Kristin Spencer, MS, NREMT-P | Vince Mosesso, MD, EMT-P | From the April 2013 Issue | Wednesday, March 27, 2013
EMT John Davis considers himself a “tough guy.” He was raised on a farm and still lives on one, the kind of place where men perform long hours of manual labor and seldom complain. Farmers don’t call in sick, and many will tell you that unless they’re critically injured, they continue working, because there’s always work to be done. John enjoys his rural lifestyle and the serenity that comes with it. But at the age of 48, he decided he wanted to become an EMT. In December 2010, he did.
As an EMT for Metro Emergency Transport System (METS) in Joplin, Mo., John is no stranger to patients who complain of chest pain. He responds to those emergencies frequently and often finds himself advising those patients not to ignore their symptoms. Yet when John started experiencing chest pain while he was on duty on May 5, 2012, he was hesitant to share his symptoms with his paramedic partner, Priscilla Jobe.
Priscilla, a paramedic at METS since 2007 and 20 years John’s junior, will confess to anyone that she seldom gets any “good” calls. According to Priscilla, she gets more transfers and alpha (basic-level) calls than anyone deserves. Surprisingly, she has never treated a patient with an acute myocardial infarction (AMI) and can count on one hand the number of critical trauma patients she has had. John, on the other hand, admits to being a magnet for trauma calls and calls that turn complicated, and he prefers it that way.
Priscilla is outgoing, energetic and gifted with a sense of humor her colleagues appreciate, while John is more subdued. It seems fate joined the two together as a means of creating some sort of balance—a yin and yang between polar opposites.
The Incident
Less than a year after John became employed with METS, he clocked in at the main station. He and Priscilla had just checked out their ambulance, Metro 6, when they received a call to a residence all too familiar to them—a “frequent flyer” they deemed needed a taxi instead of an ambulance transport. During the call John felt fine. The two dropped off the patient at Freeman West emergency department and were sitting in what local medics refer to as the “fishbowl,” the glass-enclosed area designated for ambulance personnel.
John began writing his run report when he started to feel ill. Nevertheless, he recalls he dutifully continued writing his run report even as he started experiencing the onset of a burning sensation in his chest. Like so many of the chest pain patients he assessed in the past, John discounted the pain he was experiencing, thinking it was merely heartburn.
John is like thousands of other EMTs who eat on the run, smoke cigarettes and just can’t find the time to incorporate exercise into their busy lives. He has to work overtime to pay the bills—a 90-hour week was not uncommon for him—but he rarely considered the ramifications of his fast-paced lifestyle. In the back of his mind, John knew he needed to quit smoking, lose weight and eat healthier, but he always managed to save that lifestyle change for tomorrow, next week or next month.
As John continued writing his report, the pain exacerbated, and he started turning pale and a little sweaty, according to Priscilla. Noting the changes in his skin color, Priscilla jokingly asked John if he was having a heart attack. In a somber tone John replied, “I don’t want to alarm you, but I don’t feel so good.” That signaled a red flag for Priscilla. Taking John by the arm and assisting him outside to their ambulance only a few feet away, Priscilla placed him on a cardiac monitor and checked his vital signs. Although his blood pressure was normal, he was bradycardic, short of breath and pale. “The ECG recording was junk. I couldn’t read anything,” Priscilla says. Rating his pain as a 6 out of 10 and stating he couldn’t catch his breath, John tried to remain stoic as Priscilla prepared to do a 12-lead ECG.
Priscilla says as she was acquiring her 12-lead ECG, she couldn’t believe her eyes: John was having an AMI. And not just any myocardial infarction, but one referred to in the medical vernacular as a “widow-maker,” which involves the left anterior descending artery (LAD). ST-segment elevation was evident in leads I, aVL, V2, V3, V4, V5 and V6 with reciprocal depression in leads II, III, and a VF. Priscilla asked John if he had ever had a myocardial infarction; he shook his head. “You have now,” she told him.
The last time John had been to the doctor was approximately 10 years earlier. He will be the first to tell you he doesn’t care for doctors. His last visit to the doctor resulted in a hospital admission during which he nearly died from internal bleeding from a liver biopsy gone wrong. He hadn’t stepped foot in a doctor’s office since. But during this moment, something told John this was no time for stubbornness and he needed to be evaluated by an emergency physician. When Priscilla told him she was going to retrieve a wheelchair for him, he simply nodded his head.
Priscilla, who was six months pregnant, needed assistance but couldn’t find anyone in the parking bay. Knowing a physician was just a few feet away, she retrieved a wheelchair from the entryway and ordered John to get in to it. Entering the ED doors waving the ECG, Priscilla held the ECG up against the receptionist’s window and said, “That’s my partner’s ECG.” She told the ED receptionist her partner was having a heart attack and to open the doors to the patient area.
