Joan #2

The FRU pulled up outside Joan’s house, the (stunningly good looking, heroic, intelligent, and did I mention GSOH) EMT stumbled out, grabbed his bags and made his way to the front door where he rung the doorbell.

He was met by a woman in her eighties, she was pale, she was sweaty and she really didn’t look too well.

Sit down luv”, said the EMT, “and tell me why you’ve called me”.

Well”, she said between breaths, “I’ve got this pain in my chest…”

People who are having a heart attack sometimes look like they are having a heart attack, what I mean by this is that they go into shock.  Shock is defined as a lack of oxygen to the tissues and organs of the body, often this is what happens when you lose a lot of blood, and there isn’t enough blood in you body to adequately keep your organs fed with oxygen.  Sometimes however, you get cardiogenic shock, which is a failure of the heart to pump sufficient amounts of blood to your organs.

Roughly 1 in 10 heart attacks result in cardiogenic shock, they are often heart attacks that affect the large left side of the heart.  The left side of the heart is the part that pumps blood all around you body, so it has quite a lot of work to do.  When the supply of oxygenated blood to that side of the heart is blocked, then the pump starts to falter and die.

This then results in the classic ‘look’ of a heart attack.  The patient is pale and sweaty, they breath rapidly, and look blue around the lips (cyanosis).  Their fingers are often stone cold, and they may be a bit confused.  All this is the bodies response to a lack of oxygen.

The (did I mention heroic?) EMT listened as Joan told him about the pain starting about an hour ago, and that it seemed to travel down her arm.  While he was listening to her he started to assemble an oxygen mask.  Putting it on Joan, he explained that it would make her feel better.

Oxygen is important to the organs, so we want to make sure the patient is getting plenty, this is why we put the patient on oxygen.  It can often make them feel better, although I’m not too sure if this is because of the oxygen, or because someone is ‘doing something’.

While reassuring Joan, the EMT (did I mention he is tall dark and handsome?) checked through her previous medical history, he had a little look at the tablets that she took, and found that she was on a minor treatment for high blood pressure and nothing else.

Any allergies Joan?”, he asked.

Only Penicillin”, she replied, “it makes my stomach upset”.

Alright Joan, I’m going to give you some medicine”.

There are two medicines that we give ‘on the road’ to patients who we think are having a heart attack.  Aspirin and GTN.

Aspirin was discovered to reduce your chances of death from a heart attack by 23%, it works by making the parts of your blood that want to stick together to form a clot (which will then go on to block an artery) less ‘sticky’.  So we give 300mg of aspirin to pretty much anyone we suspect of having pain related to the heart.

So aspirin is given unless the patient is allergic to it, or if they are on a better ‘anti-sticky’ drug.

It is important for me to say, that most patients don’t know what ‘allergic’ means.  An allergic reaction is something life threatening, and will make you incredibly ill.  An allergy is not “it gives me an upset stomach”.  It is really important for the medic on scene to determine if the patient is truly allergic, or just doesn't like taking the drug.

Trust me, 23% reduction in death is worth an upset stomach.

While Joan chewed the aspirin the EMT checked her blood pressure, 88/50, not good.  The other drug that he wanted to give would have to wait.

The other drug we give is GTN (glyceryl trinitrate).  The GTN we give is a little spray bottle, and is again used when we suspect that the pain a patient is feeling is related to their heart.

GTN works by relaxing the blood vessels in the body, it makes then a bit more ‘floppy’ and by extension they get a bit larger.  We are hoping that the blood vessel gets large enough that a bit more blood can flow around the clot, and supply the tissues of the heart with the much needed oxygenated blood.

Unfortunately, the drug has a side effect of dropping a patient’s blood pressure.  so the patient needs to have a fairly good blood pressure to start with, otherwise we might lower their blood pressure so much that the brain wouldn’t receive enough blood and the patient faints (or worse).  In the case of Joan, her blood pressure is too low, so the EMT can’t give the GTN.

The treatment done, all that was left was to wait for the ambulance.  The EMT was getting a bit nervous.  This woman needed to be in hospital, not in her living room.

He breathed a sign of relief, if he listened carefully he could just about hear the familiar sounds of a siren approaching.

24 thoughts on “Joan #2”

  1. Brilliant! A well written story with potentially life saving information. Much better than the usual dry lists of symptoms. You have a real gift. I would love to read more of this type.Kate

    PS. You need to add charming in your description of the EMT.

  2. There is lots of research-based evidence demonstrating that people learn and remember things more easily from story-based information than from any other kind. I've learned a lot from many of the stories on your blog, and I'm learning more from these new-style ones. And enjoying reading them, too. There's nothing more I want from a blog than that. I think it's a great idea for how to fill your weeks off. I'm looking forward to more.

  3. If your having cardiac patients (with MI's) having a professional come see them at home, but unable to transport due to logistical reasons can LAS thrombolise MI patients before scooping I wonder? Whilst your normally not far from a hospital with cardiac care facilities presumably you could be waiting long time on scene for backup/have to push through traffic slowing you right down.I live in a rural area, and spent time recently in a cardiac care suite, The ambo bods here are becoming quite happy to pump blood clot busting drugs into patients after electronicly sending us the ECG for approval. The hospital is also an hour (at a rush) from the nearest catheter lab, which could mean allmost an hour to us, followed by an hour to the hospital with cath lab facilities.

