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Expect the Unexpected and Treat Accordingly

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Things are not always what they seem to be, as was the case with the patient in the following case, whose signs and symptoms belied an even more urgent problem.

The Call

An EMS response is initiated through the public safety answering point for facial and left arm weakness. The patient -- a female in her 70s -- had developed symptoms just prior to the 9-1-1 call. The dispatch information cited no other complaints. The crew responded to find the patient with facial droop on the left and left-arm paresthesia. Pulse and respirations were normal, pulse oximetry 96% was on room air, and BP was elevated in the 190/100 range.„

The patient's history was positive for hypertension, and she was on multi-drug therapy for control. She had taken her medications in the morning and prior to onset. The medic initiated an IV lock, placed the patient on the cardiac monitor and applied oxygen. The ETA to the hospital was 20 minutes from the home. The remainder of the examination was unremarkable.

Per system procedure, the medic notified the emergency department (ED) of a patient with a positive screening for a cerebrovascular accident (CVA), using the Cincinnati Stroke Scale as the basis. The ED called for CT to be ready and a receiving room established. About 10 minutes into the transport, the patient developed significant chest pressure with nausea and dyspnea. There was no change in vital signs, but the medic noted a change in the three-lead tracing on the monitor -- ST-segment depression in lead II, and ST-elevation in V2. The medic obtained a 12-lead ECG showing significant elevation in V2ÏV5 and reciprocal depression in II and aVF.„

The medic re-contacted medical command with the change in patient status and ECG changes, reporting a "Code STEMI." This alerted medical command to call the cardiac team to the ED for a potential interventional procedure. The medic and medical command had concerns about aggressively treating the chest pain and the potential for extending the CVA symptoms by lowering the blood pressure. The orders to the medic were to try a single nitroglycerin sublingual, watch the blood pressure closely, ensure the patient was on high-flow oxygen and continue the transport urgently. The updated ETA was 8Ï10 minutes. The medic reported no change in vital signs but increasing patient anxiety.„

Upon arrival to the ED, the patient status was unchanged. The vital signs showed a stable pulse and respiration rate, with oxygen saturation of 98%. ED physician examination found one additional concern. The pulse in the right arm seemed to be compromised. Phlebotomy was performed along with a portable chest radiograph, and the patient was sent for a CT scan. The ED physician looked at the chest radiograph while the patient was en route to get the CT scan and ordered a contrast study of the chest to evaluate an abnormal mediastinum.

CT findings showed a Type 1 dissection of the ascending aorta (prior to the ligament of Treitz) and partial occlusion of the right common carotid artery. The head CT was unremarkable. The patient underwent emergent aortic repair with revascularization of the left anterior descending artery, and stent of the right common carotid. She was discharged home in stable condition with her deficits showing almost complete resolution.

Summary

This case is particularly interesting because the findings and outcome were unexpected. Both the medic and physician persisted in trying to explain the patient's issues and complaints, but remained open-minded as opposed to "putting the blinders on." As one of my mentors says, "If we listen to our patients, they will teach us something new every day."„

Gregory R. Frailey, DO FACOEP, EMT-P,is an EMS physician/system medical director for Susquehanna Regional EMS in Williamsport, Pa.„He's been active in EMS for more than 30 years and continues in the field both as an EMS provider, tactical physician and medical specialist with Pennsylvania USAR Squad 2, also based in Williamsport.„„

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