Once there, a nurse saw Priscilla in uniform, wheeling her ill partner, who presented with Levine’s sign, pallor and diaphoresis. A concerned nurse asked Priscilla what was going on. Priscilla handed the ECG to the nurse, who said, “Get him into room 29. I’ll get the doctor.”
It was there that John realized how dire his situation was. His bedside was surrounded with nurses, an ECG technician, members of the STEMI team and the ED physician. The physician placed pacing-defibrillator patches on his chest and back while nurses placed him on oxygen, initiated IVs and administered anti-platelet agents. A nitroglycerin drip was hung, paperwork was signed and the cath lab notified. John vaguely remembers the ED staff rushing him down the hall to the cath lab at full speed.
Due to the speed and precision of the ED staff, the time from the onset of John’s symptoms to the cath lab was only 20 minutes and 40 minutes to revascularization. Had he not been where he was, the outcome might have been different. John is acutely aware of that.
The Revascularization
John Cox, MD, an interventional cardiologist for the Freeman Health System in Joplin, refrains from using the term “widow-maker” in his vernacular. He thinks the term is often misused and incorrectly implies no chance of survival. A true widow-maker occurs when stenosis occurs in the first part of the LAD, he says. Yet he understands how fortunate John was to have been standing only feet away from knowledgeable healthcare professionals. Current American Heart Association (AHA) guidelines recommend a door-to-intervention time of 90 minutes or less; Freeman West boasts a 51-minute average door-to-intervention time.1
Having poor ejection fraction, John was “highly symptomatic” and, during the procedure, went in to ventricular fibrillation (VF). After one shock, however, Cox successfully restored a pulse. “Anytime we have a patient in the cath lab, we anticipate a defibrillation scenario, and we’re prepared to deal with that,” he says.
By the time John made it in the cath lab, Priscilla had contacted her field supervisor and the director of operations, Jason Smith. She waited anxiously. After about an hour, John was successfully revascularized through percutaneous transluminal coronary angioplasty, although a stent was also required to maintain coronary perfusion.
The Lesson Learned
John admits he rarely gave a second thought to his lifestyle habits, but he’s now cognizant of how his unhealthy lifestyle contributed to his AMI. Increasingly, researchers are addressing how to help reduce the incidence of cardiovascular disease.
Recently the Centers for Disease Control and Prevention (CDC) published findings of a 22-year observational study based on a national survey of nutritional and health habits.2 The specific conditions and habits considered were:
1. Smoking;
2. Physical inactivity;
3. High blood pressure;
4. Elevated cholesterol/lipid levels;
5. Elevated blood glucose levels;
6. Poor diet; and
7. Obesity.
The study found that less than 2% of Americans exhibited none of these seven factors. If you have six or seven of these factors, your risk is four times higher for cardiovascular disease and three times higher for death than someone with none or only one of them. All of these factors are treatable or preventable, for the most part, through lifestyle and medications.
They say that hindsight is 20/20. While recuperating in the hospital after his angioplasty, John reflected over the days preceding his ST-segment elevated myocardial infarction and recalled the chest pain he experienced while working in his lawn just a few days before the potentially lethal event. John admits at the time his body was giving him warning signs of things to come. He discounted the symptoms, reasoning the pain was due to overexertion, heat illness or dehydration. It never occurred to him that the episode of chest pain he experienced during exertion should have been communicated to a physician. He takes care of patients; he’s not supposed to become one.
Discharged from the hospital feeling invigorated again, John couldn’t wait to get back to work, but with a few changes: He has altered his dietary habits and has since quit smoking. He understands that because of his lifestyle, he was teasing death, and in hindsight knows that was a dangerous game to play. Fortunately for John, as serious and deadly as the “widow-maker” might be, it didn’t win. He can live to improve his lifestyle.
Do You Need a Change?
Although this is a personal story about John, it holds a lesson for all EMS providers. Too many of us put aside our own health to take care of others, or to fit in another shift. We must not underestimate the effect that our high-stress jobs have on our health. Ask yourself: Could what happened to John happen to you? If so, it’s time to start targeting those seven factors—before you become the patient.
Kristin Spencer, MS, NREMT-P, the EMS program director and instructor, and AMLS Affiliate Faculty with Crowder College in Missouri. She can be reached at kristinspencer@crowder.edu.
Vince Mosesso, MD, EMT-P, is a professor of emergency medicine at the University of Pittsburgh School of Medicine and medical director of UPMC Prehospital Care. He is also NAEMT AMLS medical director.
References
1. Moscucci M, Eagle KA. Door-to-balloon time in primary percutaneous coronary intervention: Is the 90-minute gold standard an unreachable chimera? Circulation. 2006;113(8):1048–1050.
2. Yang Q, Cogswell ME, Flanders WD et al. Trends in cardiovascular health metrics and associations with all-cause and CVD mortality among US adults. JAMA. 2012;307(12):1273–1283. Epub 2012 Mar 16.
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