, instant definitive treatment.

As an ambulance crew we can go straight to the PPCI centre by sending them an ECG straight from the defibrillator. However in this case his ECG was normal and he wouldn't have been accepted, his MI didn't become diagnostically apparent until sometime after the initial onset.

But he still got the appropriate treatment in the end and from what I heard back he was doing well following a stent being put into the artery.

* Did anyone see Trauma on Monday night? Hands up who else spent most the time laughing or shouting at the TV?!

** MI, Myocardial infarction, heart attack. His ECG showed ST elevation of approx 3.5mm in leads V2-V4. Big heart attack!
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