# Cardiac Call in a senior apartment complex.



## nemedic (Apr 4, 2011)

Here is the scenario:
   You are a Security Officer/EMT in a senior apartment complex. Your intended purpose is that of first aid, and first response in the event of emergencies requiring transport/patient requests transport. Your scope of practice is at the EMT-B Level. You are typically notified of emergencies via phone call, pull cords located in various locations in apartments and common areas, and/or lifeline pendants some residents choose to utilize. You have no transport capabilities, but a private ambulance(almost always dual medic) and a municipal engine (usual staffing is 3 FFs, usually at least one has their -B card) have an average response time of approx. 10 minutes L&S, but rarely more than 20 running non-emergent as long as traffic isn't too bad. Most of the line members of your department have a good working relationship with the local emergency services. Management of the facility has a rocky relationship at times, mostly due to set in stone, yet unwritten policies of calling for an ambulance for "emergencies" that are more than within the capabilities of the staff. One example is any fall in a common area that also involves any amount of bleeding, even in cases of rug burn and opening up of old scabs. The QA/QI is almost non-existant, and consists of  having the instructor of the monthly con-ed have a call-review using redacted narratives from run reports. The instructor is a former chief of one of the well known 3rd service in a major city in my area, and in effect tells the staff to "Call _'transporting private ambulance company redacted for privacy sake'_ for everything. That way any liability is on them and not you or _'Community where I work.'_

That being said, here is one call where management was (in my opinion) needlessly questioning my treatment. Please tell me what you would've done, and if there is anything I have missed. 

A lifeline pendant is activated in an apartment at around midnight. While responding with your EFR partner, your dispatcher makes contact with the apartment. You are told that the issue is a patient CC of "indigestion". You arrive on scene to find a male patient sitting in an arm chair in the bedroom, with his wife nervously waiting at the door to guide you to her husband. the patient reports that he was lying in bed trying to go to sleep approx. 90 minutes prior when he started experiencing "really bad indigestion" When you ask him to explain what it feels like, he rates it 10+ on a 0-10 scale and states "It's like an elephant standing on my chest". When you ask him to point out where he is feeling discomfort, he points to his sternum, and notes that it is radiating to his left arm. I radioed dispatch to call the ambulance, with a CC of sub-sternal chest pain radiating to the left arm. While waiting for the ambulance, I proceed to get vitals, history, and a med list together. Patient reported that he took 4 aspirin, a bunch of Rolaids, and Nitro x2 over the 90 minute span. Patient does not remember the last time he took any nitro, but states he took the aspirin just before he activated his life line. Initial vitals were 150's/80's, RR 18, equal and unlabored, HR was 70 and irregular. SpO2 was 93% room air. Lung sounds are clear bilaterally. Skin was pale, cool, and clammy. Pupils were equal, round, and reactive. Patient is allergic to statins and penicillin. History of triple CABG approx 1 year ago, hypertension, a-fib, CAD, and type 2 diabetes. I assisted him in taking a 3rd nitro tablet, placed him on O2 via canula at 4 liters, and checked his blood sugar, which was 270. The patient reported "That's high for me. I usually don't go any higher than 200, unless it is just after eating." I re-assessed vitals. BP changed to mid 130s/low 70s, otherwise remain as above. Pt expressed relief after nitro, which is now rated at 6-7 out of 10. Transport crew arrives on scene at this time. I reported patient's history, meds, my findings, and helped the transport crew in packaging the patient for transport. 

A few days go by, and I am asked the following:
1. Asked me if I was treating this as a cardiac issue (figured it was pretty obvious that I was)
2. He asked me why I went with a nasal canula over a non-rebreather since the SpO2 was 93%. (Keeping in mind that the patient was not experiencing SOB)

I am wondering if anyone has any studies showing the benefit of O2 in cardiac cases, and/or instances where a canula is preferable over a non-rebreather.(The manager in question is of the "NRB@ 10-15 liters is always the preferred O2 delivery method, with the ONLY exception being if the patient refuses the mask, in which case a NC can be used). I am looking for some studies online, and perusing a few of the current EMT textbooks, but have yet to find anything definitive for either argument.


