# Please tell me what I missed with this patient



## Epi-do (Feb 16, 2009)

We were dispatched for a sick person and arrive on scene to a 70-something male walking out to the street to meet the ambulance.  The patient states he has been "prepping for a colonoscopy" and is complaining of nausea/vomitting, along with "all the stuff that goes with the prep."  

He hops up into the ambulance, unassisted.  This guy looks generally healthy.  He tells us he has no allergies, the only medication he tells us he takes is insulin, and claims his only medical history is IDDM and 3 cardiac stents that were placed 5-6 years ago.

He tells us he has drank 3 cups of the "prep" for his test, and is supposed to drink 3 more, but the horrible taste made him nauseous.  He vomitted 3 times between 2100-0400.  (It is now 0630 and he just called.)  Around 0200 he had some "stomach pain, but I think it is just because I am hungry."  He states the "stomach pain" is now completely gone.

He is A&Ox3, PERL, ambulatory.  His skin is WPD, and BBS=clear.  He denies SOB/DB or CP at anytime.  He reiterates that he last vomitted around 0400, and his only complaint at this time is nausea.

His BP is 140's/80's, HR 85-95, RR 14-16.  He does not appear to be in any type of distress.  When asked what hospital he goes to he replies, "I have to go to XYZ Hospital because that is where my colonoscopy is scheduled at 11:30."

This particular hospital always asks for a blood sugar at triage for diabetic patients.  This patient tells us he hasn't checked his blood sugar since bedtime last night, so we go ahead and dex him.  It comes back at 250.

I hand the patient off to my BLS partner and we head to the hospital.  We get there, my partner gives his report to the triage nurse, and she asks him if ALS was on the scene.  He tells her yes and she then wants to know if we put the patient on the cardiac monitor.  After telling her that we did not, she wants to know why we didn't and he tells _again_ that the only thing this patient is complaining of is nausea.  The triage nurse makes a phone call to get a second opinion on where to put the patient and then gives us a room assignment.

We get to the room with the patient and my partner once again gives his report to the RN, making it clear that the only thing this patient is complaining of is nausea.  The second nurse also goes off about how the patient should have been put on a cardiac monitor.  My partner tells her that he had no complaints that would indicate a cardiac problem and he denied all CP, SOB/DB, diaphoresis, clamminess, radiating pain, or anything else you can think of that would indicate a possible cardiac issue.  The RN then tells him that since the patient has a history of stent placement, that is enough of a reason to take a look with the monitor.

So, were the nurses right?  Did I completely miss something here, or did we simply run into a couple RNs that got up on the wrong side of the bed this morning?


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## Summit (Feb 16, 2009)

Did you actually miss something or was this about procedure? Only they can tell you that at this point.

70 y/o /w cardiac history C/O N+V + stomach pain = check the monitor if you have one to check... at least in my mind, but I'm not a medic

If nothing was there, you coulda still dispoed it to your BLS partner for transport.


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## traumaangel26 (Feb 16, 2009)

With his hx, a monitor should have gone on. N&V is an indicator of cardiac problems. No, it is not always a cardiac problem, but something that needs to be ruled out.

Don't beat yourself up over this one pt, but learn from it. You will remember it next time!


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## VentMedic (Feb 16, 2009)

Cardiac patients can be a nightmare for many procedure preps because they may have to change or stop their medications such as Coumadin and ASA up to 5 days prior. 

If they had a stent, they may also have had some wall motion affected from muscle damage prior to the stent. Electrolyte balance and their whole acid/base status within their system will make them very prone for arrhythmias.


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## JPINFV (Feb 16, 2009)

Atypical (silent) presentations of cardiac problems are common with patients that have a history of diabetes. Live, learn, hit the next one out of the park.


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## rescuepoppy (Feb 16, 2009)

Sounds to me like you were treating this patient based of of what you saw. Putting on monitor would not be unreasonable,but I was not there to see what you saw so probably not really anything missed.


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## ptemt (Feb 16, 2009)

The "prep" he drank was likely the colon cleanser called "Fleet."  You fast for 24 hours and drink "Fleet."  Fleet tastes awful and then it emptys out your system on its terms.  The colonoscopy itself is a sunny day at the park compared to the misery of drinking fleet.  Tastes awful is an understatement and while it does its work you do not stray far from the toilet.

