# Chest pain



## EMT B (Jan 13, 2013)

Dispatched at 17:32 for a 17 yo female with chest pain. get on scene to find the patient laying on the couch. pt appears to be about 5'6 and 110 lbs, She appears sligtly diaphoretic. patient states she was having "chest pains around her heart and was having painful shocks down her left arm and her neck". the mother states the pain is common but never this bad. 

bp: 119/71
hr: 102 
SpO2: 97% 

heart and lung sounds all were normal. administered 325mg ASA with no releif. called ALS. ALS does a 12 lead ekg which shows sinus tachy. 

pt is transported in position of least discomfort. 


what do you guys think it is? im stumped.


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## Thricenotrice (Jan 13, 2013)

Did they give nitro? How was the pt presenting? Overall presentation, how bad was the pain, quality, all the opqrst stuff?

You said the pain is common? What is the history, any defects, so on? 

Need a better painted picture


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## Aidey (Jan 13, 2013)

Anxiety.


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## JPINFV (Jan 13, 2013)

Medical history?
Have someone pull the mom into another room for "questioning" and ask the patient about tobacco, alcohol, drugs, sex.

Also, ASA isn't administered for pain control, so I wouldn't expect relief even if it was a MI.


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## NomadicMedic (Jan 13, 2013)

Anxiety.

I would not give ASA or NTG.


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## Anjel (Jan 13, 2013)

Was she breathing hard? Or just laying on the couch chilling?

What was she doing when it started?

I'm going with anxiety and a BLS transport, if med control will allow.


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## abckidsmom (Jan 13, 2013)

Aidey said:


> Anxiety.





n7lxi said:


> Anxiety.
> 
> I would not give ASA or NTG.



17 yof + mom, and a cell phone.  You're seeing an anxiety show.  A few digging questions can identify who the show is for.


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## RustyShackleford (Jan 13, 2013)

MID call.......Muffin In Distress


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## mycrofft (Jan 13, 2013)

Caffeine level??

1. Was pulse regular? Was it by palp or auscultation?
2. Was EKG automated or over-read by human, and did it include a rhythm strip?


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## EMT B (Jan 13, 2013)

the onset was about 15 mins prior to our arrival.  she was watching tv. respirations were normal. nothing makes it better or worse. she does have a history of this happening but the doctor didn't know what it was.  pain was a 9/10. like i said the pain radiated to her neck and left arm. 

she last had a coffee friday morning at school. she does not regularly drink coffee. also she is not sexually active, she does not smoke, however she has had alcohol before. the last time was 3 months ago at a party with her friends. she had 2 shots of vodka, a glass of boxed wine, and a bottle of gatorade. 

unfortunately i do not have the ekg printout :/

pulse was regular by palp


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## JPINFV (Jan 13, 2013)

EMT B said:


> she last had a coffee friday morning at school. she does not regularly drink coffee. also she is not sexually active, she does not smoke, however she has had alcohol before. the last time was 3 months ago at a party with her friends. she had 2 shots of vodka, a glass of boxed wine, and a bottle of gatorade.




Was the social  history taken in front of any of the patient's parents?


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## EMT B (Jan 13, 2013)

no it was done during transport

edit: mom drove to the hospital in pov


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## mycrofft (Jan 13, 2013)

Good on the pulse. I assume the EKG was an automatic reading , like the one that called my a-fib "Occasional PVC'S, sinus rhythm".

PAT maybe?


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## EMT B (Jan 13, 2013)

no, the paramedic read the ekg strip and said sinus tachy. 

edit: also i dont think its PAT because her resting heartrate is usually in the 90s (from the mother). i also have no reason to believe she lied about the drugs or the sex because she told us the truth about the drinking


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## EMT B (Jan 15, 2013)

Aidey said:
			
		

> I suggest you post this question in the relevant thread so that everyone can see the question and answer.
> 
> 
> 
> ...



from pm


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## Clare (Jan 15, 2013)

Aspirin would not be overly harmful and if it is myocardial ischaemia secondary to coronary artery occlusion it would confer benefit

I do not think it is myocardial ischaemia and it is most likely idiopathic or psychosematic


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## EMT B (Jan 15, 2013)

i was just going by protocol. chest pain and pain in the left arm and neck/jaw area gets asprin


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## Aidey (Jan 15, 2013)

Your protocol very likely means cardiac related chest pain. If someone got punched in the chest and left arm would you give them ASA?


