This another great case study from Vince DiGiulio, EMT-CC. As always, some details have been changed to protect patient privacy.
It's Monday night and you're working triage in a busy emergency department. The waiting room is full when a very pleasant 62 year-old man presents to the desk with a chief complaint of chest discomfort. You sit him down in a wheelchair while he gets registered and perform a quick "eyeball" examination.
The patient is a well-appearing middle-aged male in no acute distress, who actually appears younger than his stated age. He is alert, oriented, and answers all questions appropriately, with skin that is warm and dry and a strong radial pulse that's not too fast or too slow. His breathing is unlabored and he states that he has been experiencing some minor chest discomfort for around for two days.
You figure that he's not going to collapse in the lobby and leave to speak with the triage RN while he signs some paperwork. The two of you decide to bring him back to the dedicated ECG nook, where the nurse will perform a triage assessment while you obtain vitals and run a quick ECG.
- Onset: 2 days ago
- Provocation/Palliation: He cannot describe any provoking factors, but states "I usually rest and it eventually goes away"
- Quality: Midsternal chest pressure
- Radiation: None
- Severity: "Not bad at all, maybe a 3 out of 10."
- Timing: Intermittent, with spells lasting for 10 minutes or so and possibly increasing in duration more recently. The current episode has lasted at least 15 minutes.
Using an automated monitor, you obtain the following vitals:
- Pulse: 92 bpm
- BP: 147/88 on his left arm
- Resps: 20, unlabored, and clear bilaterally
- SpO2: 96% on room air
- Temperature: 37.1 C (98.8 F) orally
At the same time, the nurse elicits the following information:
- Signs/Symptoms: Intermittent midsternal chest pressure x 2 days. No diaphoresis, nausea, vomiting, SOB, or dizziness.
- PMHx: No significant medical history besides well-controlled HTN and an appendectomy in his 20's
- Meds: "some blood pressure medication"
- Allergies: NKDA
- Last In's/Out's: Dinner
- Events: "This discomfort started a couple of days ago. It comes and goes, but my wife wanted me to get checked out and I finally gave in after dinner when it started to return."
You run the following 12-Lead:
There is no old ECG in your electronic medical record for comparison, and when you walk back to the main department, you cannot find a physician to look at the tracing. One is performing an I&D of a peritonsilar abscess, while the other is probably with a patient somewhere but MIA.
Every room is filled, most of the hallway beds are occupied, and there is certainly a line forming at the front desk while you're wandering around in back.
- Are you concerned about this ECG?
- Do you need to pull a physician away from someone else to look at it?
- Does he need to jump to the front of the queue and get a room right away?
- If you were in the field, how would you treat and transport this patient?