Yes to the EKG, rule out cardiac.


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## VentMedic (Feb 16, 2009)

Oral sodium phosphate (OSP) solutions, including FLEET, Visicol and OsmoPrep, draw water into the gut to promote cleansing. They may be easier to tolerate, but can cause dehydration and electrolyte imbalances. A high phosphate load may also not be safe for patients with kidney, heart, liver, or certain intestinal diseases. 

Polyethylene glycol (PEG) solutions such as Golytely, Colyte, Nulytely, Trilyte and Halflytely work by pushing a large volume of fluid through the bowel to force out waste. They cause no significant electrolyte shifts, so they are considered safer than OSP solutions but still have some risks for patients with certain disease processes or conditions. 

The nausea and vomiting can also lead to cardiac complications in sensitive patients since the vagus nerve and sympathetic trunk is involved in the vomiting reflex.

A stent is also a temporary fix which buys time. For some patients who are not compliant (and even if they are) with their medications, diet and exercise or have a strong family history, stents can be very temporary and these patients are ticking time bombs waiting for the next occlusion.  They must be re-evaluated periodically especially after the 5 year mark.


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## VentMedic (Feb 16, 2009)

One more small note: in our hospital system, patients over the age of 40, or any age if they have risk factors, and those with known cardiac problems get a 12-lead ECG before the procedure.


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## eric2068 (Feb 16, 2009)

Don't kill yourself over this. I probably would have just off the Hx. Don't sweat the nurse.


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## marineman (Feb 16, 2009)

Like others have said it's not worth losing any sleep over it. Just the other night I was listening to an older mediccast episode and they recommended applying a monitor on any patient with a chief complaint between the naval and the nose. Based on that I think I would have done a 4 lead but it's a lot easier to think about these things when playing armchair quarterback. Patient lived, he's not any worse for wear because of not doing it so it's really not something to get upset over.


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## MSDeltaFlt (Feb 16, 2009)

Epi-do said:


> We were dispatched for a sick person and arrive on scene to a 70-something male walking out to the street to meet the ambulance.  The patient states he has been "prepping for a colonoscopy" and is complaining of nausea/vomitting, along with "all the stuff that goes with the prep."
> 
> He hops up into the ambulance, unassisted.  This guy looks generally healthy.  He tells us he has no allergies, the only medication he tells us he takes is insulin, and claims his only medical history is IDDM and 3 cardiac stents that were placed 5-6 years ago.
> 
> ...




Epi,

There is nothing in the above post that would tell me you had to put him on a cardiac monitor, *or else*.  I honestly would have done the exact same thing you did.  I do have a couple of questions.  What was found to be the problem with this pt?  Also, *if* there was anything found, *what* would you have done to *fix* it?


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## BLSBoy (Feb 16, 2009)

I would have, if nothing else, to bill for ALS1. 

Do an ALS assessment, and triage to BLS. You get ALS1 rate. 

However, with his hx, whats a quick 12 lead gonna hurt?

Teach your basic something.


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## daedalus (Feb 16, 2009)

JPINFV said:


> Atypical (silent) presentations of cardiac problems are common with patients that have a history of diabetes. Live, learn, hit the next one out of the park.



I disagree. A cardiac monitor was not warranted for this patient, who was being taken to the hospital for an outpatient test. We are no longer in the age where we can practice CYA medicine because its expensive and does not improve patient care.

On a down to earth prospective, Epi, I believe you gave this patient very advanced care just by checking him out and giving him a ride to the hospital inside of an ambulance. That is overkill for this patient, but it can be justified in the off chance he had some sort of reaction to the "prep". He did not need a cardiac monitor. 

I can see how anorexia and vomiting can lead to electrolyte issues which could lead to cardiac problems, but we do not hospitalize people with the flu in telemetry units. 

Stick to your guns and defend your decision if you think you were right.


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## VentMedic (Feb 16, 2009)

daedalus said:


> I can see how anorexia and vomiting can lead to electrolyte issues which could lead to cardiac problems, but we do not hospitalize people with the flu in telemetry units.


 
Yes we do especially if they have a history that is significant. They are also found in the ICUs and CCUs on ventilators. Read the stats on the death rate from the "just the flu" in "at risk" patients. Wonder why the flu vaccine get promoted so heavily?

