DFIB Posted May 31, 2012 Posted May 31, 2012 (edited) This is my first scenario so I hope I don't screw it up but I decided I gotta step up sometime. Please be gentle. You are going to an apartment in on the south side of town, not a bad neighborhood, but not the Country Club set either, for a chest pain. You have Engine 54 responding with you. It has a Lieutenant who is an EMT, one Paramedic, and two first responders. You are the paramedic, and your partner is a AEMT. As you arrive, all looks quiet. It's cold out, so there are no people out milling around. You go to the door and it is opened by a woman who looks to be in her 50's perhaps. She says she thinks her husband is having a heart attack. EDIT:spelling Edited May 31, 2012 by DFIB 1
Bieber Posted May 31, 2012 Posted May 31, 2012 Let's make patient contact. What does he look like? Skin, level of consciousness, work of breathing? Levine's sign? Let's feel for a pulse too, how's that? Describe your pain to me, sir. While you're doing that, let's get him on the pulse ox and get a blood pressure while we're at it.
DFIB Posted May 31, 2012 Author Posted May 31, 2012 (edited) Let's make patient contact. What does he look like? Skin, level of consciousness, work of breathing? Levine's sign? Let's feel for a pulse too, how's that? You see a man who the wife introduces as Lincoln. He is a tall, skinny man, about 60 years old, sitting on a small sofa. He is exhibiting Levine's sign. He is breathing rapidly and rocking back and forth. Pulse is 128 and irregular. EDIT: Skin is pink, warm and sweaty. Describe your pain to me, sir. While you're doing that, let's get him on the pulse ox and get a blood pressure while we're at it. "The pain is sharp, It hurts so bad; Can you help me?" BP is 168/100 in right arm. SPO2 is 97% -98% on room air. Edited May 31, 2012 by DFIB
Bieber Posted May 31, 2012 Posted May 31, 2012 Hi, Lincoln. Can you point to where exactly the pain is? Does it go anywhere? Let's push on his chest and see what kind of response we get. What makes it better? What makes it worse? Position? Exertion? Movement? Touch? Let's go ahead and put him on the EKG as well and get a 12-lead while we're at it. PMH? Meds? When did the pain start? Has it been continuous since onset? Have you ever had this pain before?
DFIB Posted June 1, 2012 Author Posted June 1, 2012 (edited) Hi, Lincoln. Can you point to where exactly the pain is? Does it go anywhere? Lincoln is clutching his chest at his upper sternum, "It hurts right here and goes straight through to my back" Let's push on his chest and see what kind of response we get. What makes it better? What makes it worse? Position? Exertion? Movement? Touch? Lincoln grunts and breathes sharply when you push on his chest. When you push you notice a depression in his sternum. Nothing provokes or Palliates the pain. Let's go ahead and put him on the EKG as well and get a 12-lead while we're at it. The ECG shows atrial fibrillation that's running from about 80 all the way up to 150. There are no ST elevation changes, but there are inverted T waves in Leads V1 - V4 PMH? Meds? Patient states "He was helping his wife fix supper" No cardiac history, he has bad knees and a shoulder that keeps popping out of joint. Meds: Patient takes Prinival and vitamins. He thinks the vitamins are Centrum Silver. When did the pain start? Has it been continuous since onset? Have you ever had this pain before? Patient responds "It started 15 minutes ago while I was helping my wife with supper. Nothing has ever hurt like this, I think it is getting worse" EDIT: spelling Edited June 1, 2012 by DFIB
Bieber Posted June 1, 2012 Posted June 1, 2012 Lincoln grunts and breathes sharply when you push on his chest. When you push you notice a depression in his sternum. The hell? Lincoln, is that normal for you? Any recent trauma? Ever had to receive CPR? The ECG shows atrial fibrillation that's running from about 80 all the way up to 150. Noted, his pressure is steady for now but I'll keep an eye on it. There are no ST elevation changes, but there are inverted T waves in Leads V1 - V4 I'm thinking anteroseptal ischemia based on that, however along with the rest of his presentation I'm growing concerned that this could be related to his aorta. Patient states "He was helping his wife fix supper" No cardiac history, he has bad knees and a shoulder that keeps popping out of joint. Meds: Patient takes Prinival and vitamins. He thinks the vitamins are Centrum Silver. Patient responds "It started 15 minutes ago while I was helping my wife with supper. Nothing has ever hurt like this, I think it is getting worse" Prinivil? Does he have a history of high blood pressure? How tall is he? Any history of connective tissue disease (Marfan's, Ehler's-Danlos syndrome, etc)? Great scenario so far, man.
DFIB Posted June 1, 2012 Author Posted June 1, 2012 (edited) The hell? Lincoln, is that normal for you? Any recent trauma? Ever had to receive CPR? Lincoln responds, "It has always been that way". Patient denies recent trauma and states "CPR? Is that that breathing sickness"? Prinivil? Does he have a history of high blood pressure? How tall is he? Any history of connective tissue disease (Marfan's, Ehler's-Danlos syndrome, etc)? Great scenario so far, man. Patient is 6' 5" tall He has been taking Prinivil for high blood pressure for about a year although "Sometimes I forget but remember when I get a headache" "I forgot this morning but took it about 2 hours ago" Patient states "A Dr. mentioned something about that "connector" disease when he fixed my shoulder but he was really expensive and I never went back" Hey Bro. How often do we get to run a scenario without everyone messing with your line of thought? Pretty cool. EDIT: Patient asks "Am I gonna die? It hurts really bad!" But he is hard to understand, his speech seems a little slurred. Edited June 1, 2012 by DFIB
Just Plain Ruff Posted June 1, 2012 Posted June 1, 2012 Yep you are gonna die. how's that for messin with your line of thought Beibs? 1
nypamedic43 Posted June 1, 2012 Posted June 1, 2012 Allergies? Specifically to aspirin or nitro. Any cialis or Viagra in the last72 hours? Any nausea? Rate the pain on 10 scale. Let's get him on the stretcher and on some oxygen. I would also be moving toward the ambulance and get a line in him.
Bieber Posted June 1, 2012 Posted June 1, 2012 Yep. Marfan's syndrome. He's tall, got pectus excavatum, hypertension, a history of a "connector" disease, sharp chest pain radiating to his back. No aspirin, definitely no nitro, no oxygen. Let's get a couple of large bore IV's NS TKO and take him in nice and easy non-emergency traffic. Let's also consider an anti-hypertensive (labetolol or metoprolol I'm thinking) and get him in. Let's also get another blood pressure and compare it to the opposing arm. He's got a bum aorta. "Lincoln, I think you may have a tear in one of the large arteries of your body. We're going to get you in and checked out by the docs. Try to relax and not worry, we're going to take very good care of you."
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