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## Clare (Jan 15, 2013)

EMT B said:


> i was just going by protocol. chest pain and pain in the left arm and neck/jaw area gets asprin



I also agree that this means suspected myocardial ischaemia, if there is not objective evidence of myocardial ischaemia then you should not be treating for it


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## EMT B (Jan 15, 2013)

well yes i thought it was cardiac, however ALS did not, and I was wondering how you guys came up with Anxiety


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## Aidey (Jan 15, 2013)

The reason we all said anxiety is as follows. 

1. She is 17.
2. She has no cardiac history.
3. She is 17.
4. She has normal vital signs.
5. She is 17.
6. She has no history of trauma.
7. She is 17.
8. She has no history of respiratory illness. 
9. She is 17. 
10. She is not at high risk for pulmonary embolism.
11. She is 17. 
12. She has a normal EKG. 
13. She is 17.
14. She has had this before without a diagnosis. 
15. She is 17.
16. She is not at high risk for endocarditis/pericarditis/pleurisy. 
17. She is 17. 
18. There is no sign she has a pneumothorax.
19. She is 17.
20. There is no sign she has a pleural effusion. 


I could keep going, but I think you get the point.


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## EMT B (Jan 15, 2013)

why does anxiety initially present with cardiac symptoms? or is it different in everyone?


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## Aidey (Jan 15, 2013)

I suggest you do some reading on anxiety and how it can present.


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## EMT B (Jan 15, 2013)

will do. thanks for all your help guys!


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## leoemt (Jan 15, 2013)

I doubt its anxiety. Not everything that isn't Cardiac is Anxiety. Yes Anxiety can cause heart palpatations and tachycardia. It also causes shortness of breath and headaches. 

Any history of Anxiety attacks? History of Cardiac? Was she worried about something?

What was she doing the last time this occurred? How often does it occur?

I would consider a Caffeine reaction especially if she doesn't intake caffeine regularly. 

Unlikely but also a consideration of Angina needs to be made - especially with the referred pain in the jaw. 

Just because she is 17 is no reason to overlook a possible Cardiac problem. Many kids develop Cardiac problems especially with the poor diets and lack of exercise. Granted she is not obese but that does not rule out a cardiac issue. 

It is possible for a cardiac problem to go unseen in the field as I found out recently. If this is chronic she should probably have a holter monitor for a day or two to see if it catches the problem.


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## Aidey (Jan 15, 2013)

A caffeine reaction would present with a higher heart rate and blood pressure than she is exhibiting. Caffeine and other stimulants cause chest pain secondary to ischemia from either tachycardia and poor perfusion or vasoconstriction (or both). 

You don't have to be worried about something to have an anxiety attack. They can be triggered by subconscious stimuli.

What is the rate of non-congenital cardiac events in 17 year olds with normal 12 leads? 

Also, please define "many kids". 

Angina is caused by oxygen deprivation to the heart muscle. What exactly do you propose is causing angina in this patient?


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## JPINFV (Jan 15, 2013)

Not all that is cardiac is ACS, and 17 is a really good reason to push ACS far down the list.


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## EMT B (Jan 16, 2013)

if its not ACS, and its not Anxiety, than what is it?


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## NomadicMedic (Jan 16, 2013)

EMT B said:


> if its not ACS, and its not Anxiety, than what is it?



You posted the scenario... You tell us. 

To me, it sounds like neuralgia... Comes and goes, is common, no docs have been able to find a cure, feels like an electric shock... I would transport her, but not treat her for ACS.


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## EMT B (Jan 16, 2013)

after followup it turns out it is anxiety


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## HMartinho (Jan 16, 2013)

EMT B said:


> if its not ACS, and its not Anxiety, than what is it?



hyperthyroidism. (or something metabolic)

This is just one example among many others.


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## Anjel (Jan 16, 2013)

EMT B said:


> after followup it turns out it is anxiety


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## mycrofft (Jan 16, 2013)

Don't give anxiety short shrift. 
It is a symptom (hyperthyroidism, impending angina or MI, mental illness, social illness, polypharmacy legal and otherwise) as well as a fact of life for people such as teenagers. Extreme sadness has been empirically linked to sudden death among some groups ("so-called "broken heart syndrome").