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## Shishkabob (Apr 4, 2011)

Oh the joys of non-medical providers questioning medical providers on calls they weren't present on.



Unless the patient is profoundly short of breath, cyanotic or something of that nature, the most they'll get is a nasal cannula from me.  



Bring the people questioning you the new AHA guidelines and have them read through the ACS section... clearly states that unless the patient is extremely short of breath, a mask is not warranted.




> If the patient is dyspneic, hypoxemic, has obvious signs of heart failure, or an oxyhemoglobin saturation <94%, providers should administer oxygen and titrate therapy to provide the lowest administered oxygen concentration that will maintain the oxyhemoglobin saturation 94%



Going from 93% to 94% rarely ever warrants 15liters via NRB.


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## usalsfyre (Apr 4, 2011)

Well, the AHA now recommends titrated oxygen therapy, is that good enough?

Your supervisor is an idiot who is clinging to the treatment of yesteryear. There's preciously few cases where high concentration O2 is helpful, and a lot of cases where it's probably harmful. Good luck on convincing him of that.


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## nemedic (Apr 4, 2011)

Thanks for the idea on bringing in the new AHA guidleines. didn't think of that. Also, he has his basic, but uses it on the 1 in a million chance someone isn't available due to being on another call, and has (i kid you not) called an ambo for falls from standing height on patients that are not injured in any way at all, but just need help getting up due to osteoporosis and/or arthritic joints. He routinely overrides the clinical judgement of the on scene provider. Had one time where I was on a "choking" call I was on at one of the on property dining areas. the hostess called us for a "choking" that was someone with a common cold, that coughed a few times while eating some ice cream. I got a set of vitals, made sure there was no actual choking, and called in that it was going to be a refusal. He got on the radio and ordered the dispatcher to call 911 due to it being a choking call. He then made it a mandatory policy to automatically call 911 on any reported choking, stating "if the officer were to arrive on scene to find a completely obstructed airway, it would've wasted 2 minutes (average response time for us dispatch-arrival on scene). Usually we call the transport company direct, as opposed to 911. This is due to the PD Dispatch answering the 911 call, dispatch giving the info, and then connecting us to the ambo dispatch, which usually takes about 90 seconds- 2 minutes before we start talking to the ambo dispatch. We had the argument about it being a waste of time calling 911 since PD almost never responds unless a theft call or we specifically request the cruiser. the guy actually threatened me with an insubordination write up after i refused to call 911 on a chest pain call while dispatching, and called the ambo directly. he reminded me of the policy. I reminded him that time is muscle, and I wasn't going to delay transport to talk to PD who wouldn't have responded, and that I would have to say the exact same message to the ambulance dispatch anyways.


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## MrBrown (Apr 5, 2011)

*Brown removes elephant from the patient and has him stand on supervisor


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## angrynuni (Apr 27, 2011)

I was thinking something close to that, as in, did you try removing the elephant?

Also, dumb people who think they are important and thus project their mental deficiency outward suck.


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## NomadicMedic (Apr 27, 2011)

MrBrown said:


> *Brown removes elephant from the patient and has him stand on supervisor



Best post of the week.


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## Veneficus (Apr 27, 2011)

I was going to actually start a thread on this, but figure it would fit nicely here.

I was having a conversation yesterday with an anesthesiologist about oxygen usage.

I brought up the point that in order to survive, humans need an oxygen concentration of 11% in inspired air. 

With the possible exception of my home town due to pollution  the average oxygen concentration in the world is 21%. 

10% above what is needed to support life or open combustion.

My question was: "why are we using oxygen at all?"

After much thinking and discussion among a number of doctors present, we came to the conclusion it was to basically directly alter the PaO2.  We then got into a discussion about unbound (aka dissolved) oxygen in arterial blood and its ability to perfuse (or rather not perfuse) tissue.