What would have been done for this same patient if the test prep was not in the picture and just the cardiac history was known? What would have been your thoughts if the patient told you he had not taken certain meds like Coumadin and ASA for at least 3 days? Sometimes the obvious can mask the truly significant issues. Also, given the fact that the patient had probably been on Coumadin and ASA for at least 6 years, what GI complications might be present?

There is a lot to assess with these patients but as many suggest, just drive the patient to the hospital. It seems almost contradictory now that once hospital staff do start to recognize what can be done by prehospital providers, the EMS providers revert to being ambulance drivers. This statement is not directed at Epi-do.

The RN has studied beyond the obvious and has been made aware of certain complications of various tests and their preps. Unfortunately, the nurse assumed others might also have similar knowledge.


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## Summit (Feb 16, 2009)

Now this debate is getting interesting.


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## JPINFV (Feb 16, 2009)

daedalus said:


> I disagree. A cardiac monitor was not warranted for this patient, who was being taken to the hospital for an outpatient test. We are no longer in the age where we can practice CYA medicine because its expensive and does not improve patient care.



According to the OP the patient was going to the hospital for nausea and vomiting while preparing for the test, not taking the ambulance to the hospital for the test. I'll echo what Vent just asked, would you acquire a 12 lead under the same conditions minus the scheduled colonoscopy?


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## daedalus (Feb 16, 2009)

JPINFV said:


> According to the OP the patient was going to the hospital for nausea and vomiting while preparing for the test, not taking the ambulance to the hospital for the test. I'll echo what Vent just asked, would you acquire a 12 lead under the same conditions minus the scheduled colonoscopy?



Minus the laxative prep, yes I would preform a 12 lead. However, a bad reaction to the bowel prep is many times more likely, so that would be my working diagnosis. Therefore, I would not preform an expensive test to rule out cardiac issues in *this* case.

Minus the bowel prep, yes I would like to preform a 12 lead. 

VentMedic, at risk populations who are already sick can easily be hospitalized because of simple infectious diseases, however healthy people are generally not hospitalized for isolated cases of vomiting.


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## JPINFV (Feb 16, 2009)

daedalus said:


> Minus the laxative prep, yes I would preform a 12 lead. However, a bad reaction to the bowel prep is many times more likely, so that would be my working diagnosis. Therefore, I would not preform an expensive test to rule out cardiac issues in *this* case.



I'm not too up to date on the cost of procedures, but how much does acquiring a 12 lead actually cost? Also do you acquire a BGL on patients who are altered with a history of neuropsych disorders (i.e. dementia)?


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## VentMedic (Feb 16, 2009)

daedalus said:


> VentMedic, at risk populations who are already sick can easily be hospitalized because of simple infectious diseases, however healthy people are generally not hospitalized for isolated cases of vomiting.


 
You consider this guy healthy?

70 y/o
IDDM 
3 cardiac stents that were placed 5-6 years ago.


Other things to consider:
Why was the patient getting a colonoscopy? Routine or diagnostic?
When was his last EKG? Did he already have one done as part of the pre-procedure prep?

Depending on why the test was being done and the person's ability to handle stress can trigger complications also.  Some people might prefer open heart surgery to having a colonoscopy.



JPINFV said:


> a history of neuropsych disorders (i.e. dementia)?


 
Almost all of our neuropsych patients get ECGs especially if they have been treated or will be treated medications for their psych disorders. They will also be closely monitors if they are also on any respiratory medications during that treatment.

If the patient calls an ambulance and has probably been through the healthcare system a few times, I seriously doubt if they are going to be concerned about what an EKG costs. Nor, should you make it their concern by telling them you are not doing a test because it costs too much. They may take that as discrimination.


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## daedalus (Feb 16, 2009)

JPINFV said:


> I'm not too up to date on the cost of procedures, but how much does acquiring a 12 lead actually cost? Also do you acquire a BGL on patients who are altered with a history of neuropsych disorders (i.e. dementia)?



Its not a question of how much it costs, but how much it is billed for.


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## daedalus (Feb 16, 2009)

VentMedic said:


> You consider this guy healthy?
> 
> 70 y/o
> IDDM
> ...


You and I seem to differ in our subscriptions to common sense. I would not have preformed a field EKG.


