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Sunday, July 21, 2013

Treat Your Patient

Treat your patient, not the monitor is something that most medics have heard (and hopefully most do).

We had a call for a syncopal episode. The 70 year old man had been mowing his lawn when he started to feel too warm. He went into the kitchen and sat down to take a break. He promptly passed out for about 15 seconds according to his wife who witnessed the entire event. After regaining consciousness the patient vomited rather violently.

Upon our arrival the patient was pale and very diaphoretic. Now sitting on the couch, he related the story of what had just happened to him (with his wife filling in details that the old man either forgot or didn't think were pertinent). While he talked we worked.

He was a touch hypertensive at 160/92. His heart rate was in the low 90's and his breathing was non labored. His sugar was 201 (which he blamed on his wife's homemade apple pie). He was in NSR on the monitor (for you ER RN's out there that panic if we medics don't get a pulse ox it was 99% on room air).

My patient was overweight, a diabetic, had high blood pressure and high cholesterol. He denied any chest pain or discomfort at any time  as well as any difficulty breathing. The man kept saying he was just feeling week and sweaty.

Before AMR rolled up we shot a 12 lead. The patient had a LBBB and ST elevation in leads V1 through v4. I know right now some of you are yelling that a LBBB is a STEMI imposter. Or at least in can be. According to Sgarbossa's criteria an AMI can be diagnosed if there is ST elevation ≥5 mm in a lead with downward (discordant) QRS complex. Our patient only had 4mm of elevation.

However, I am one to treat my patient, not my monitor. The patient was still pale, sweating profusely and weak. We transported him to a STEMI center just as a precaution. At the ER the MD met with me and the AMR medic and went over the 12 lead. He reaffirmed what we saw and didn't think that this guy was having and MI but agreed that his presentation was such to make a medical professional worry a little. As if on queue the patient started throwing up again and seemed to get weaker.

Not my patient any more.
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