19F Chest pain - confused me

[EMS49393]

FLEMTP: Thank you for that post. I appreciate where you are coming from since I've seen nothing but cookbook medics since I left Missouri. I just can't bring myself to do a lot of screwing around with this and that intervention when a patient is compensating. They might be "textbook" unstable, but are they really unstable? In many instances they are not so critically unstable that they can't wait for very definitive interventions beyond what we are able to provide or the additional diagnostics available to determine their exact needs.

We carried Retavase in Missouri for the STEMI patient. Although they were trialing thrombolytics at the hospital for ischemic CVA's, I certainly wouldn't dream of administering that drug to a stroke patient, no matter how much I felt the stroke to be ischemic in nature. My CT machine has been down for years in my ambulance, and all the repair orders have been neglected. My point is, just pushing something because you can, or you think you should is dangerous without proper education, diagnostics, and consideration.

I really get tired of hearing the phrase "I did it because the protocol told me to." They are guidelines and are not always appropriate for every patient encountered. This young lady with chest pain is a prime example. There are no cardiac protocols in PA that truly fit this patient. There is a chest pain protocol and a narrow complex tachycardia protocol, but neither of them really fit this scenario. She's likely not having an MI (unless she's been abusing cocaine) so going down the ACS protocol is just ridiculous. She does have a "narrow complex tachycardia" but she is really relatively stable, so I just can't see baking the cake through that algorithm and screwing with her compensatory mechanisms. I can see monitoring her closely, and helping her to calm down (likely being her problem).

Despite my unpopular stance, I'm going to continue to swear up and down that the major problem with EMS in this country is the lack of needing a degree to work. You just can't make a truly informed decision without education, period.

 

[Aidey]

I have a better idea before ya'll jump into using medications like adenosine.

how about some calming reassurance and some good ol' normal saline? if her rate comes down, it was anxiety, and dehydration.

She said she takes xanax every day.. but did not take it today.. seems pretty simple to me.

Why is it that most people are just so ready to jump into pushing drugs?

I had a patient the other day that was in a sinus tach... on the 4 lead it looked MARGINALLY wide... but it did not have the typical morphology of v-tach. My partner, who is a Paramedic by licensure working as an EMT in our system, saw it and was like.. "um.. monitor! look at the monitor! Do you want the amiodarone?" I glanced over, saw it was sinus tach with what was probably a mild Bundle branch block, and said, nah, just a 12 lead is cool.

The patient had a complaint of mild epigastric pain after eating meat he thought was possibly rancid, but he cooked it to kill whatever. He was smoking a cigarette upon our arrival and ambulated to the truck.

Not exactly something requiring a drug, or panic, but there are quite a few paramedics that seem to jump right into both..

i'll never understand it.

I understand it, but it doesn't make it any less stupid.

Because a large portion of those providing paramedic education/service present it in an almost military style of "You will do this when you see... or you are wrong, and the patient is going to die, the protocol will be breached you will lose your license, and get sued for an amount of money you will never earn in your life..."

Thinking is not on the menu, reacting is.

You also have to remember you work for one of the best services anywhere. A large population of systems in the US don't want paramedics to actually think. Few actually provide their employees with professional educational opportunities or try to constantly increase the capabilities an thereby value of their employees. I bet we could name >95% of them just from reputation.

We both see it all the time I am sure, it is still madness. You even see it here on the ACLS threads and the like. "because the protocol says..." "Because my instructor said..." "Because there are solicitors waiting around every corner, reviewing every run report waiting to catch a paramedic in anyway deviating from cookbook so they can litigate for all the poor :censored::censored::censored::censored::censored::censored::censored:'s worldly possessions."

I agree with both of you. After speaking with several people about cases they had like this, I have come to the conclusion that we SUCK at telling SVT from ST, and adenosine should be taken out of the protocol in my area. If they are unstable then they should be cardioverted. If they are stable, then leave the drugs alone!

I heard someone declare a HR of 180 in a 3 yo /c a fever was SVT. I had a fire medic want to give adenosine to a 93 yo woman /c a HR ranging between 130-190. Hmmm, irregular...rate over the ST threshold...93 years old...how many people even need to look at the strip to know what it is?

And for those who truly are in SVT, it is not an uncommon idopathic event in young adults, especially young women. It resolves on its own, and doesn't need emergency treatment. I have had episodes of SVT myself, and I have also managed to get my HR up into the 180s-190s when working out. Was there chest pain and SOB associated with both? Yup, but it is a totally different sensation.

Chest pain in fast ST isn't really unexpected. The way it was explained to me is that the heart is a muscle, when it is beating 160 times a minute the muscle is working hard. When you work your arm and leg muscles hard what happens? They hurt (Duh. The duh was actually included by the doc giving the lecture).