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## BigLouie2314 (Jan 19, 2013)

Aidey said:


> The reason we all said anxiety is as follows.
> 
> 1. She is 17.
> 2. She has no cardiac history.
> ...



So apparently a 17yo can not have any legitimate acute medical problem. Have you considered pneumomediastinum? Drugs? Cocaine? Did anybody ask if the pt used any illegal drugs? Yes, she has no cardiac hx but how many young kids can have prolonged QT syndrome? More common thinsg could be URI, GERD, chest wall pain, myocarditis, precordial catch syndrome. Can't just think it's always "anxiety" because the pt has no documented hx or is 17 years old. No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.


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## Hunter (Jan 20, 2013)

BigLouie2314 said:


> So apparently a 17yo can not have any legitimate acute medical problem. Have you considered pneumomediastinum? Drugs? Cocaine? Did anybody ask if the pt used any illegal drugs? Yes, she has no cardiac hx but how many young kids can have prolonged QT syndrome? More common thinsg could be URI, GERD, chest wall pain, myocarditis, precordial catch syndrome. Can't just think it's always "anxiety" because the pt has no documented hx or is 17 years old. No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.



No one said she couldn't however the index of suspicion for an acute mi on a 17 y/o is very low. But the cases of the examples you gave without any other history are very very unlikely. Besides it's happened before without diagnosis, which means it's probably happening again.


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## Handsome Robb (Jan 20, 2013)

EMT B said:


> well yes i thought it was cardiac, however ALS did not, and I was wondering how you guys came up with Anxiety



Experience. 

Most medics here wouldn't have even done an ALS workup. Once the monitor goes on it doesn't come off. 

Not saying its right, but it happens all the time. 

Probably would get kicked out by EMD as a priority 3 call.


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## BigLouie2314 (Jan 20, 2013)

Can't tell you how many providers (medics, nurses, even ED docs) have been burned tossing things up to anxiety without in-depth and proper assessments.

Yea, I used do it all the time, triage something back to BLS knowing its a BS chest pain, but one days that BS chest pain, is actually going to be one of those "less-likely" problems, which si what happened to me, which is why nobody, no matter age, hx, etc., just gets tossed up to "anxiety."


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## Aidey (Jan 20, 2013)

BigLouie2314 said:


> So apparently a 17yo can not have any legitimate acute medical problem. Have you considered pneumomediastinum? Drugs? Cocaine? Did anybody ask if the pt used any illegal drugs? Yes, she has no cardiac hx but how many young kids can have prolonged QT syndrome? More common thinsg could be URI, GERD, chest wall pain, myocarditis, precordial catch syndrome. Can't just think it's always "anxiety" because the pt has no documented hx or is 17 years old. No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.



Oh they definitely can, but she is not one of them. 

Pneumomediastimum, GERD, chest wall pain/costochondritis, precordial catch syndrome etc are all great examples of conditions that don't normally require emergency treatment. Or any treatment outside of OTC meds. 

Myocarditis is expected to have other signs/symptoms, including possible EKG changes. She has also been evaluated for this before without a diagnosis. 

With the exception of cases of tracheal inflammation, a URI doesn't cause chest pain. And even with tracheal inflammation that is a stretch. 

Long QT syndrome doesn't cause chest pain on its own. Palpitations from an arrhythmia could cause chest pain, but she had no signs of irregular beats or an arrhythmia. 

So what if she has done illegal drugs? As I've mentioned before, she had no signs of a stimulant overdose. If she smoked pot and got chest pain, WTF is the ED going to do about it?


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## NomadicMedic (Jan 20, 2013)

Do a through assessment, but it's usually horses, not zebras.


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## Shishkabob (Jan 20, 2013)

BigLouie2314 said:


> So apparently a 17yo can not have any legitimate acute medical problem.... No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.




Sure it can, but just because it "can" be something doesn't mean I'll treat it as such.  After doing my assessment, we go off of my diagnosis.  I, like most medics here, don't go all willy-nilly with things to do without actually thinking about a cost/benefit for the given situation.


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## usalsfyre (Jan 20, 2013)

BigLouie2314 said:


> No, it may not be a typical MI, but it absolutely could be a legitimate medical problem.


Last time I checked panic attacks were a pretty legit medical issue, funny you don't seem to put them in that category.

No one is saying write it off. But evaluating risk factors is a big part of medicine.


