Call review #2

Code 3 for chest pain.

This is not really a call review, since this is not what I do here, but I think it’s an interesting call in some ways.

A polite but anxious 53-year-old woman tells me she “bent over” and began feeling a discomfort in her chest with tightness in her throat. She tells me she has “an arrhythmia problem.” She does not know what specific arrhythmia. She has not heard of PSVT, A-fib, WPW, etc. She has no other significant medical history.

We convert her PSVT with Adenosine.

“How many times have you had similar events?”

“About 15 since I was a teenager.”

“You’ve never gone to the hospital for this?”

“No. They always stop. The longest one lasted 12 minutes. My cardiologist hasn’t been able to see what rhythm it is.”

She’s worn Holters without anything interesting showing up.

We medical people are a skeptical bunch – how often do we nod politely but dismiss it afterward when a patient tells us they have a medical problem that isn’t presenting with a tangible symptom that we can see?

Sometimes that’s just how things work out. She has been averaging more than 2 years between each event, so it’s totally conceivable that it hasn’t been captured on an EKG somewhere. If we didn’t see it today, she probably would have gone to her cardiologist for her 16th episode without making any progress toward any treatment plan.

Usually people know they have PSVT. But not always.

This reminds me of a patient in Garcia and Holtz’s 12-Lead ECG: The Art of Interpretation:

The first thing we noticed was the markedly prolonged QT interval. In case you have never seen a prolonged QT interval, this is as prolonged as it gets! Anyway, the patient recounted that, since she was a young adult, she would suddenly faint for no reason. She had seen many doctors, and they had no reason or diagnosis for the fainting. She was labeled a crackpot and placed on many antidepressant and antipsychotic medications over time. She lost her job because of the meds and became homeless. Her only statement was, “I’m really not crazy, I just fall out.”

Well, this doctor believed her, especially after looking at her ECG. Right after placing her on a monitor, the doctor started to examine her heart. He noticed that she slumped, and looked up to see her unresponsive. The monitor showed torsades de pointes. About 1 minute after she collapsed, during the chaos of gathering resuscitation equipment, she awoke and said, “See doc, I told you I pass out!” This poor patient’s life was ruined because no one saw a prolonged QT interval. She had Romano-Ward syndrome and ended up doing fine.

Not everyone lies. Even though it sure seems like it sometimes.

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One thought on “Call review #2”

  1. The problem of course is that the patients rarely read the textbooks let alone the journals. Therefore they persist in doing things that the aforementioned publications tell can’t happen.

    One of the nice things about EMS is that we sometimes see things so early in their evolution that we can catch things rarely seen in the hospital. That’s something that we don’t get a lot of recognition for, but should.

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