One of the best things about EMS 2.0 is the ability to network and learn from EMS professionals all over the World.
Since I’m interested in ECGs and STEMI care I occasionally use the search engine at Twitter to see what folks are talking about when it comes to emergency cardiac care.
During one of those searches I came across this tweet by @in_the_city.
EKG geek? I’m your Huckleberry!
This piqued my curiosity so I answered @in_the_city.
To be honest I was expecting one of the obvious mimics of acute STEMI.
Here’s the story in @in_the_city’s own words (with minor edits).
“EMS is dispatched to an area nursing home that specializes in pediatric patients with special needs and other wards of the state. The patient is a 19 year old ventilator-dependant black male with a chief complaint of a low grade fever 99.8 F taken tympanically.
The patients physician has been consulted and while the patient is responding to Tylenol he wants the patient taken to the ER for rehydration and the probable insertion of a PICC line.
PMH: Cerebral Palsy, Hypertension, Diabetes, Asthma, Respiratory Failure
Meds: Not recorded
The patient presents as follows:
NonVerbal. GCS=4-2-4 This is normal for this particular patient.
Airway is patent, with a number 6 portex tracheotomy tube in place and connected to the facilities ventilator.
Breathing is being assisted by the ventilator, with the patient taking an occasional spontaneous breath over the programed rate.
Circulation is apparently being maintained, with a normal steady radial pulse and good distal pulses in the feet.
Blood sugar 118
PERRL pupils, clear bilateral breath sounds.
Skin parameters are all normal.
Taking our time we attach the patient to the transport vent with the following settings:
Assist Control Tidal Volume 500 RR 14 FiO2 40% Peep 5.
As per system policy, this patients is considered an ALS patient due to being on a vent so we attach our monitor leads and print a 6 second strip to put with the chart.
At that point, we felt like we were being punked by someone. The elevation was evident to the both of us, in our nonverbal no complaint having vent patient! But neither of us wanted to be less than thorough so we hooked up the 12 lead.
So, since I saw ST elevation, my partner saw ST elevation, and the stupid computer in our Zoll E series saw ST elevation we had no choice but to suspect that our nonverbal complaintless patient was having an inferior wall STEMI.
When we arrived everyone pounced on our patient… at least until my partner showed the physician our 12 lead and she informed us that we had “wasted her time”
She didn’t elaborate. We felt bad. Then found out that benign repolarization effects about 1% the population and is common in young black males. The way to tell the difference (apparently) is that the ST segments, while elevated are scooped.
It really threw me that the repolarization isn’t seen globally, and is localized in those dang inferior leads. But live and learn.”
So what do you think?
I’ll share my thoughts once you’ve had a chance to weigh in.
Other great case studies can be found HERE.