ERDoc Posted October 10, 2007 Share Posted October 10, 2007 FF523 as is typical of you, you come out with some of the most absurd posts. As I and others have said in the past, your arrogance and ignorance are going to get you and your pts killed. Your post shows why protocol monkeys should be outlawed. Chest pain does not equal aspirin. You are OK giving a medication that will make bleeding worse to someone with a potential fatal bleed? It is a good thing that you don't carry heparin or even worse thrombolytics. I am afraid to think of the number of people you would send to an early grave. If you can't differentiate ACS from disection in the field, you don't belong there. No, you cannot make a definitive diagnosis but you can make an educated decision. Spend a few minutes talking to your patients and less time trying to see how many skills you can use and you can pull apart the story and possibly do the right thing for the pt. Try asking more about the pain than just where it is and when it started. The pain from a dissection is usually a ripping or tearing that is greatest at onset and gets better. There are several other differneces but I will let you look them up for yourself (consider it a test to see how truly professional you are). I do not have xray vision, but I know how to take a good history and decide that it may be wise to hold on the aspirin until I know there is no disection. You should be doing this also. No one is going to knock you if you withold aspirin and can justify it. Document your reason and tell the ER staff, "I didn't give him any aspirin because I was concerned for a dissection because of XYZ." You should also be careful giving nitro to a pt with a possible dissection. Can you tell me why? Link to comment Share on other sites More sharing options...
firefighter523 Posted October 10, 2007 Share Posted October 10, 2007 vs , tearing CP doesn't mean that it is a disection. ACS can also present with tearing CP. Just because the pt thinks it might be tearing, could mean it feels more like crushing to the next person. You don't know. It is up to you if you want to withhold ASA, I do know this, ASA decreased mortality by up to 26% in MI pt's if given right away. What if the pt already takes 81 mgs a day, and the disection is not complete yet, say it is just an anyurism right now. Is your 325 mgs really going to kill the pt , since he has been taking 81 for the past 10 yrs??? Doubt it... Link to comment Share on other sites More sharing options...
firefighter523 Posted October 10, 2007 Share Posted October 10, 2007 Yes sir, I think the reflex tachycardia from nitro might do a dissection harm, refer to my post below yours, just because someones states that his pain feels tearing, doesn't mean that it is automatically dissection? And, what about the person that is on profilactic ASA, will your lousy 324 kill him, or if it IS a lesion, will it increase his chances by just a little bit??? The more and more we interact, the more and more I think your are a 2nd year resident!!! Please get off the med com radio, stop practicing giving orders until you finish with your books yougin'! Link to comment Share on other sites More sharing options...
vs-eh? Posted October 10, 2007 Share Posted October 10, 2007 vs , tearing CP doesn't mean that it is a disection. ACS can also present with tearing CP. Just because the pt thinks it might be tearing, could mean it feels more like crushing to the next person. You don't know. It is up to you if you want to withhold ASA, I do know this, ASA decreased mortality by up to 26% in MI pt's if given right away. What if the pt already takes 81 mgs a day, and the disection is not complete yet, say it is just an anyurism right now. Is your 325 mgs really going to kill the pt , since he has been taking 81 for the past 10 yrs??? Doubt it... Very true. Ischemic CP can present in a myriad of forms. Solid clinical assessment +/- diagnostic tools can aid in that assessment. I assume ALL of your CP aren't treated with (forgive me) MONA. All things being equal (and speaking in the context of thoracic aneurysm), I would have a greater degree of suspicion for a thoracic aneurysm than anything else. Tell the ER your suspicion base on clinical assessment (and withholding certain medications) and you're cool. Pulling internet stats does not help your knowledge as a practical clinician... Link to comment Share on other sites More sharing options...
