One of our faithful readers, Nicholas Eisele, sent in this interesting case study. As always, changes have been made to protect patient confidentiality.
After a long night of car wrecks, you get dispatched right before shift change on a Sick Person call.
As you arrive, your partner states she may have been here once or twice, usually for chest pain. A woman is waiting for you outside.
You meet the patient's wife on the porch and she leads you inside to her husband, sitting in a recliner, holding his chest. He appears to be in mild distress with moist, pale skin. As you kneel beside him to begin your assessment he speaks up.
"I said don't call the ambulance, it is just indigestion."
Deftly you obtain a history while your partner grabs a set of vitals.
- Bypass x 5
- Stent placement, "last Christmas"
- Type 2 Diabetes
You nod your head while the patient explains his reluctance, "to miss a good tee time this morning". You coax a medication list from him as well.
His wife adds that he was up all night and vomited more than once. She also informs you he has, "serious morphine and PCN allergies."
Your partner taps you on the leg before she quickly runs down the vitals.
- Weak radials, "barely palpable"
- Pulse: 80, regular
- BP: 88/46
- RR: 24
- SaO2: 95% on room air
The cardiac monitor is attached.
The patient remains adamant that he does not need to go to the hospital. However, he consents to a 12-Lead ECG.
Due to his diaphoresis, it takes multiple attempts to acquire a readable ECG.
What is the rhythm?
What does the 12-Lead show?
Should this patient be allowed to refuse?