We hope you enjoy this case, as always some details have been changed to protect patient privacy.
It's around 05:00 when the tones go off at your fire station for a medical response at a large apartment complex.
You leave the bunkhouse with the engine crew and check enroute. Dispatch relays you are headed to a 50 year old male with chest pain.
Upon your arrival to a first floor unit, you find the door unlocked and the patient sitting in a chair in his living room. He appears anxious, is pale and is holding his chest. The engine crew begins obtaining vital signs and places the patient on the cardiac monitor.
The patient tells you he was awoken from sleep with "some really bad pressure". He'd had the same pain, "come and go yesterday," and that he saw his doctor and was diagnosed with "strep throat".
When you ask about any other history he says he only has high blood pressure and high cholesterol, but denies taking any medications at all.
- Pulse: 56, strong and regular
- BP: 136/94
- Resps: 22, labored
- SpO2: 96%
- Skin: pale, clammy
The patient is placed on a nasal cannula at 4 L/min.
You perform a focused assessment of the patient's chest pain:
- Onset: yesterday
- Provocation/palliation: nothing makes it better or worse, not reproducible upon palpation
- Quality: "Pressure"
- Radiation: localized retrosternal, does not move
- Severity: 8 of 10
- Timing: "went away 8 hours ago, woke me up so I called 911."
One of the firefighters hands you the 3-Lead as your partner is placing the electrodes on for a 12-Lead.
The patient denies any medication allergies and is handed 324 mg of chewable aspirin. Your partner hands you the 12-Lead.
Due to the wandering baseline you ask your partner to work on a cleaner tracing. The patient is instructed to breath slowly and to stay still. After the second attempt your partner hands you the following 12-Lead.
The patient states he feels very nauseous.
You're 10 minutes from the nearest hospital, 15 minutes from the nearest PCI center, and your patient has been to them both.
- What do you think is wrong with the patient?
- Is the recent diagnosis of "strep throat" important?
- Should this patient go to the PCI center or to the community hospital?
- How would you continue treating this patient?