The second call was to the canteen of the local police station, for a member of staff choking on a fishbone. Great, I thought, a rare opportunity to watch a police officer get punched in the back without anyone getting in trouble! (I jest, of course I love the police. I couldn’t do their job, dealing with breaking bad news and horrible criminals all day long. It would drive me mad.)
Anyway, I was disappointed when we arrived because the patient, Alan, a) wasn’t a police officer, he was a handyman doing some work at the police station b) was standing up chatting to some other members of staff and it wasn’t entirely clear which one we were supposed to be attending to. It turned out that Alan wasn’t so much choking on the fish bone but had swallowed it and could now feel it in his throat. The “waste of time and taxpayers’ money” buzzer in my head started to sound.
Still, Steve and his crewmate were very professional and took Alan back to the ambulance for a full set of obs. Steve stuck something resembling a spatula and a torch down Alan’s throat and tried, without any success, to locate the offending fishbone. He explained that he couldn’t see anything, but if Alan wanted, we could pop him up to the hospital for an x-ray.
“Do you think this needs a blue call?” joked Steve’s crewmate. And I laughed my head off.
Then Steve took Alan’s temperature, and his blood pressure, and his oxygen saturation levels. And his pulse. And raised one eyebrow.
“I think there’s something wrong with this machine,” he muttered, using his fingers to take the pulse at Alan’s wrist instead.
In highly technical terms, a normal pulse is between 60-80 beats a minute and goes like this: be-dump, be-dump, be-dump. Alan’s pulse was 44 beats a minute and went like this: bump, bump, be-dump-bump, bump, bump, be-dump, be-dump, bump, bump. As Steve put it, it was almost regularly irregular. It was not at all the sort of pulse you’d expect from a otherwise healthy 40 year old with a fishbone stuck in his throat.
“Alan,” said Steve. “Have you ever had your heart tested?”
“No?” said Alan, a bit confused. What had this got to do with fishbones?
“Well, you’re about to,” said Steve, firing up the 12-lead ECG (a machine which records heart rhythms).
Minutes later, we had a print out. A normal ECG looks something like this. Alan’s printout looked something like this (or at least it did to the untrained eye). I understood the writing on the printout, though - the ECG machine’s option was that there was ST elevation and therefore Alan was having a heart attack.
Steve, his crewmate and I all looked goggle-eyed at the print out, then set about asking Alan if he had any other symptoms at all, in particular chest pain. Alan told us that he’d had chest pain on and off for the last two years, but at this moment felt absolutely fine. Except for the fishbone in his throat. He was looking at us like we were a bit mad.
“Do you think this needs a blue call?” said Steve’s crewmate again, and of course, this time he was serious.
“It could be a silent MI,” (MI = heart attack. Silent MI = heart attack without the normal symptoms of chest pain etc.) muttered Steve. “But he’s got no symptoms at all… and he’s only 40… and he’s had chest pain for two years… my guess would be that he’s got an ongoing cardiac condition which has been undiagnosed. Let’s take him to the nearest and get a doctor to have a look at the ECG, and if they suspect an MI, we can always take him on to the hospital with the cardiac unit.”
So with that decided, we explained to Alan what was going on and wasted no time in getting him to the nearest A+E and summoning a doctor to look at the ECG. She agreed that Alan almost certainly wasn’t having a heart attack and this was an ongoing problem, but nonetheless he was wheeled into Majors to be seen immediately.
“What about the fishbone?” whimpered Alan as we bade him farewell. “I can still feel it, you know.”
And the moral of this story is that you should always take a full set of obs, however rubbish you think the call is.
May 10th, 2008 at 5:31 pm
truer words have never been written…
suspect everything, trust nobody and most importantly of all…document
May 11th, 2008 at 12:46 am
We once had a man who showed up in ED after he slipped off a ladder. Acutally could remember his leg slipping off a wet run. Anyway, he’d banged his chest on the way down. An ambulance was called and he was sent to ED. No one thought too much off of it, but one of the nurses in ED thought we should just check his ECG seeing as he had some chest pain, even though he had hit his chest falling off the ladder.
And was that fortuitous. Massive inferior ST elevation –> straight to the cath lab where he had it fixed.
Interestingly enough, I went back and looked over his ambulance report, and there it was ST elevation on their rhythm strip. So another good lesson; It’s always a good idea to read the ambulance documentation and look at their ECGs!
May 11th, 2008 at 1:34 am
Always check the documentation. I had 3 3-lead ECG’s printed out done in the ambulance while suffering chest-pain (20 minute ride to the hospital) with Pericarditis (1st Degree Heart Block). Now i’m only 22, and once i’d gotten to the hospital they decided to keep me for 6 hours, no antibiotics, no meds (Apart from the couple of sprays of GTN the paramedics gave me), and then sent me home. No ECG, nothing.
Lets just say a second ambulance was called, and the A&E doctors finally looked at the ECG’s. Result? Straight up to the cardiac care ward full flow IV antibiotics, stayed for a couple of nights.
Moral? ALWAYS get a full set of OBS and when handing over make SURE the A&E staff understand what you’re giving them.
May 12th, 2008 at 2:34 pm
Hmmm. Somehow I’m being (unintentionally) controversial on your blog this week. Another tke would be: never do obs on someone who has probably just swallowed a fishbone awkwardly and scratched their throat or they are likely to end up being over-investigated, possible quite invasively, made very worried, possibly made ill (iatrogenically) and actually not have had anything wrong with them in the 1st place….. Just a thought….
May 12th, 2008 at 7:26 pm
I laughed out loud when I saw the picture of Mr. Messy. I was not expecting that!
May 12th, 2008 at 8:22 pm
geepeemum: obviously I am not an expert on ECGs, but wouldn’t the fact that Alan’s ECG looked a bit like Mr Messy, had ST elevation and an irregular pulse of 44 per minute mean that there must be something seriously wrong with his heart, even if it wasn’t something acute like a heart attack? Wouldn’t it need treating? Is it possible that there was nothing really wrong and that was just normal for him?
May 13th, 2008 at 4:15 pm
I think I’m kind of playing devil’s advocate here
but… possible yes. The trouble is, once you’ve seen an abnormal test, no one would ever have the guts not to follow through with it. We’re always taught to treat the patients not the test results but that’s very hard to actually do. (Sorry that a comment appeared above with my blog post on it. I’m not sure how that happened. Please feel free to delete it…)
May 16th, 2008 at 12:06 am
Moral of the story should be to the patient, if you have chest pains, even if you think its ‘just a touch of stress’ get it checked. And checked again if it carries on!! I had chest pains for two years before I got them checked. I thought it was just stress, until I discovered that my dad had ARVC ( form of cardiomyopathy or enlarged heart in very simple terms) . I did my research before seeing the GP, who did an ecg and said I was fine, armed with said research I showed that ARVC can show a normal ecg so should be checked with an echo, got my echo and yep I have ARVC. Now I am getting my children checked, not fun. Hopefully they will be clear, or at worse in very early stages and they will never end up like me!! But if I had not done my research and had believed the GP when she said I was fine ……
June 1st, 2008 at 3:17 pm
Not doing obs just isn’t an option for the ambulance service. It actually surprises me that GPs don’t always do obs if they’re considering sending a patient to hospital - they can tell you so much about their condition.
Don’t get me started on GPs though….
June 14th, 2008 at 1:18 pm
[...] Source: Observance Shift: 2 - Anticipate the Unexpected [...]