And then we've got WPW...adenosine = v-fib. If you don't know what WPW stands for, what it is, how do identify it and why adenosine is bad, you don't know enough to be giving anyone adenosine.

To the OP, what was the issue you had with the run?

 

[Melclin]

Overwhelmingly satisfying.

First of all: There was no twelve lead available. No vagal maneuvers tried. No particular stressors other than uni of late. I've heard of the difference between monitoring mode and diagnostic mode before, but its not something we talk about at uni and I've never seen it used on the road. Maybe the service monitors are different than at uni but as far as we're concerned there is one mode. :unsure:

Now, both my partner and I interpreted the rhythm to be sinus tach. We both felt that what this girl needed was to be calmed down. Her history of anxiety, plus stressors plus caffeine and not much sleep = anxiety attack. I felt coaching her breathing and utilizing some relaxation/bio-feedback techniques were warranted. Ventmedic's voice was floating around in my head saying "hyperventilation syndrommmmeeeee, hyperventilaaaatttitonnn syndrommmme" "don't fob off the anxious tachypneic pt"), but I still felt on the balance of probabilities this was not an emergent job, and it was worth spending some time calming the patient, taking her home to get her xanax if it wasn't far and giving that a shot (she was quite sure it was an anxiety attack), maybe giving her doctor a ring getting some advice and organizing for an checkup/doctors cert for the exam.

If we couldn't drop the heart rate at all, and the sensation in her chest continued, then maybe some IN fentanyl to calm her/treat the discomfort and transport non-emergently to the nearest public ED for a looksie.

What actually happened instead was that the instructor corrected our ECG interpretation to SVT and continued to prompt my partner into: cannulation, IV morphine (to which the patient became nauseated and received metaclopramide), activation of MICA backup, and emergent transport to a cardiac center.

She felt that the not at the top of what I thought was a T/P combination was actually a retrograde P wave in the middle of a large T wave and that it was dead-set SVT. She seemed to want to emphasize the instability of the patient (she seemed fine to me) based primarily on the the SVT and the pale skin (the pt was wearing a lot of make up but I thought it was just that the actress happened to be wearing make up). She was quite sure that this girl would be chemically cardioverted. She also said that an anxiety attack would not provoke a rate of a 170, to which I intuitively disagreed, but had no evidence with which to support the idea.

 

[Aidey]

^^^ And that ladies and gentleman is EXACTLY why we need to reconsider adenosine use pre-hospitally. I know it wasn't given in this case, but it is the overall issue of people not being able to tell what is SVT from what isn't.

 

[EMS49393]

She also said that an anxiety attack would not provoke a rate of a 170, to which I intuitively disagreed, but had no evidence with which to support the idea.

I have no evidence to support this either, however I've personally had my heart rate that high over too much caffeine an anxiety, so the blanket statement that it will not provoke a rate of 170 doesn't hold water with me.

Now that you've presented the remainder of the story, I have to agree with your line of intervention versus the instructors line. Unfortunately, the instructors appear to always be correct.

 

[slb862]

too much caffeine

My very first call as a Paramedic was very similar:

40ish yo guy out jogging, developed CP.

BP-normal 120's/80's
P-elevated (170's)
R-28
Cardiac Monitor-ST, no ectopy
NKDA
PMH: none healthy
12 lead: ST
Sweating, denies N/V and no radiation.
Pt. states out drinking last night, not a heavy drinker, but got sloshed. (states he smoked a pack of cigarettes, states he doesn't smoke) Woke up this am, slammed 4 diet cokes, went out for a morning jog.
Classic caffeine "overdose", on top of being dehydrated.

He survived, and felt better after a liter of NS.

 

[clibb]

Now, both my partner and I interpreted the rhythm to be sinus tach.

How can you confuse that with Sinus Tach? There are no P waves.

 

[Veneficus]

I'm interested in your views. I've read several of your posts and find them intelligent and well written. It's actually refreshing since the main reason I hate my career is the lack of required education and subsequent progress. I enjoy a good dialogue.

It is not benzos that really worry me. Both Benzos and barbiturates have been used for centuries and despite the side effects, the mechanisms and understanding of them are well established.

But it doesn't mean it should be the first choice.

I think a lot of the psychiatric diagnosis do not qualify as pathology. Obviously there are people with such severe psychosis that they require pharmacological or intervention.

The problem I see is that most psychiatric illnesses are actually coping mechanisms. When a physiologic coping mechanism gets out of control, that is where medicine needs to come into play. Examples abound in other organ systems. Liver fibrosis, ectopic myocardial contractions, certain immune responses, etc.