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## Epi-do (Feb 16, 2009)

traumaangel26 said:


> With his hx, a monitor should have gone on. N&V is an indicator of cardiac problems.



I guess, what I am just not getting is why his hx of stents *5 years ago* would indicate a need for a monitor today.  I realize diabetics may not present with typical cardiac issues, but I really am not getting why NV alone would justify a monitor.

I do agree that N&V can indicate cardiac problems, but alot of times there are other things going along with it to make one think it may be cardiac.



			
				VentMedic said:
			
		

> Polyethylene glycol (PEG) solutions such as Golytely, Colyte, Nulytely, Trilyte and Halflytely work by pushing a large volume of fluid through the bowel to force out waste. They cause no significant electrolyte shifts, so they are considered safer than OSP solutions but still have some risks for patients with certain disease processes or conditions.



It was Trilyte he was taking.  I just couldn't remember the name of it when I wrote the original post.



			
				MSDeltaFlt said:
			
		

> What was found to be the problem with this pt? Also, if there was anything found, what would you have done to fix it?



We didn't make it back to that particular hospital as of yet today, so I do not know if anything was found.



			
				daedalus said:
			
		

> A cardiac monitor was not warranted for this patient, who was being taken to the hospital for an outpatient test.



Actually, the patient called 911 for the NV.  It was not a scheduled transport for an outpatient test.  He just made sure we knew he had the test scheduled at 1130 and was concerned that he wouldn't be out of the ER in time to make the test.

I really am not trying to be "difficult," I really am just not seeing how this particular patient's history + complaint = cardiac monitor.  As a new medic, I typically tend to be overly cautious with my patients, but I just didn't see a need here to do any advance interventions.  

I really do want to understand the reasoning behind this and a simple "because of his history" answer just isn't making enough sense to me.  If that were the only reason, then wouldn't it stand to reason that every single diabetic I run on that has a cardiac history should get put on the monitor?  "Excuse me sir, I know that you fell and twisted your ankle, but I need to check your heart because of your medical history" seems like overkill to me.

As for the nurses, it was more the snippy attitude they had about the whole thing that I have an issue with, than them questioning why he wasn't put on a monitor.  If you feel I could have done something better for my patient, teach me, don't chastize me.


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## VentMedic (Feb 16, 2009)

daedalus said:


> You and I seem to differ in our subscriptions to common sense. I would not have preformed a field EKG.


 
The OP asked whether the RN was justified in asking why this patient was not being assessed by an ALS provider. The RN's education gives him/her a deeper understanding about many complications about each type of disease processes as well as the prep for different tests. Sometimes this knowledge can make one more cautious or have more questions that should be answered. The RNs are with a patient a lot longer than EMS providers and like to anticipate things before they go wrong. 
So, caution is used with patients that do present with a significant history in the hospital setting. 

Unfortunately the RN made the mistake that prehospital providers have the same level of knowledge and take the same precautions as hospitals. The RN was probably wrong for making that assumption. The EKG will probably be done anyway in the ED and maybe again prior to the colonoscopy. Cardiac monitoring will also be available during the procedure. 

As I already stated, just get the patient to the hospital. Given his hx, something made him call at 0600. If he just wanted a ride to the hospital for the test, he would have called at 1000 to make sure he got to the test on time. He too might understand how brittle his medical history makes him and recognizes the need for some caution. 

Epi-do





> As for the nurses, it was more the snippy attitude they had about the whole thing that I have an issue with, than them questioning why he wasn't put on a monitor. If you feel I could have done something better for my patient, teach me, don't chastize me.


 
Given the hx along with the N/V and the PEG (even though it is less likely to shift the electrolytes drastically), I would have put him on a cardiac monitor and may not have done the 12-lead...depends. 3 stents that are 6 years old can become a problem depending on how closely they have been monitored especially with the IDDM hx. As I said before, stents may be a  temporary fix and many patients end up with a CABG within 10 years of placement or at least returning to the cath lab a couple of times.

The N/V does not have to be a sign of a cardiac event that is occurring but rather the cause of one that can occur for the reasons I mentioned in earlier posts. 

Some of us "healthy" types have arrhythmias when actively vomiting or feeling the urge and if dehydrated or haven't eaten for a couple of days may have PVCs. But, if healthy, we can quickly get back to homeostasis.


