Testing Question

[INems]

You were just called out to the workplace of a female in her late 40's that is unresponsive.

Below is what I said and did. What would you have done differently and why?

BSI. Scene safe. Only patient. NOI- unresponsive. C-spine possible. No further assistance at this time.

Upon arrival- Patient is A/O x3. Complains of chest pain with radiating sensations down her left arm and up into her left jaw.

Transport is Priority at this time.

Airway is patent. Breath sounds are clear bilaterally in the lungs. Circulatory is good. No bleeding or mass bruising indicating a closed hemorrhage.

Complaint of chest pain

No allergies

Meds include: Aspirin regimen, nitro, Plavix, and another med for blood pressure.

Pertinent History: Had a cabbage done 10 yrs prior. No further history given.

Last oral intake: about an hour ago.

Event: shoveling corn at the grainery.

Onset: about 4 hrs. ago. Thought it was just heartburn due to spicy foods consumed.

Provocation: Nothing is working. Took 1 nitro about 15 min. ago.

Quality: Crushing and squeezing pain.

Radiating Pain: Down left arm and up into left jaw.

Severity: on the 1-10 scale Patient rates at a 8 or 9.

Time: started having arm and jaw pain about 2 hours ago. Ignored the pain due to already mounting medical bills. Husband also has history of heart problems.

Focused physical: Lungs are clear bilaterally. Pupils are PEARRL.

Vital signs: BP 160/92, HR 120, pulse is heavy and uneven. Skin is cooler and drier than normal. Breathing is shallow and slow.

O2 is by non-rebreather at 15 lpm. Start ALS for Cardiac complications. Prepare for Trans.

Contact MC for nitro and aspirin. 1 Nitro to be given and no aspirin at this time.

If no effect than 1 more can be given in 10 mins.

Gave one nitro after verifications were met.

Second Vital sets: pulse is uneven and thin. BP 80/50, HR 150, skin is starting to show signs of hypoxia. Breathing is labored and shallow.

Reconsider as a Priority Rapid Transport. Treat for shock and call ahead to hospital for response team.

Keep re-evaluating all vitals and interventions.

[scratrat]

I'm guessing you're a basic?

Coming from a paramedic stand point, the only thing I disagree with is giving Nitro. That has nothing to do with you or this case, I just don't feel nitro should be given at a Basic level without having an EKG readily available first. She may have had an inferior wall MI with right ventricular involvement, which is why her blood pressure tanked. Or she may have taken sexual dysfunction medications (yes, women do this too). Or her chest pain was caused by an arrythmia. I noticed her heart rate jumped up to 150 and you were initially sent for an unresponsive person - leading me to believe she may have had a syncopal episode. With her current complaint of chest pain, I'm venturing to say there's an arrythmia under there somewhere.

The only thing I would have mentioned would be maybe assisting ventilations. The theory being that her respirations are now increasingly labored despite high flow O2, she shows signs of hypoxia and her heart rate skyrocketed....she's impending failure..

[JakeEMTP]

Yeah, not I big fan of giving Nitro w/o a 12-lead and a patent IV. I realize it might be above your scope of practice and that is not your fault, it is the systems. Did you take a set of V/S before administrating the second Nitro? You've gone to far brother. W/o a patent line, Nitro should NEVER be given. How do you reverse the low BP now? Better start bagging, call 911 and get the AED, your pt. is about to code.!

[DFIB]

I think we are missing the the crucial point. She was a nitro taker that had already taken one with no effect. Radiating crushing chest pain. Doesn't sound like pectoral angina. I would have requested ALS intercept as soon as I suspected an MI. High priority transport. Load and go. ASA was a good call.

If MC recomended nitro that is his business I think i would have questioned his call on a direct line and recuested confirmation after he had a chance to review the case again.

I agree with scratrat and jake EMTP. I would begen assisted ventilations and prepare the airway adjuncts, AED, and suction as a precaution.

[INems]

Thank you gentlemen for your honest opinion here. I am a Basic and I do plan on taking ALS and TacMed at the first available opportunity I have. Having heard your opinions, I do agree with the impending code. The first set was taken and then MC was called. The second set was taken approx. 5 minutes later due to the signs of hypoxia. The test was based on 2 EMT-Bs on the bus (which means no IV's or 12-leads, which I wish they would go ahead and cover during our course and include it in our scope of practice which would stop a lot of problems like this, but unfortunately, that is never likely to happen in Indiana anytime soon) with one first-responder already at the scene (in this case, a dept. head).

