Pre-decisions, Part 1

Let me run you through a fictional scenario and see what you think.  I hope it will illustrate the best way to preplan decisions in EMS.

You respond to an internal medicine office to find a 56-year old female patient without complaints.  The lady stopped by her doctor’s office because she gets chest pain every day for the last week when she is active – climbing stairs and step aerobics class.  Last night she didn’t sleep well and could not get comfortable, but did not have chest pain.  Her description is that she felt vaguely anxious.  She has a history of mild hypothyroidism for which she takes levothyroxine, but has no allergies.  She is warm, pink, and dry; completely oriented and cooperative; and appears to be in no apparent distress.  As a matter of fact, she seems a bit confused as to what the big deal is.

She has a blood pressure of 132/68, pulse rate of 90 beats per minute, and a respiratory rate of 14 per minute with no respiratory distress and clear breath sounds.  She reports neither recent trauma nor recent illness (other than the recurrent intermittent chest discomfort during exertion).

Her ECG:

Well, that's not good.
(Photo courtesy HavocOneThree, with permission)

This is a sinus rhythm with bigeminal PVCs and normal axis.  The sinus beats show ST elevation in V1-V3, but there is also the possibility of left ventricular hypertrophy* – the ST changes may be due to that, or they may be due to an anteroseptal MI.  The ST changes look a bit aggressive and convex for LVH, to my eye.  There is poor R wave progression, with V1-V3 negative before V4 is predominately upright.

So you press her, ask leading questions, and beg.  But she still will not claim a complaint at all – she states that she feels completely normal and is still not even sure she needs to go to the hospital.

She agrees to be transported, however, and you apply oxygen via nasal cannula, administer 324mg chewable aspirin PO, and establish an IV.  Her repeat vitals are unchanged, and her pulse ox is 100% on 2L.  You are four or five minutes away from a PCI facility.

So here are the questions for discussion:

• Should she be a STEMI alert?
• Should you transport her emergently (lights & sirens)?

After arriving to the hospital, you hand off the patient and the ED staff get a cardiology consult.  It is decided to cath her and see what is going on. 

During the informed consent discussion, the patient refuses the cath.  She states she only has an hour until she has to be home for some family stuff.  As the hospital staff works very hard to convince her to agree to the cath, the patient suffers a VF arrest (about 30-45 minutes after you dropped her off).  She is defibrillated, pulses return, and the emergent cath shows 100% LAD occlusion that is stented.

Does that bit of hindsight change your thoughts on whether she should be a STEMI alert and/or whether to transport her emergently?

I’m interested in your thoughts.  Please share in the comments.

*The simplest way to determine the possibility of LVH is to remember the number 35: Find the deepest S wave in V1 or V2 and measure the depth.  Find the tallest R wave in V5 or V6 and measure the height.  If the number is greater than 35mm, you have a positive finding.  Add to that whether there is a lateral strain pattern.  The final part is whether or not aVL is greater than 12mm tall.  In this case, V2 is 27mm deep plus V5 is 16mm tall – 43mm.  There is a strain or strain-equivalent pattern of the ST and T wave in the low lateral leads.  But aVL is small – so there is only a fairly strong possibility of LVH here, not guaranteed.