Much better...

Thanks for all the concern! I'm feeling muuuuch better!

Now to one of the main reasons I wanted to do a global health elective to begin with! Ie. Alternative practices that actually improve patient outcomes but not necessarily the standard of care in the US.

Case: 47 y/o mildly obese IndoFijian M with no known medical hx, presents with sudden onset crushing chest pain a/w diaphoresis, dyspnea and radiating pain to the L arm. This occurred about 2 hours prior to arrival. Associated with mild nausea.

Ok it sounds like he is having an acute MI (myocardial infarction) and he was! ECG below...

The standard of care in the US according to AHA guidelines is reperfusion therapy. It should be given to all eligible patients with a STEMI (ST elevation MI), whether it is PCI (percutaneous intervention) or fibrinolytic ("clot buster") therapy, in a timely manner. This is for all eligible patients that have sx onset within the prior 12 hours. PCI is much more superior than thrombolytics (level A evidence) so measures should be taken to get patients to a PCI capable center as soon as possible with certain stipulations.

Most patients with a STEMI should present to a PCI center with "door to balloon" time being 30 minutes. Transfer to a PCI center should be initiated if it will take less than <120 minutes from transfer and start of PCI, according to the new 2013 AHA guidelines. If this can't be achieved than thrombolytics should be given within 30 minutes of arrival. Kinda wordy but here's a flow chart that explains it more clearly.

Being that I work in such a large tertiary care center with PCI readily available 24 hours a day, I have actually never started thrombolytics on a STEMI patient.

Pre -thrombolytic ECG, notice the scary ST elevations in V1/V2, avR with reciprocal ST depressions in the inferiolateral leads... for the non medical people, he is having an active heart attack.

Post STK ECG

Post STK ECG - notice normalization of his ST elevations

His chest pain was markedly improved. Vitals stable. Pretty cool...

So for this patient his STE are most prominent in V1 and V2 localizing to the septum. It could be branches of the LAD (s1 or d 1) or even ostial LAD very close to L main, considering all the STD and prominence of avR.

STE in avR often represent left main occlusion, however it more often implies significant subendocardial ischemia which could be due to left main or 3 vessel disease, or a severe proximal LAD disease. Left main diseases generally causes rapid death; most who survive left main ACS have some flow and thus have widespread ST depression.

He would probably benefit from having interventional cardiology treat him if he really has 3 vessel, left main disease etc. There is a team of interventional cardiologist that come to Fiji, once or twice a year for a few weeks. Patients will get CABGs, PCI, and pacemakers for those that are screened to benefit the most from these interventions (also screened for ability to pay as I am told).