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CASE REVIEW | By James J. Augustine, MD, FACEP Stutter Steps Off-and-on pain signals something serious ATTACK ONE RESPONDS to a midday call for a man with diffculty breathing. His concerned wife meets the crew at the door and asks them to accompany her to the basement. She reports her husband is doing well at the moment, but when she called he was having jaw pain and had become short of breath. The crew fnds the man in a basement bathroom, where he is changing out of his exercise clothes. He is in no distress. They converse as he finishes cleaning himself up. He is 47 years old, in good health and had some pain in the left side of his jaw while doing his daily exercise routine. He quit exercising, and the pain stopped. He got back on the treadmill and began running again, and the pain returned, and he got unusually short of breath. When he stopped his pain lessened, but he was still short of breath. His wife was concerned and called 9-1-1. "Asked about the episode of shortness of breath, the patient says it was fairly sudden in onset." is a featured speaker at EMS World Expo 2013, Sept. 8–12, Las Vegas Convention Center, Las Vegas, NV. 20 For more information, visit EMSWorldExpo.com JIM AUGUSTINE At this point the man says he is completely pain free and not short of breath at all. He wants to know if he and his wife can go to the hospital on their own. The paramedic asks to check his vital signs and get some more details of his history before answering. Placing a pulse oximeter on the man's finger, the crew checks a quick blood pressure. His oxygen saturation is in the high 90% range, and his pulse rate is regular and rapid. The paramedic asks about prior medical problems and any history JUNE 2013 | EMSWORLD.com of cardiac risk factors. The man and his wife say he is healthy and on no medicines, but he has an extensive family history of heart disease and strokes, and that is why his wife is so concerned. He has never had chest pain or heart palpitations or exercise problems. His last EKG was a year ago during a physical and he was told it was normal. He has had no other heart testing. He has also had no injury to his jaw or recent dental problems. Asked specifically about the episode of shortness of breath, the patient says it was fairly sudden in onset, just as his jaw started hurting again on the treadmill. "Sir, if there is no other reason for your jaw to hurt and you suddenly got short of breath, we are concerned about you," the medic tells him. "Even if you feel fine now, we all know those symptoms could be associated with heart problems. Would you please let us do a simple heart test and watch you on the monitor and take you to the hospital?" The patient and his wife exchange uncertain glances, and the paramedic is concerned the man will refuse treatment. Making firm eye contact, he pushes a bit. "Sir, that episode must have been pretty bad at the time, or you wouldn't have said anything to your wife and had her call 9-1-1. I am glad you are feeling better now, but we would suggest you let us do an EKG and give you some aspirin and transport you to the hospital. We will monitor you, and you will both feel better after a thorough exam and testing in the emergency department." That's enough for the wife, who expresses her support, and the man concedes. The patient has no history of aspirin allergy and so is given a dose, and his 12-lead EKG shows a normal sinus rhythm and no acute changes of any INITIAL ASSESSMENT A 47-year-old male in no distress but with a history of jaw pain and shortness of breath. ❯ Airway: Intact and uncompromised. ❯ Breathing: In no distress and breathing normally. Lungs clear on auscultation. ❯ Circulation: Regular pulse rate and quality. Normal capillary refll, pink skin. Neck veins not distended, good peripheral pulses. ❯ Disability: No neurologic defcits. ❯ Exposure of Other Major Problems: No trauma or history of injury to the jaw. VITAL SIGNS Time HR 1230 84 BP 144/84 RR Pulse Ox. 20 98% 1238 104 130/76 28 95% 1247 104/80 24 94% 92 AMPLE ASSESSMENT ❯ Allergies: None. ❯ Medications: None. ❯ Past Medical History: No history of medical problems. Family history of coronary artery disease and early deaths in multiple relatives. ❯ Last Intake: No recent food intake. ❯ Event: Patient develops pain and some shortness of breath during transport. type. He is placed on the EMS cot. The patient and his wife request that he be transported to the community hospital a short distance away, although he has no local physician and has had no prior hospital treatment of any type. His wife starts closing up the house and will follow the ambulance to that hospital. The patient is smiling as he's loaded in the ambulance. But about five minutes into the transport he tells the paramedic, "You know, that pain in my jaw has come back." The paramedic looks at the threelead cardiac monitor and pulse oximeter. They show normal values