  4. LAS at present do not thrombolyse, its the general concensus that here in london we are never further than 10-15 mins away from an A+E unit, and thrombolysing does have its risks (further infarcts and cva). However, as we are able to read and interpret ECGs, and after a couple of pilot schemes we are now able to 'blue' straight to a cardiac cath lab, thereby giving the patient a better chance of recovery IMHO.

  5. watch out for over-acronymisation… I know you're an EMT and not a paramedic, but perhaps a term like “medic” would read easier? The particular culprit is the line “the EMT cant give the GTN”, that would be easier for me at least as “the medic can't use the spray”.Oh, and on allergies… I'm lucky enough not to have any, but my sister vomits copiously within ten minutes every time she's given a certain antibiotic. Does that count as allergy? We've always listed it as one, on the basis that there's no point a doctor giving her something if she's only going to spew it straight back up. But it's not life threatening…?

  6. But where I come from and what I think of a “medic” is a doctor treating medical conditions, or indeed a MEDICal student. Alternatively a “medic” is someone trained to provide simple care in the armed forces situation. Certainly not a Emergency MEDICal Tech.So on the accronym front maybe:

    “Emergency Medical Technition, (EMT)” would be what your looking for.

  7. I'm a long time reader of your blog but never commented before. Just wanted to say I think your writing style is excellent – informative, entertaining, and moving. Keep up the good work!Graham

  8. Hi TomI've been reading your blog for a long time now, but never commented. I just want to say that if I had read this a couple of years ago maybe i would have not waited to see the doctor 4 days, and then finding out that i was having a heart attack. I was saying the same things as Joan, I thought it was indegestion, over worked arm, the whole nine yards. I mean who would have thought a 33 year old woman would be having a heart attack.

    They told me i had a 95% blockage in the LAD part of the heart. They also referred this as the “widow maker” They said that if i had waited another day or two i probably would not be here to watch my children grow up.

    Thank You Tom for your blog, for teaching us, and for entertaining us.

  9. Hi Tom,Like loads of others I have been reading but never commenting. I am an Enrolled Nurse currently in my final year of the degree in Nursing with particular interest in A&E and critical care. I think your blog is excellent and Joan very informative to the non-medical ppl. If I can suggest something, just explain all the abbreviations coz even I (having a different system to yours in my country) sometimes find some difficulty with them. Otherwise, the blog is massive. Keep it up.

  10. I love the blog and I think this story is very educational. A few years ago I did a St Johns Ambulance “First Aid at Home” course and they recommended the aspirin approach – but they only said one tablet. I don't have access to a packet at the moment but 300 mg is probably 2 / 3 tablets? If it's a 23% reduction for 300mg what's the reduction for 1 tablet (or to put it another way should one make very sure to always have the full dosage available?)

  11. Hi Tom,I guess since everyone else is coming out of the woodwork I will too. Love reading your entries, been reading for some time, have never commented. Thanks!

  12. Oi! I thought I looked like Douglas Fairbanks…And I have all my own teeth thank you very much.

    (Do I work with you?)

  13. Well, we use aspirin that you can buy over the counter, so I think the standard dose for a 'headache' aspirin is 300mg.Lots of preparations have aspirin and something else (caffine, paracetamol, dexasomethingorother) So that may be why the weights don't quite match up. I think if you look at the ingredients the tablet will have 300mg aspirin.

    Of course I may be wrong.

  14. You know, I didn't define EMT, because I thought the people reading this blog would know what I do for a living…;-)

  15. Doesn't sound like an allergy to me, but a severe intolerance. You see, she might be alright if the antibiotic is given through a vein.Still, 'allergy' is often a shorthand for 'don't give me that, I don't like it', and so we only really challenge it if we think that the benefits will exceed the side effects.

  16. Eeek!But also very, very common. It's why I don't mind going out to people who have chest pains – an MI/Angina/Chest Infection is a lot less work than someone who is dead…

  17. On the topic of allergies. I never know whether to put down an allergy to albuterol or not. It gives me tachycardia, which is something I'd rather avoid, but as a severe asthmatic, it's often the first thing whoever is treating me reaches for in an emergency.

  18. yes alright you great ninny (said with the confidence of a woman who doesn't live in London and therefore won't need your professional help). ;-)What I mean is, acronyms are a bugger for reading when they pop up in prose.

    Even when they are defined at the beginning of a piece, it means that readers – particularly new readers – have to keep checking what it means. And an acronym which is everyday to you, and becoming familiar to your regular readers, is still going to be pretty alien to a first-time reader.

    Not that you should cut them out completely, but beware…

  19. G'day TomYou didnt mention pain relief in your treatment ie BLS = penthrane or ALS IV access and morphine. Reduction in pain would of course be of significant benefit to the cardiac chest pain Pt particularly where you are unable to give GTN.

    What are your protocols there?

  20. Entonox, Nubain or Tramadol, all at homeopathic doses. We will soon have morphine…alll 2.5mg of it over 2-3 minutes…Tut!

    But yet another topic for another post…

    (Oh, and the pain relief comes in the next post)

  21. good work- in Oz (Vic) we can now adminster 5mg Morph straight up (and up to a total of 20mg), and maxolon if nausea arises.Nicely written as always- a nice change of format.


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