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## Handsome Robb (Jan 20, 2013)

Outside of calming/coaching and potentially benzos in really severe cases there's not much EMS is going to do for anxiety or a panic attack.

But with that said what does EMS do for most things? 

Definitely is a real medical issue though, no one can argue against that.


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## Shishkabob (Jan 20, 2013)

Robb said:


> Outside of ..potentially benzos in really severe cases there's not much EMS is going to do for anxiety or a panic attack.



Naw, it goes on long enough, they'll pass out and fix themselves.  Save the paperwork from using controlled substances.   



PS, if you ever want to scare a firefighter, do exactly that:  Get an un-coachable anxiety patient, sit there just looking at them and wait for them to pass out.  h34r:


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## Handsome Robb (Jan 20, 2013)

Linuss said:


> Naw, it goes on long enough, they'll pass out and fix themselves.  Save the paperwork from using controlled substances.
> 
> 
> 
> PS, if you ever want to scare a firefighter, do exactly that:  Get an un-coachable anxiety patient, sit there just looking at them and wait for them to pass out.  h34r:



:rofl: 

I know they'll do it but I've never seen someone bad enough to. Always been able to coach them down. Never given benzos for anxiety either but can do it under standing orders. I like your way better. Fire here would WIG!


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## Shishkabob (Jan 20, 2013)

I've done it and it is rather funny.



Fire: Aren't you going to do something?

Me: No

Fire:  But they can't breathe

Me: Eh, they'll pass out soon

Fire:  WHAT?!




Disclaimer:  I myself have had a panic attack with air trapping.  It sucks.  But hey, it is what it is.


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## DrParasite (Jan 20, 2013)

12 lead, transport to cath lab, STEMI alert.  treat with NTG, ASA, and ensure the cardiologist is waiting for you when you cross the doors.

Nah, I would actually walk the patient to the ambulance, sit her on the bench, and transport her to local ER.

And RRob's right, under 35 with chest pain and normal breathing would get coded by EMDs as a Priority 3 call.


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## abckidsmom (Jan 20, 2013)

DrParasite said:


> 12 lead, transport to cath lab, STEMI alert.  treat with NTG, ASA, and ensure the cardiologist is waiting for you when you cross the doors.
> 
> Nah, I would actually walk the patient to the ambulance, sit her on the bench, and transport her to local ER.
> 
> And RRob's right, under 35 with chest pain and normal breathing would get coded by EMDs as a Priority 3 call.



When have you ever known someone to answer yes to "Is she breathing normally?"


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## DrParasite (Jan 20, 2013)

it happens once in a while.  

Priority Dispatch EMD makes it a required question and results in numerous unnecessary upgrades.  i didn't make the system, my boss just requires that i use it.


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## Shishkabob (Jan 20, 2013)

"No she's not breathing normally, that's why I called you!  Why aren't you sending the amberlamps?!"


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## abckidsmom (Jan 20, 2013)

DrParasite said:


> it happens once in a while.
> 
> Priority Dispatch EMD makes it a required question and results in numerous unnecessary upgrades.  i didn't make the system, my boss just requires that i use it.



I strongly, strongly agree with everything about MPDS.  I think their method is the best one out there, and when stupid people call 911, you'll get that every time.  A necessary evil, I think.

I like how they don't allow dispatcher-driven downgrades.  Too many crispy people out there would mess that up.


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## Clare (Jan 21, 2013)

abckidsmom said:


> I strongly, strongly agree with everything about MPDS.  I think their method is the best one out there, and when stupid people call 911, you'll get that every time.  A necessary evil, I think.
> 
> I like how they don't allow dispatcher-driven downgrades.  Too many crispy people out there would mess that up.



MPDS is what we use and is pretty good, having recently gone through a huge review where every single possible detriment has been reviewed and assigned a classification depending upon how time critical the problem is and how much of a threat it presents to the patients life so a lot of the old stuff that used to automatically be a priority one eg had seized but no longer fitting is now normal road speed, also things like cuts and flu and abdominal pain gets the Sierra jeep or phone advice instead of an ambulance.

Instead of being sent willy nilly to absolute BS on a one the new model means that things on a one are immediately life threatening or time critical.


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## Christopher (Jan 21, 2013)

n7lxi said:


> Do a through assessment, but it's usually horses, not zebras.



Had a 15yo thrown from a horse, and out of blind habit placed them on the monitor....only to find a previously undiagnosed congenital complete heart block requiring pacemaker implantation. Dumb luck saves the day.