If your problem is you are depressed because you lost your job, can't pay your bills, aren't very successful with romance, etc. then certain levels of anxiety and/or depression are physiologic. Until it actually has a strongly negative effect or a person's biochemistry is so altered they cannot recover from the compensatory mechanism is where medicine should come into play.

In earlier western society and in many nonwestern societies, it is a family or other social support group that has the largest positive effect on resolving the issues.

Take for example indiginous tribes in South America. Some guy loses his house in a flood. He is depressed, homeless, doesn't have an insurance plan to compensate him for losing everything.

So the local shamen gies him a stimulant to chew, (similar to cocaine) performs an exorcism like ritual, and sudenly with the evil spirits gone, his life takes a dramatic upturn.

Let us analyze this witchcraft a little deeper though.

His problems are attributed to an outside supernatural source, therby absolving him of a feeling of guilt or fault. He is given some temporary (one time use) pharm therapy, and the public ritual calls public attention to his plight. Now being absolved, in celebration other villagers help him build a new house, bring him gifts and have a feast to sole his immediate food and neccesary possession problems, and then he is suddenly an attractive mate or hunter, etc.

All of it stems from a form of highly ritualized social support. The root of the problem is addressed.

If he was just given his stimulant, none of his issues would be addressed and as soon as the stimulant wore off, he would require some more in order to prevent relapse. Eventually he will be so doped up, he will then be a burden on society around him or abandoned.

With the exception of the most serious levels of disorder, modern therapy is basically overcompensating the defense mechanisms by altering biochemical pathways without addressing the root issues so that normal brain function can return.

Most modern western societies have lost the social support mechanisms for a variety of reasons too numerous to describe in a post here.

We have tried to replace those mechanisms with various pharmacological agents or "counciling." What that equates to is what I describe "help light" (counciling) which can have a real impact in minor cases, or a "nuclear option" (pharm) that is often considerably more than a person needs to get back to normal compensation levels.

It turns into an imprecise game of playing with a chemistry set without addressing the root causes. It is the same as treating a dysfunctional liver caused by heart failure without doing anything for the heart.

Pharm therapy without counciling or social support just basically makes people "high" by stimulating or inhibiting various chemical processes. You certainly don't need to pay a doctor for that. Your local street pharmacist can do the same for much less.

The trouble is there is negative stigma about social support programs as well as many psychological services not affordable or covered by insurance/effectively funded by the social systems. we simply cannot replace social support networks (the hyperspecialization of modern western society actually makes social support more neccesary as individuals no longer have the broad range of knowledge and skills to properly cope with many adversities.) Primates require social interaction for health. People are Primates.

Again, the pharm therapy does work and in certain patients is certainly indicated and beneficial. But there is a culture of trying to use pharm therapy as a simple easy to use magic cure.

"Don't use a cannon to kill a mosquito."

 

[Smash]

Further to the above, recent years have seen a flood of Ritalin being prescribed for children with "ADHD" or "ADD". Whilst some may indeed actually have such a disorder, there is a growing realization that the majority of behavioral problems can be attributed to other causes such as sleep deprivation (I'm always astounded at the number of residences we attend late at night or early in the morning to find children up and about at an hour that I wish knead in bed!) or just plain old needing a bit of discipline.
However, we seem, as a society, to be interested in two things above all others: the quick fix and abrogation of any kind of personal responsibility.

This is not intended to diminish the impact that mental illness has on individuals or on healthcare/society, but it does seem we are keen to throw drugs at things that could be managed more appropriately with other means.

 

[Melclin]

How can you confuse that with Sinus Tach? There are no P waves.

There is a p wave. The argument was whether the notch in the middle of the complex in between the two QRSs is a retrograde p wave in the middle of a t wave, or that the notch is the begining of the natural decline of the t wave and that it is followed by a normal p wave.

To further confuse matters I've since seen the actual written version of the standard scenario and it says the patient is "monitored in Sinus Tachycardia".

 

[Aidey]

How can you confuse that with Sinus Tach? There are no P waves.

I'm 100% sure that if we were able to slow that down, more obvious P waves would show up.

 

[FLEMTP]

First of all: There was no twelve lead available. No vagal maneuvers tried. No particular stressors other than uni of late. I've heard of the difference between monitoring mode and diagnostic mode before, but its not something we talk about at uni and I've never seen it used on the road. Maybe the service monitors are different than at uni but as far as we're concerned there is one mode. :unsure:

Now, both my partner and I interpreted the rhythm to be sinus tach. We both felt that what this girl needed was to be calmed down. Her history of anxiety, plus stressors plus caffeine and not much sleep = anxiety attack. I felt coaching her breathing and utilizing some relaxation/bio-feedback techniques were warranted. Ventmedic's voice was floating around in my head saying "hyperventilation syndrommmmeeeee, hyperventilaaaatttitonnn syndrommmme" "don't fob off the anxious tachypneic pt"), but I still felt on the balance of probabilities this was not an emergent job, and it was worth spending some time calming the patient, taking her home to get her xanax if it wasn't far and giving that a shot (she was quite sure it was an anxiety attack), maybe giving her doctor a ring getting some advice and organizing for an checkup/doctors cert for the exam.