ERDoc Posted October 10, 2007 Share Posted October 10, 2007 vs , tearing CP doesn't mean that it is a disection. ACS can also present with tearing CP. Just because the pt thinks it might be tearing, could mean it feels more like crushing to the next person. You don't know. It is up to you if you want to withhold ASA, I do know this, ASA decreased mortality by up to 26% in MI pt's if given right away. What if the pt already takes 81 mgs a day, and the disection is not complete yet, say it is just an anyurism right now. Is your 325 mgs really going to kill the pt , since he has been taking 81 for the past 10 yrs??? Doubt it... The extra aspirin is not necessarily going to kill the pt but you may leave the surgeon with a bloody mess that will increase the chances of the pt not making it off the table. You are right, a tearing sensation does not make it a dissection, but it should raise your suspicion for a dissection especially in the setting of other signs and symptoms. I can see that developing a differential is difficult for you since you seem to be protocol driven and unable to make clinical judgements. An aneurysm and a dissection are not the same thing. They are seperate entities and your use of them interchangably goes to show your lack of education. When you site statistics and solid numbers, you need to cite your reference (and Wiki does not count). Show us the evidence for your 26%. Link to comment Share on other sites More sharing options...
vs-eh? Posted October 10, 2007 Share Posted October 10, 2007 The extra aspirin is not necessarily going to kill the pt but you may leave the surgeon with a bloody mess that will increase the chances of the pt not making it off the table. You are right, a tearing sensation does not make it a dissection, but it should raise your suspicion for a dissection especially in the setting of other signs and symptoms. I can see that developing a differential is difficult for you since you seem to be protocol driven and unable to make clinical judgements. An aneurysm and a dissection are not the same thing. They are seperate entities and your use of them interchangably goes to show your lack of education. When you site statistics and solid numbers, you need to cite your reference (and Wiki does not count). Show us the evidence for your 26%. Wayyyyyyy ahead of you doctor... Link to comment Share on other sites More sharing options...
ERDoc Posted October 10, 2007 Share Posted October 10, 2007 Wayyyyyyy ahead of you doctor... Yeah, I realize that. Not sure how I missed it. Good job, carry on. Link to comment Share on other sites More sharing options...
fiznat Posted October 10, 2007 Share Posted October 10, 2007 It is up to you if you want to withhold ASA, I do know this, ASA decreased mortality by up to 26% in MI pt's if given right away. The key words in that sentence are "...in MI pt's." Of COURSE ASA helps in the AMI patient, absolutely. No one is arguing that. The danger is if the patient is NOT having an AMI, and is instead suffering from something that can possibly be made much worse by the ASA. You can't possibly be defending the idea that every chest pain patient gets ASA without thought as to the true etiology of the complaint. Same goes with NTG in RVI. "You should be okay?" Are you serious? Link to comment Share on other sites More sharing options...
ERDoc Posted October 10, 2007 Share Posted October 10, 2007 Yes sir, I think the reflex tachycardia from nitro might do a dissection harm, refer to my post below yours, just because someones states that his pain feels tearing, doesn't mean that it is automatically dissection? And, what about the person that is on profilactic ASA, will your lousy 324 kill him, or if it IS a lesion, will it increase his chances by just a little bit??? The more and more we interact, the more and more I think your are a 2nd year resident!!! Please get off the med com radio, stop practicing giving orders until you finish with your books yougin'! Do you want to be the surgeon that has to take a risky case to the OR after some yahoo just made the situation worse reguardless of how little that increase was? I don't know too many that will be very happy. I'm still waiting for your reference to the 26% decrease in mortality that you brought up. I would be careful calling people's credentials into question. If I remember correctly several people have asked you about yours and you have failed to respond. I am not a second year resident. I have 10 years of EMS experience (as an EMT), 5 years of undergrad, 4 years of medical school, 3 years of residency and 2 years as an attending. As far as the youngin comment, according to your profile I am about 6 months younger than you. And what were your qualifications? Link to comment Share on other sites More sharing options...
vs-eh? Posted October 10, 2007 Share Posted October 10, 2007 Wait a sec... Now people may have issue with this firefighter523 guy... And potentially for good reason... But scaramedic called me "brilliant" I think, in a deleted post...and yes I saw that post... I deserve all my kudos. Is "cum up pans" an actual word or phrase? Because I need that. Link to comment Share on other sites More sharing options...
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