The whole scenario was kinda weird in the way it was laid out to me. The vitals is what truly tripped me up. I guess that if I had more "training" on this type of scenario than this would have made more sense to me.

Thank you for responding.

[JakeEMTP]

Yeah, we weren't trying to bust your balls. Just some overall opinions and concerns. Quite frankly, if you can't interpret a 12-lead, there isn't much point in adding this to your scope unless of course you have the ability to transmit to the hospital. Acquiring a 12-lead is easy, reading it and correctly interpreting it are quite another.

Good luck with your class and keep the questions coming. There is no such thing as a stupid question here and this site is an excellent resource for you. There are some really smart and experienced providers on here.

Edited August 15, 2011 by JakeEMTP

[INems]

Thank you Jake. I really do appreciate your time in looking at this for me. I don't feel like anyone was bustin my balls or anything. I'm just not that knowledgeable as of yet in the ways of the EMTB. The whole 12-lead is what is throwing me. Hence why I want to get ALS taken soon. At least that way I will have the ability to learn to read and accurately interpret the 12-lead. I have the ability to transmit to the hospital, but the docs there are of the mind that if it wasn't done at the facility then it's not accurate at all. I can work up a 12-lead, but it's getting the proper information out of the docs that is the real time killer. Couldn't say any of this for the test because it is "technically" outside the scope of practice here.

I will keep the questions coming. Thanks for the help.

[DFIB]

Keep up the good work and enjoy the ride.

[DwayneEMTP]

Did you copy/retype that from the scenario gave you, or did you retype it from memory?

If from memory...good on you man. There is a lot of information there..

Good calls, though I'm going to disagree with my peers regarding giving the Nitro. This pt is obviously in trouble, she's already got a self administered nitro script which will allow her to take several doses without starting an IV on herself, so I think that Nitro was a good call.

She's got every hallmark symptom for a significant MI, and she's missing those significant for IWMI, bradycardia/hypotension* and at least not reported, likely not checked at this level, JVD (jugular vein distention) though as a hallmark isn't always noticeable in all patients.

Depending on what was reported to the doc I'm surprised that he withheld a little baby aspirin, but I'm sure he had good reasons for that...

So anyway. Would I prefer an IV before giving Nitro? Of course...but it sounds as if we'd rather watch this chick die than take a chance on killing her...May be the better option of course, though in my limited experience I've rarely, very rarely, seen an exciting drop in B/P secondary to nitro when the patient wasn't already borderline hypotensive.

This heart is hungry, and getting tired, and there's a chance that the Nitro can help at least a little bit with both issues. Risk benefit based on original vitals is one sided in my opinion. (Yeah, I know the science says that it works for shit, but it's great in theory, and it's really the only tool that I have that may help this rapidly declining patient)

Bottom line is that if I run on this patient and say...the Terminator blew up my ambulance and jump bag, but somehow my bottle of nitro was spared, I'm going to try and improve her condition with Nitro instead of sit on my hands waiting to do CPR. (Of course I know no one would be sitting on their hands..but you know what I mean)

Cool thread...

Dwayne

Edited to add citation.

*http://www.cepcp.ca/main/paramedic/cme/Section%202.pdf (pg 5)

Also, Scrat, it's good to see you back man!

I miss having you here...

Dwayne

Edited August 15, 2011 by DwayneEMTP

[JakeEMTP]

Hey Dwayne! What's up bro"?

I guess I wasn't to clear, but I was trying to get the OP to realise that getting a set of V/S post 1st nitro and pre 2nd administration is paramount. If they had, perhaps they might have held off on the second dose. Sure, with an initial BP of 160 over something, I might have given the nitro w/o a line. By the V/S after the second nitro though, it appears we might have a inferior MI here. The pt. is compensating, time to shit or get off the pot.

The good thing I guess, is ALS (you know how I hate that!) is on the way.

One of the reasons I hate SL Nitro is, once it's administered there's no reversing it. I much prefer a nitro drip. At least you can stop it! That is for a different discussion though. I don't want to hijack our new member's first post.