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## JPINFV (Feb 16, 2009)

VentMedic said:


> Almost all of our neuropsych patients get ECGs especially if they have been treated or will be treated medications for their psych disorders. They will also be closely monitors if they are also on any respiratory medications during that treatment.
> 
> If the patient calls an ambulance and has probably been through the healthcare system a few times, I seriously doubt if they are going to be concerned about what an EKG costs. Nor, should you make it their concern by telling them you are not doing a test because it costs too much. They may take that as discrimination.



I was using the neuropsych patient as an example of when you would still run a routine POC test (glucose measurement) even though any ALOC could easily be explained by the underlying disorder.


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## daedalus (Feb 16, 2009)

VentMedic, You like to make passive aggressive hits on prehospital providers, and it is becoming a pattern. Perhaps these nurses had no idea what they were talking about. After all, they are not trained in the medical model. If you hear hooves, think a horse, not a zebra. The patient had ingested bowel prep, than vomited. 

Your philosophy of patients always having hidden zebras because of the lack of education of prehospital providers is a little silly.


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## VentMedic (Feb 16, 2009)

JPINFV said:


> I was using the neuropsych patient as an example of when you would still run a routine POC test (glucose measurement) even though any ALOC could easily be explained by the underlying disorder.


 
I knew what you meant but I was pointing out there are many indications for an ECG or at least cardiac monitoring.   

Another example: If I do just a 10 - 15 mg Albuterol tx in the back of an ambulance or in Flight on any patient, regardless of age and hx, they get a cardiac monitor.


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## daedalus (Feb 16, 2009)

VentMedic said:


> I knew what you meant but I was pointing out there are many indications for an ECG or at least cardiac monitoring.
> 
> Another example: If I do just a 10 - 15 mg Albuterol tx in the back of an ambulance or in Flight on any patient, regardless of age and hx, they get a cardiac monitor.



But there is indeed an indication, because you administered a beta agonist.


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## JPINFV (Feb 16, 2009)

I'm not sure if I would consider an atypical presentation of an MI in a patient with risk factors for atypical presentations to be looking for Zebras. The entire point of DDxs is to rule in/out diagnosises. You don't just compile a list and pick the most likely, espeically when it's fairly easy to rule out some of the items on that list with POC testing.


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## VentMedic (Feb 16, 2009)

daedalus said:


> Your philosophy of patients always having hidden zebras because of the lack of education of prehospital providers is a little silly.


 
Hidden zebra? The patient had 3 stents that are 6 years old, IDDM, N/V and the age of 70. 

But, you are right. No need to learn anything else or look for different things. Every disease or condition is simple with no complexities and the EMT book provides everything you need to know. 

Wonder why some want the education levels increased in EMS?

I've already read enough anti-education remarks on this forum the past two days. It seems like the next generation in EMS won't be setting the education stanard at a higher level either. 

As an EMT-B, you need to advance your own education before criticizing Paramedics and RNs. Who are you to judge the knowledge and protocols another healthcare provider who is a higher level than EMT-B and may work in a different environment? I also think your listed occupation of GOMER transporter in your profile pretty much sums up what you think of your job and this profession along with the concept of patient care.  The term GOMER transporter can be as offensive to patients as was the use of the words Ambulance Driver in the serious article about atypical symptoms in women having MIs.  You took great offense to that by the way you posted that thread.


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## chute43 (Feb 16, 2009)

I think the nurse mainly heard the pts hx and not the complaint. I believe that higher level providers(generally RNs) sometimes forget we practice signs/symptom based medicine(we treat what we see), where as they practice medicine based upon diagnostic test (lab values, ultrasounds, EKGs etc). This is ofcourse my opionion based upon my own observations, and not an across the board the shot at RNs.

Just my thought. We used to have a fair amount of RNs questioning why we didn't treat CP secondary to MVAs with Nitro/ASA. Because all they heard was CP, and nothing else. So  I now say "sternal pain secondary to MVA"

kary


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## MSDeltaFlt (Feb 16, 2009)

I can see where Vent is coming from here.  Her education, training, and experience alone blows everything I got out of the water hands down.  So, yeah, technically this pt probably should have been put on a cardiac monitor.

Would I have actually done it?  Uh... er... um... naw.  Don't think I would have.  That being said, I still think Epi was justified in her decision.

My humble 0.02.


