Thursday, May 11, 2006

Triage Tales 14

Disclaimer: The following story is a work of fiction. All similarities to people, places, things and events are coincidental by nature.

M.P., 50 year old male, comes in the ER with a complaint of right sided chest pain, starting 12 hours prior to admission, VAS 7/10, and aggravated with movement. PE shows pinpoint tenderness on the 2nd and 3rd ribs at the right midclavicular line.

No comorbidities for this patient except for a vague "blocked heart vessel" (explained more robustly in Filipino, "may bara ang ugat sa puso"). No contraindications for reperfusion therapy.

Normally in better staffed and better equipped centers, this chest pain would still be worked up for a more serious Acute Coronary Event. But since this is the Philippines, a less discriminating intern or anybody else wouldn't have taken much notice of the patient. Probably sent him home on pain meds.

Triage decides that he needs to be worked up at least. ECG shows regular sinus rhythm, normal axis, bradycardia, no ST-elevation or depression. Why is there bradycardia in this patient? No beta-blockers or other drugs in the medication review.

Treatment Officer treats this as ACE: Aspirin, Sublingual nitrates then nitroglycerin drip, Heparin, Oxygen. VAS score goes down to 2/10.

During all these time, the supposedly "responsible" companions (patient's wife and sister) appear to be lost. This is not good; they are supposed to be the "runners" - facilitate labs and procure supplies for their patient in this manpower- and resource-poor Emergency Room.

Imagine the consternation of the Treatment Officer when, after 2 hours, these companions still have not gotten a Social Service classification and filled the three prescriptions (all meds have been sourced from somewhere else and should be replaced).

Patient's case is referred to Medicine. The resident accepts this patient and thinks more of costochondritis for this patient. The resident is also amused that the Treatment Officer nearly dies trying to work up chest pain, and ends up having chest pain himself.

Postscript: CK-MB and CK-total levels are equivocal, but the Medicine resident waits and gets a Troponin I positive result. So the patient has an non-ST elevation MI after all. His wife damn near gave the Treatment Officer a heart attack too.

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