17 year old male CC: Syncope – Discussion

This is the discussion for 17 year old male CC: Syncope.

You may wish to go back and familiarize yourself with the details of the case.

Let's take another look at the 12-lead ECG.

It wasn't that long ago that I was trying to convince paramedics to perform 12-lead ECGs on chest pain patients.

I can still hear some of them saying things like:

  • "I don't need a 12-lead ECG to tell me when a patient is having a heart attack."
  • "I've never used 12-leads before and I've always given outstanding care."
  • "It's not our job to diagnose patients in the field."
  • "We're not cardiologists."
  • "It takes way too much time to acquire a 12-lead ECG."
  • "The hospital doesn't listen to EMS anyway."

Perhaps you've heard your own excuses.

Fast-forward to today and (at least in my EMS system) it's no longer debatable as to whether or not chest pain patients require a 12-lead ECG.

The new frontier is patients with syncope, general weakness, shortness of breath, etc.

In the first place patients with syncope, general weakness, or shortness of breath are sometimes experiencing acute STEMI (the anginal equivalents) and you've probably seen dozens of examples of each on this blog over the years.

On the other hand, sometimes they're experiencing complications associated with other problems that can often be identified with a 12-lead ECG if you know what to look for.

There were a lot of comments for this case that brought me back to the "old days" of hearing things like "it's not our job" or "we're not doctors." 

Paramedics are not board certified emergency physicians. That's true and I have no quarrel with that statement.

That doesn't mean we shouldn't do our due dilligence prior to allowing a patient (or guardian) sign a "no treatment, no transport" form, or an AMA form, or whatever you call it in your agency.

Any refusal must be an informed refusal. That means it's incumbent upon you to obtain a careful history, perform a physical exam, assess vital signs, and when appropriate record other diagnostic tests like a BGL, SpO2, or an electrocardiogram.

From there you should engage the patient (or the patient's guardian) in a discussion about the risks associated with refusing care, and it's extremely lazy and dishonest to tell every patient, "You may die if we don't take you to the hospital." regardless of what the complaint is.

I live in a subtropical environment that gets very hot and humid in the summer. We see 2.25 million tourists a year. They're not used to the climate and syncope is a very common complaint.

Is syncope a potential warning sign of a fatal condition? YES!

Is syncope often benign? YES!

Can a paramedic be trained to tell the difference between a high-risk patient and a low-risk patient? YES!

If the paramedic is not trained to tell the difference between a high-risk and a low-risk patient then the paramedic should be on the phone with Online Medical Control explaining the situation. Perhaps that's not a bad idea regardless.

In this case:

  • There was no family history of unexplained sudden deaths, faintings, seizures, drownings, or congenital heart diseases.
  • The patient's syncope was associated with difficulty swalling Mellow Yellow (it was not sudden or unexplained or exercise induced).
  • The patient "perked up" immediately after passing out. There was no post-ictal period and the patient was not incontinent of urine.
  • The patient's 12-lead ECG does not show arrhythmia, ischemia, prolonged QTc (446 ms is not significant), WPW or Brugada.

However, the ECG does meet the voltage critieria (for adults) in the precordial leads. However, no P-wave abnormality and no "strain pattern" is present.

Since the patient was only 17 years old and appeared to be a very athletic young man the treating paramedic felt fairly certain this was a normal ECG.

However, this is one of those occasions where the ability to transmit the 12-lead ECG to the emergency department came in very handy.

The 12-lead ECG was transmitted to the on-duty ED physician who reviewed the ECG and agreed that the patient was very low risk.

The patient (and the patient's mother) were advised that nothing life-threatening was found in the evaluation, but that EMS wasn't  giving this young man a "clean bill of health". They explained that EMS couldn't rule out all life-threatening causes of syncope in the field because we don't do blood work, we can't perform a CT scan, and that all diagnostic tests have a sensitivity and a specificity. In other words, it's entirely possible we're missing something. In addition, we're not doctors (that should please some of you).

A refusal was signed and the patient (and his mother) went back to their dinner. They were advised to call 9-1-1 again if they changed their minds or if symptoms returned.

In my opnion, this EMS crew did an outstanding job. If we're being completely honest about it we'll admit that some paramedics would have gotten on the radio and announced "false call" the moment the patient came outside and tried to cancel EMS.

How many of the rest would have been this thorough in their patient assessment?

In the last analysis the patient (or the patient's legal guardian) makes the decision as to whether or not the patient will be seen in the emergency department when the patient possesses present mental capacity. I've seen plenty of cases where paramedics have manipulated patients into refusing care out of sheer laziness or some kind of misguided attempt to spare the emergency department from seeing a patient who was a "non-emergency" in their opinion.

If find that to be appalling but that clearly wasn't the case here.

As a final thought George W. Bush experienced a similar fainting when he choked on a pretzel while watching a football game back in 2002. Remember that one? I still remember the detailed animations on the nightly news that explained how choking and coughing stimulated the vagus nerve.

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