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## daedalus (Feb 16, 2009)

VentMedic said:


> Hidden zebra? The patient had 3 stents that are 6 years old, IDDM, N/V and the age of 70.
> 
> But, you are right. No need to learn anything else or look for different things. Every disease or condition is simple with no complexities and the EMT book provides everything you need to know.
> 
> ...


Sounds like someone needs to laugh and smile every so often. The cool thing is, once I get my california paramedic license, I will get to decide not to preform EKGs everyday of my career, no matter what somebody tells me on the internet.

You also do not get to decide what is offensive and what is not. Get off that high horse and go have a good time at a comedy show, it will be and _educational_ experience for you. Comedy tradionaly pokesfun at offensive topics. You could say...comedy makes us a little more _human_


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## VentMedic (Feb 16, 2009)

daedalus said:


> Sounds like someone needs to laugh and smile every so often. The cool thing is, once I get my california paramedic license, I will get to decide not to preform EKGs everyday of my career, no matter what somebody tells me on the internet.


 
It is about the patient and not your ego with the "because I can attitude".  You do what is best for the patient and don't base it on their ability to pay or belief that patients are GOMERs. 



daedalus said:


> You also do not get to decide what is offensive and what is not. Get off that high horse and go have a good time at a comedy show, it will be and _educational_ experience for you. Comedy tradionaly pokesfun at offensive topics. You could say...comedy makes us a little more _human_


 
Medicine is not intended to be a comedy show.  Although some of our patients are humorous at times, they can have very serious disease processes that must be addressed.  When it comes to patient care, I am serious about my profession(s).  If I am on a forum talking about comedy shows or some other fluff stuff, I'll make jokes.   

You still have a long way in your education, although not that long in CA, to be a Paramedic.  You can easily research many of the things that I make statements about to sort out the data for yourself.  Often I post the links to the information so you don't have to trouble yourself searching.


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## fma08 (Feb 16, 2009)

VentMedic said:


> *70 y/o
> IDDM
> 3 cardiac stents that were placed 5-6 years ago.
> *



That would have been enough for me with a complaint of nausea and vomiting to warrant a monitor or XII lead. Again, one newbie's opinion.

The question is, what do you feel you should have done. We weren't there, we didn't see/examine the patient at all. Do you think you should have done something different? If so what and why? Did you learn anything from the call? Those are the more important questions.


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## daedalus (Feb 16, 2009)

My program is 12-14 months long, about average across the united states. It may not be the longest, but its certainly better than a mill.


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## daedalus (Feb 16, 2009)

fma08 said:


> That would have been enough for me with a complaint of nausea and vomiting to warrant a monitor or XII lead. Again, one newbie's opinion.
> 
> The question is, what do you feel you should have done. We weren't there, we didn't see/examine the patient at all. Do you think you should have done something different? If so what and why? Did you learn anything from the call? Those are the more important questions.



Thats the way I feel. N&V after ingesting bowel prep is not an indication for 12 lead EKG. I agree with VentMedic in the fact that the patient will recieve procedural EKG monitoring, but that is not my job on scene.


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## Epi-do (Feb 16, 2009)

fma08 said:


> The question is, what do you feel you should have done. We weren't there, we didn't see/examine the patient at all. Do you think you should have done something different? If so what and why? Did you learn anything from the call? Those are the more important questions.



I am guessing these questions are for me.  Honestly, I don't feel as if there was anything different I should have done.  After hearing what others had to say, I understand why concern regarding a cardiac event could be warrented, but honestly don't think that was his issue.  He was so concerned about how long he was going to be in the ER and whether or not he would get released in time to make it to his scheduled test that I can't help but wonder if he didn't just want a ride downtown so he would be there for it, but I digress.  Even though I didn't put him on the monitor, I did do a complete assessment otherwise before turning him over to my partner.  

Probably the biggest thing I have taken away from this run is that while I already take PMHx into consideration when evaluating/treating my patients, some histories may warrent taking a second look at the patient and just double checking to make sure there isn't more to the story.  That, and I need to trust myself more and try to not second guess myself so much. Then again, the reason it is called experience is because you get it right after you needed it, right?


