Editor's note: The dosage of fentanyl in the below article was corrected to read 20 mcg (it previously read 20 mg). We regret the error.
San Diego Fire-Rescue was dispatched for a 50-year-old male reporting headache and dizziness. During the initial assessment, the patient also admitted to some chest "soreness," describing his chest discomfort as two out of 10 without radiation.
He had no shortness of breath or nausea, and his skin was normal, except for coolness at the extremities. He had high cholesterol with no other history, except a family history of myocardial infarction in middle age. The patient appeared in no acute distress and had symptoms that probably wouldn_t have woken him had they occurred during the night.
Vitals: pulse 84 strong/regular, BP 150/70, respirations 18 full/effective, lungs clear, pulse oximetry 98% on room air and skin as noted. The initial 12-leads demonstrated ST elevation in V1, V2, V3 and V4, with reciprocal changes indicating an anterior MI. The crew did four 12-lead ECGs in the field. The patient received nitro, nitro paste, aspirin and oxygen en route to the hospital.
The patient appeared fine, belying the potentially fatal coronary blockage inside his chest. His healthy presentation even took the emergency department (ED) physician off guard. But once the physician examined the ECG results, the cardiac cath team was activated and the ball was set into motion.
Once the ED physician confirmed the ECG findings, the procedure was expedited. The cardiologist described what was about to transpire and welcomed the crew and its intern to watch the procedure. The cath lab staff proceeded as if this was a routine procedure, but any error in their actions might have meant the difference between a favorable or unfavorable outcome for the patient. They communicated with the patient every step of the way and remained cognizant of his condition. The staff administered 1 mg of Versed and 20 mcg of fentanyl. As they continued preparing the patient for the procedure, the nurse confirmed they would begin by investigating a potential block in the left coronary artery indicated by the ECG.
The cardiologist verified that both branches of the left coronary artery (LCA) were blocked and inserted the first catheter up to the LCA. As suspected, he found total occlusion in the left anterior descending (LAD) artery.
To open the blockage, he inserted a stent-and-balloon system and restored blood flow through the LAD. After restoring flow, the patient_s hemodynamics stabilized and ST-segment elevation normalized. The cardiologist then went to work on the circumflex artery, which had two spots where plaque deposits had nearly occluded the entire artery, so two more stents were placed.
The time between dispatch and ED arrival was 27 minutes. The door-to-balloon time was just 24 minutes. The entire catheterization procedure lasted an hour and a half.
The patient recovered fully. Rapid recognition and intervention both in the prehospital setting and at the hospital ensured the preservation of heart muscle, thereby decreasing his morbidity and mortality and improving his quality of life.
CarolynGain, EMT-P, is a paramedic with San Diego Fire-Rescue Department and a flight paramedic with Mercy Air. She is also an assistant, instructor, preceptor, and mentor for EMSTA College.