Chest Discomfort/Tightness & Pacers Case

[whit72]

I would have performed a stress test in the living room, if the findings were positive, I would have catheterized her right there by lamp lite to rule out any blockages. If blockages were noted I would have moved to the ambulance to possibly do a stent placement and open heart bypass if need be. Of course depending on how close it was to shift change. I don't want to generate unnecessary overtime.

Kidding, for those who cant differentiate between the two.

[1EMT-P]

The patient did not have a fever and she had a normal CXR per the Radiologist.

[FireMedic47]

I definately would have obtained a 12 lead if it were available. Intermittent right sided chest pain.......load of stuff comes into mind. Pleural effusion but you said had a normal xr.........possibly Angina with some of the PMH you described.

[medic001918]

On top of a more detailed history for this patient, the 12 lead would be an absolute. While having a pace maker can make a 12 lead more difficult to interpret, you may be able to see if her pacemaker is malfunctioning (maybe not capturing every time it fires) or if it's a demand pacer, you might see some underlying beats that don't have the pacemaker disrupting their etiology. This would allow you to make a better determination of what might be going on with this patient. And the majority of 12-lead EKG's on the lifepack monitors show up as "abnormal EKG." That doesn't mean that they are abnormal. The machine goes strictly on a numbered criteria to determine what's normal and what's not. One thing that I've suggested to medic students and new paramedics is to take the EKG when it's printed and to fold the machine's interpretation over so they can't see it while looking at the strip. This prevents them from reading something there and then trying to make their interpretation fit what the machine suggests. It's better to evaluate the 12 lead yourself, then you can see if the machine agreed. But by then you've already made an unbiased decision as to what you're going to call the rythem.

I would have attempted to talk the patient into having the IV done, but if she wouldn't take it I wouldn't get too concerned with it. Before going the NTG route for this patient anyway, I'd want to know more about her chest pain. What did it feel like? Did it travel anywhere? What was she doing when it started? Did she get diaphoretic with any of the episodes? Did she get nauseous with any of the episodes? Severity? The pain was described as intermittent, so it's possible that in your presence she doesn't have any pain at all and has no complaint at the moment. I'd leave the 12 lead on, wait for the episode to repeat itself and be ready to try to capture a 12-lead in the event that she experiences the pain again (maybe looking for that pacemaker problem).

I would have probably gone with the Asprin as it's a safe bet, but I can't say that given the story that I've been presented with I would have really pushed NTG as well without knowing more. The information given isn't really enough to make that decision. More history and more assessment would go a long way for this patient in to determining what was happening with her. That being said, I'm not saying that the assessment was not done, but it wasn't posted here for us to follow along.

Shane

NREMT-P

[jwraider]

"Medications: Albuterol MDI, ASA 81mg, Ativan 4mg, Lasix 40mg, Lexapro 20mg, Lopressor 100mg, Protonix 40mg, Wellbutrin 300mg, Co Q10 120mg & Vitamin E 400IU.

PMHX: Allergies, Anxiety, Asthma, Brady-Tachy Syndrome ( Dual Chamber Demand Pacer), Chest Discomfort/Tightness, Depression, HTN & SAH. "

Why is she taking protonix? I thought it was for acid reflux which I don't see that in the history. I'd ask her if she has GERD and what she does for the symptons and possibly suggest drinking a glass of milk if she didn't have any ideas.

Total newb here interested to know if that helps or I just killed the patient with my milk idea =)

[1EMT-P]

I asked about that & apparently the patient's Allergist put her on the Protonix because he felt that she had both Asthma & Gerd..