You are called for severe chest pain.
The patient is a 38 year old male who describes the abrupt onset of a severe pain in his chest about 30 minutes before his wife called EMS. While sweat streams off his face, he tells you that he has never felt pain this intense. He isn’t sure if it’s pleuritic, and he endorses some shortness of breath. The pain radiates to his shoulders, back, and epigastrium. Despite the severity of the pain, he is actually far more worried that his left lower extremity is numb, and that he can’t move it – he repeatedly tells you in a loud voice that “Something’s wrong with my leg! What’s wrong with my leg?”
With the assistance of his wife, you find that he takes HCTZ and lisinopril for HTN, but he doesn’t smoke or use recreational drugs. In fact, he’s a coach for a high school cross-country running team, and looks like he’s in pretty good shape.
Vitals signs are
- HR: 50
- RR: 30
- BP: 230/140
- SaO2: 99%
Besides profound diaphoresis, the exam is unrevealing. An ECG is obtained:
You give him aspirin 325 mg, and 3 sprays of nitroglycerin, with neither a change in his symptoms nor in his vitals. In fact, 10 mg of morphine IV (max per your protocol) doesn’t improve the discomfort, and he is still yelling about both the chest pain and his leg. Your partner mutters to you “I’m starting to think this is mostly anxiety…”
It is almost 2300 hours. You have three choices of destination hospital:
- A “stand-alone” ED that is capable of delivering tPA for STEMI within 30 minutes. It’s just around the corner.
- A small community hospital ED that just started performing primary PCI, but they’ll have to call a team in from home. Despite that delay, they will activate based on a prehospital report, and their door-to-balloon times have been excellent. They are 20 minutes away.
- A level 1 academic hospital that is 35 minutes away. They don’t activate the cath lab based on EMS interpretation, since they usually “want to see it for ourselves.”