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## mycrofft (Feb 16, 2009)

*Oh crikey. I'm a nurse and a former EMT-Ambulance (nowadays EMT-B)*

You have caught me on a day I am sick unto death of knowitall armchair nurse "administrators" and especially  nurses with no field experience who decide to add to the mix. Please don't anyone take this as a universal truth, but you have to know that many, many nurses think EMT's are basically moving men, know-it-all noobs and need to be kept in their place. Sorry, that's how it is in many places, if it is different for you, you have done an excellent job and the nurses are being allowed to work realistically and not prodded into senseless "fannyflage" (backside coverage) by their managers and administrators.

Vitals reveal cardiac signs? Pt anxious, in pain, SOB, or a little too keen to explain some chest pain away as "gas"? If your protocols call for an EKG, do it, but if we do EKG's (start IV's, do ABG's, etc.) on every person who is the equivalent of this patient who vomits and is a diabetic with a _half-decade old_ hx of cardiac stent but has normal vital signs, what kind of professional autonomy/judgement is that? If the nurse bothers you, tell her to take it up with your manager and give that nurse your manager's card.


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## Ridryder911 (Feb 16, 2009)

Wow! I swear even in first aid classes we teach one of the most ominous signs of an AMI (especially silent) is nausea? Especially those with a hx. of stent placement (oh by the way, stent re-occlusion is about 5 years) and diabetics as mentioned do present with even more silent conditions. 

Want to make that a valid case and explain yourself upon why you did not? Since, you have a patient with a + cardiac history, s/s of an AMI. This is how many AMI's are missed. 

p.s. XII leads are not charged at any higher rate than traditional ECG. 

Again ... think outside the box, sometimes it is Zebras. 

R/r 911


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## VentMedic (Feb 16, 2009)

mycrofft said:


> You have caught me on a day I am sick unto death of knowitall armchair nurse "administrators" and especially nurses with no field experience who decide to add to the mix. Please don't anyone take this as a universal truth, but you have to know that many, many nurses think EMT's are basically moving men, know-it-all noobs and need to be kept in their place. Sorry, that's how it is in many places, if it is different for you, you have done an excellent job and the nurses are being allowed to work realistically and not prodded into senseless "fannyflage" (backside coverage) by their managers and administrators.
> 
> Vitals reveal cardiac signs? Pt anxious, in pain, SOB, or a little too keen to explain some chest pain away as "gas"? If your protocols call for an EKG, do it, but if we do EKG's (start IV's, do ABG's, etc.) on every person who is the equivalent of this patient who vomits and is a diabetic with a _half-decade old_ hx of cardiac stent but has normal vital signs, what kind of professional autonomy/judgement is that? If the nurse bothers you, tell her to take it up with your manager and give that nurse your manager's card.


 
Some think I have an attitude but you are one bitter nurse. I don't know about your co-workers or if you even work with any other nurses, but there are many, many very good nurses and other professionals out there. This should not be a free for all to bash a profession or provide a negative mindset for those that do not have the opportunity to work with other professionals at any length to form an opinion except for heresay or an occasional rude remark encountered in the ED. 

EMS providers do take things rather personally because they do not deal with many other professionals for very long. They see only a snippet of what life is like in the hospital. In 15 minutes that nurse may have been screamed at by 4 doctors, an RRT with an attitude stressed for time and maybe 5 patients. You can also include other departments and RNs as they are trying to get their patients moved through the system. So yes, maybe the nurse does not know your specific protocols in the field, but EMS providers probably do not know the ED staff's protocols either. But just keep adding to the flames that keep EMS isolated from the rest of the world of medicine with inciting the bashing of nurses and other hospital personnel. 

In addition to that, the diagnostic suites send potential colonoscopy patients to the ED for further screening when their pre-procedure 12-lead ECG or cardiac monitor shows something suspicious. Even in the Pulmonary Labs which are considered outpatient, abnormal rhythms for which the patient has no history gets sent to the ED. N/V during a test may also get sent to the ED. 

BTW, how long before a 3 stent 70 y/o with IDDM needs a CABG? More stents? Which has the longer survivablitiy rate? CABG? Or, 3 or more stents? A stent does not reduce the risk of another cardiac event and one patient can receive many stents as occlusions develop. However, a patient's body may eventually say no more and a CABG or death is the option.

How many women or older patients will present with the cardiac signs you described? Some elderly patients who come to the ED with the "flu" are surprised to learned they have had a heart attack. You might also remember how John Cougar Mellencamp was surprised when he found out he had an MI at 43. His symptoms were also not textbook.