We then started brainstorming under what conditions you would need to do that. The list was respectable, with a little over 10 conditions. (I think 12 was our final count, but we tossed the list after the discussion)

After this little excercise in physiology, we concluded that even with the most recent guidlines of oxygen use, (which have been in place far longer in the hospital than most recently in EMS) that oxygen is still probably considerably overused.

We then reiterated the mantra than giving a medication that is not indicated is in fact a medical error.

Just something to ponder...


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## sir.shocksalot (Apr 27, 2011)

Veneficus said:


> I brought up the point that in order to survive, humans need an oxygen concentration of 11% in inspired air.
> 
> With the possible exception of my home town due to pollution  the average oxygen concentration in the world is 21%.
> 
> ...


Oh Vene, you and your silly logic, we don't use that in EMS. When my granddaddy became the first Paragod working for the FD he jammed needles into peoples hearts and gave high flow oxygen to everyone. Because that was the way it was done then isn't that obviously the best way it should be done always? 

Oxygen is the most over used drug on the ambulance, and Zofran and Fentanyl are the most under used IMO. The sad part is that most Paramedics don't know what evidenced based medicine is, or have any understanding of human physiology enough to logically think through why oxygen isn't necessary the majority of the time. I know in my area the thinking won't change until the protocols change, or a few paramedics pick up a book, which ever comes first.


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## Aprz (Apr 27, 2011)

Veneficus said:


> I was going to actually start a thread on this, but figure it would fit nicely here.
> 
> I was having a conversation yesterday with an anesthesiologist about oxygen usage.
> 
> ...


However, it looks like >19% is the minimum without experiencing deficits so I wouldn't say 21% is too much over what we need; It's like a margin of error.

http://www.newton.dep.anl.gov/askasci/zoo00/zoo00755.htm

Was just Googling and that was probably the best source I could find.

I definitely agree that oxygen is overused though.


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## systemet (Apr 28, 2011)

Aprz said:


> However, it looks like >19% is the minimum without experiencing deficits so I wouldn't say 21% is too much over what we need; It's like a margin of error.
> 
> http://www.newton.dep.anl.gov/askasci/zoo00/zoo00755.htm
> 
> ...



While FiO2 is the parameter that we're most able to control, I think the ambient pressure is also very important.  An FiO2 of 0.21 at sea level gives a PiO2 of 160 mmHg.  If we drop a couple of percentage points, the PiO2 doesn't change much.  On the other hand, at the top of Everest, the FiO2 may remain 0.21, but the ambient pressure is now a third, and PiO2 is around 40 mmHg [One of the reasons everyone dies at high enough altitude.]

To some extent, a lower FiO2 (or PiO2) can be compensated for by a greater respiratory rate or tidal volume.  The degree to which, and the length of time over which this can occur is going to depend on physiologic reserve.

Obviously someone who is acutely sick, or has chronic disease is going to have less reserve, and less ability to cope with a change in oxygen supply.

I'd be interested in hearing more about Vene's discussion.


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## Veneficus (Apr 28, 2011)

Aprz said:


> However, it looks like >19% is the minimum without experiencing deficits so I wouldn't say 21% is too much over what we need; It's like a margin of error.
> 
> http://www.newton.dep.anl.gov/askasci/zoo00/zoo00755.htm
> 
> ...



_ "* 15-19 percent: Decreased ability to work strenuously. May 
impair coordination and may induce early symptoms with individuals 
that have coronary, pulmonary, or circulatory problems.
    * 12-15 percent: Respiration and pulse increase; impaired 
coordination, perception, and judgment occurs.
    * 10-12 percent: Respiration further increases in rate and depth; 
poor judgment and bluish lips occur.*
** 8-10* percent: Symptoms include mental failure, fainting, 
*unconsciousness*, an ash-colored-face, blue lips, nausea, and vomiting."
_


excerpt from the link:
http://www.newton.dep.anl.gov/askasci/zoo00/zoo00755.htm

I'm not willing to argue 12 over 11.


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