If we couldn't drop the heart rate at all, and the sensation in her chest continued, then maybe some IN fentanyl to calm her/treat the discomfort and transport non-emergently to the nearest public ED for a looksie.

What actually happened instead was that the instructor corrected our ECG interpretation to SVT and continued to prompt my partner into: cannulation, IV morphine (to which the patient became nauseated and received metaclopramide), activation of MICA backup, and emergent transport to a cardiac center.

She felt that the not at the top of what I thought was a T/P combination was actually a retrograde P wave in the middle of a large T wave and that it was dead-set SVT. She seemed to want to emphasize the instability of the patient (she seemed fine to me) based primarily on the the SVT and the pale skin (the pt was wearing a lot of make up but I thought it was just that the actress happened to be wearing make up). She was quite sure that this girl would be chemically cardioverted. She also said that an anxiety attack would not provoke a rate of a 170, to which I intuitively disagreed, but had no evidence with which to support the idea.

My opinion is that your "instructor" is in need of some serious "instruction" of her own!

 

[gicts]

What would the benefit of intranasal fentanyl be over IV in this situation?

 

[EMS49393]

What would the benefit of intranasal fentanyl be over IV in this situation?

Iam suddenly confused. Why is this girl getting fentanyl?

 

[Sam Adams]

I'm in agreement here, why the fent.?

Advanced Life Support wouldn't have even been dispatched to this call in these parts. She needs hugs, not drugs.

 

[dixie_flatline]

She needs hugs, not drugs.

I lol'd

 

[gicts]

Iam suddenly confused. Why is this girl getting fentanyl?

My guess is a poor decision of a sedative for anxiety in an over blown treatment choice for this scenario. Tis what the OP said the treatment was though if that is the question.

 

[medic417]

Fentanyl may have been chosen for multiple reasons. It would help relax the patient. If it was actually cardiac in nature it is quickly becoming a favored treatment. Just to name two quick ones.

Just because the patient tells you a history of anxiety does not rule out the cardiac possibility. By immediately saying its FHS ( Female Hysterics Syndrome ) you may be missing the big picture. Perhaps the pale cool skin is improper perfusion caused by a cardiac event rather than just her hyperventilating and panicking. Even if this was a panic attack has she now actually pushed herself over the edge and now is having a true cardiac episode.

Age is not a determining factor to cardiac problems. Do not put blinders on.

Melclin have you been able to follow up at the hospital to see what the actual diagnosis was?

 

[sir.shocksalot]

Iam suddenly confused. Why is this girl getting fentanyl?

Mel said it was for anxiety and the slight chest discomfort that the pt was complaining of.
I agree with what others have said, this pt is not in any emergent need of electrical or pharmacological intervention, and as one person so perfectly put it, she "needs hugs, not drugs".
That being said, I'm just throwing this out there, but why not give her some adenosine/vagal maneuvers? If you are going to call it SVT you could certainly argue that her anxiety may have some basis from her heart going 170 mph and fixing the rhythm may relieve some of her anxiety. My understanding is that adenosine would be indicated in this person, but what makes some of you smarter and more experienced medics than myself say that adenosine is too risky/ not warranted in pre-hospital treatment. (I'm just trying playing devils advocate and trying to learn a little, I would have tried vagal maneuvers and tried to calm her down myself.)

 

[Aidey]

Fentanyl may have been chosen for multiple reasons. It would help relax the patient. If it was actually cardiac in nature it is quickly becoming a favored treatment. Just to name two quick ones.

Just because the patient tells you a history of anxiety does not rule out the cardiac possibility. By immediately saying its FHS ( Female Hysterics Syndrome ) you may be missing the big picture. Perhaps the pale cool skin is improper perfusion caused by a cardiac event rather than just her hyperventilating and panicking. Even if this was a panic attack has she now actually pushed herself over the edge and now is having a true cardiac episode.

Age is not a determining factor to cardiac problems. Do not put blinders on.

Melclin have you been able to follow up at the hospital to see what the actual diagnosis was?

I think this was a scenario, not an actual patient.

I also don't think that everyone is dismissing this has FHS. I believe there is an anxiety component that is being exacerbated by some benzo withdrawal, caffeine overload, lack of sleep and minor dehydration.