I respectfully requested they take up riding Zebras to help out future paramedics.


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## Glucatron (Jan 27, 2013)

At 17, MI is extremely unlikely but I wouldn't throw it out completely. I would separate her from the mother and gather as much history as I could. Is she on BC? What has been going on in her life? Has she taken any drugs? It could be a caffeine thing. Anxiety is certainly high on the list. ASA, I might give, age isn't a contraindication. I would explore the pain and see if I can get an honest answer on what hurts, how it hurts, etc... What physical condition is she in? Is she obese? Does she have any medical history. That would be a tough one for me, too. Especially if she is presenting with classic MI symptoms. Anxiety really can mimic a cardiac emergency. The patient is already panicking and then their own physical reactions can panic them more.


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## Medic Tim (Jan 28, 2013)

Glucatron said:


> At 17, MI is extremely unlikely but I wouldn't throw it out completely. I would separate her from the mother and gather as much history as I could. Is she on BC? What has been going on in her life? Has she taken any drugs? It could be a caffeine thing. Anxiety is certainly high on the list. ASA, I might give, age isn't a contraindication. I would explore the pain and see if I can get an honest answer on what hurts, how it hurts, etc... What physical condition is she in? Is she obese? Does she have any medical history. That would be a tough one for me, too. Especially if she is presenting with classic MI symptoms. Anxiety really can mimic a cardiac emergency. The patient is already panicking and then their own physical reactions can panic them more.



You would be giving asa just in case?
Or do you have another reason?


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## Glucatron (Jan 28, 2013)

I am not sure I would give ASA but I might if she is presenting with symptoms of an MI. I would consider that as a possibility. I guess what I mean is that it wouldn't be _wrong_ to give ASA if the EMT suspected an MI. ECG is showing sinus tach at 102 so I'm guessing the medic isn't that worried. There would need to be a more detailed examination like if it hurt more if you press on the chest, visually inspecting the area and medical history but she is exhibiting symptoms typically associated with an MI. Whether it's caused by an undiagnosed heart defect or maybe the patient was very sedentary and a clot in the leg broke off. One of the medics I worked with had an 18 year old patient who was played video games chronically and had an MI. The blood pressure would lesson any suspicion because if there was a cardiac issue the vessels would constrict to compensate. I'm going to say my main reason for giving ASA, if I chose to, would be that the MI is one of my differential diagnoses supported by her signs and symptoms (diaphoresis, chest pain and shooting pain in the arm).


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## Melclin (Jan 31, 2013)

Was SSRI withdrawal or discontinuation considered? The nature of that particular problem is controversial, but there is some suggestion that "electric shock" type symptoms as well as other less descript things.. nausea.. diaphoresis... I think. 

Maybe an atypical description of precordial catch syndrome, costocondritis or tietse syndrome. The suggestion that its common but never this bad points me in this direction. Asking for a little clarity with the pts description or asking the same few questions in different ways could provide a lot of clarity here. 

I'd be almost certain that its a mostly benign condition. 




Robb said:


> Experience.
> 
> Most medics here wouldn't have even done an ALS workup. Once the monitor goes on it doesn't come off.



Really? So if a person was tachycardic and you ask you partner to whack the monitor on while you chat to the pt and at the end of the exam you decide that the pt's condition if totally benign....you can't take the monitor off and you have to transport? Is that by convention or by protocol? 

I find that interesting but quite odd to be honest.


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## BradMedic (Feb 6, 2013)

At the risk of sounding BLS. Treat your patient , Not your monoitor.
 Sounds like anxiety and the cynic in me says possible drug/attention seaker.
 I would start with calming techniques maybe oxygen, or even a saline neb! ( i've had it fool "Drug Seekers" into thinking they were getting a special new drug.  and calms some axiety pts down. Coaching her breathing as well.. All that can be done as you complete your primary assesment, ecg and vitals.


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## NomadicMedic (Feb 6, 2013)

BradMedic said:


> At the risk of sounding BLS. Treat your patient , Not your monoitor.
> Sounds like anxiety and the cynic in me says possible drug/attention seaker.
> I would start with calming techniques maybe oxygen, or even a saline neb! ( i've had it fool "Drug Seekers" into thinking they were getting a special new drug.  and calms some axiety pts down. Coaching her breathing as well.. All that can be done as you complete your primary assesment, ecg and vitals.



I certainly don't thinking bragging about "tricking your patient" is the best way to frame up your argument as a skilled clinician. In other words, ethically... It's wrong.


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## Medic Tim (Feb 6, 2013)

BradMedic said:


> At the risk of sounding BLS. Treat your patient , Not your monoitor.
> Sounds like anxiety and the cynic in me says possible drug/attention seaker.
> I would start with calming techniques maybe oxygen, or even a saline neb! ( i've had it fool "Drug Seekers" into thinking they were getting a special new drug.  and calms some axiety pts down. Coaching her breathing as well.. All that can be done as you complete your primary assesment, ecg and vitals.



Facepalm


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## Handsome Robb (Feb 6, 2013)

Melclin said:


> Really? So if a person was tachycardic and you ask you partner to whack the monitor on while you chat to the pt and at the end of the exam you decide that the pt's condition if totally benign....you can't take the monitor off and you have to transport? Is that by convention or by protocol?
> 
> I find that interesting but quite odd to be honest.



We don't have a written protocol about it but the thought of QA/QI is "if you were suspicious enough to use the monitor you need to ride in with the patient."

Not saying it is or isn't right, that's just how it is here. Every ambulance is ALS so it's not taking two resources out of service to transport that patient with an ALS provider attending.


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## Melclin (Feb 7, 2013)

Robb said:


> We don't have a written protocol about it but the thought of QA/QI is "if you were suspicious enough to use the monitor you need to ride in with the patient."
> 
> Not saying it is or isn't right, that's just how it is here. Every ambulance is ALS so it's not taking two resources out of service to transport that patient with an ALS provider attending.



I suppose there is a certain amount of logic to that. 

We tend to put the monitor on as a matter of being thorough, but how much a rhythm strip can really change you decision in and of itself as far as leaving people at home goes is probably questionable over all.

Certainly though, we've all had patients around here in whom we chucked the monitor on in the interests of being thorough for that pt we thought was a sook and low and behold, a block/arrythmia/something else was evident.

I've heard plenty of anecdotal evidence of people in stable VT with reasonably  atypical symptoms being discovered only by ECG.

I personally had a patient I thought was mildly depressed until I discovered discovered him to be in an Af of 200, despite his palpated irregular pulse of 72 consistent with his hx of chronic Af. 

Ah now I'm rambling. Melclin out.


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## usalsfyre (Feb 7, 2013)

BradMedic said:


> At the risk of sounding BLS. Treat your patient , Not your monoitor.


If I'm going to discard what the monitor is telling me...why am I hauling around 30 extra pounds of kit?


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## Handsome Robb (Feb 7, 2013)

Melclin said:


> I suppose there is a certain amount of logic to that.
> 
> We tend to put the monitor on as a matter of being thorough, but how much a rhythm strip can really change you decision in and of itself as far as leaving people at home goes is probably questionable over all.
> 
> ...



I agree with everything you're saying here. I don't understand why we can't do a 4-lead on ILS patients then remove it or even allow the Intermediate to attend the patient on the way in with the 4-lead still in place for the sake of being thorough and possibly discovering an underlying condition that may warrant further assessment in the prehospital field. I like to think of myself as a thorough medic and tend to put people on the monitor more than many others.

I too have had a few interesting experiences with patients presenting with benign, atypical symptoms in the presence of arrythmias, particularly pulsatile VT. 

Had a guy when I was even newer than I am now who was ambulating around sucking on some copenhagen, joking with the FD, in no obvious distress, pink warm and dry and walked to the ambulance climbed on in. His only complaint was "a lump in my throat",  nothing else whatsoever. He ended up being in VT at ~190 and like your AF patient, his palpable pulse was much lower than 190. Only reason he went on the monitor was when I asked if he'd ever felt this sensation before he started "they put me to sleep and barbecued me with those paddle thingys".



usalsfyre said:


> If I'm going to discard what the monitor is telling me...why am I hauling around 30 extra pounds of kit?



Yea...you covered that already. 

In the famous words of one of my many mentors: clinical correlation! Use the quantitative/qualitative assessment tools along with clinical presentation to make an informed clinical decision. Not one or the other.


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## EMT B (Feb 7, 2013)

Melclin said:


> Was SSRI withdrawal or discontinuation considered?



is this still a consideration even though the patient was never on an SSRI?


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