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## Margaritaville (Feb 16, 2009)

Amen, RR911!


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## emtfarva (Feb 16, 2009)

*This is only for Epi.*

Everyone else can read this but this comment is for Epi.

Epi, I am at the Basic level, so what I say doesn't mean much to some peoples eyes. I once brought a sz Pt to the ER, well my partner did, she is a medic. When we got to the ER the nurse told us to put the Pt in the Hall. From my experience any sz Pt should be placed on at least a 3 lead. I am not saying that maybe they weren't busy and didn't have a telly bed available. But in my eyes this Pt should be on some type of ECG. Get to your case, maybe it wouldn't have hurt to put the limb leads on and check. But I think you were right to hand it off to the bls provider. I think sometimes Nurses forget things. I think they heard Cardiac hx and was expecting a 12 lead. Personally I would not have called for als for this Pt. I had a Pt one call with cc of n&v. The Pt was dierphratic and dry heaving when I found the Pt. My partner at the time wanted to walk the Pt down the stairs. I said no. The Pt, I found out later, was in a-fib. She wasn't a diabetic and she had no hx. In the back of my head I thought she has some kind of cardiac issue going on. I was right. so don't let one thing fool you. I guess what I am trying to say is, next time at least do a 4 lead. Don't beat up yourself about it, learn from it.


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## Epi-do (Feb 16, 2009)

Ridryder911 said:


> Wow! I swear even in first aid classes we teach one of the most ominous signs of an AMI (especially silent) is nausea? Especially those with a hx. of stent placement (oh by the way, stent re-occlusion is about 5 years) and diabetics as mentioned do present with even more silent conditions.
> 
> Want to make that a valid case and explain yourself upon why you did not? Since, you have a patient with a + cardiac history, s/s of an AMI. This is how many AMI's are missed.
> 
> R/r 911




Nausea and vomitting can be indicative of cardiac issues, but it can also be indicative of a laundry list of other things.  That list can include food poisoning, gastritis, gastroenteritis, gall stones, DKA, drug overdose, intoxication, pancreatitis, the flu, various infections, GI bleed, etc, etc.  Therefore, by itself, nausea and vomitting can't be considered indicative of anything in particular.  PMHx, other signs/symptoms, VS, and pertinent positives/negatives all must be taken into consideration.

This patient's blood sugar was higher than I was expecting to see, but could be attributed to the vomitting.  Otherwise his VS were all within normal limits.  He had absolutely no other complaints and said the nausea/vomiting coincided with drinking the Trilyte.  Everything did not add up to suspicion of a cardiac event, given the information I had before me.

Had I known that stent re-occlusion is in the ballpark of 5 years, or any of the other info Vent has provided about stents, I may have made different choices regarding this patient.  Unfortunately, that is not something I have ever been taught.  "I didn't know" is not an excuse, I have learned something new, and plan on doing some reading on my own to learn even more.  That being said, I still do not believe the big picture for this particular patient added up to suspicion of a cardiac event.

I do plan on following up on this patient to find out exactly what the ER determined.  I will be sure to pass along what I find out.


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## daedalus (Feb 17, 2009)

Nausea Differential:

Adverse drug reaction
Addison disease
Alcoholism
Anxiety
Appendicitis
Brain tumor
Bulimia
Cancer
Chemotherapy
Chronic fatigue syndrome
Concussion
Crohn's disease
Depression
Diabetes
Dizziness
Exercise
Flu
Food poisoning
Gastroenteritis
Gastroesophageal reflux disease
Gastroparesis
Heart attack
Hydrocephalus
Irritable bowel syndrome
Kidney failure
Kidney stones
Medications
Ménière's disease
Migraine
Morning sickness
Narcotics
Nervousness
Norovirus
Pancreatitis
Peptic ulcer
Sleep deprivation
Stress
Superior mesenteric artery syndrome
Sugar high diet
Tobacco smoking and second-hand smoke
Tullio phenomenon
Withdrawal Syndrome
Vertigo
Vestibular balance disorder
Viral hepatitis
Acute HIV infection


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## Sasha (Feb 17, 2009)

daedalus said:


> Nausea Differential:
> 
> Adverse drug reaction
> Addison disease
> ...




Oooh. Someone can use wiki.


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## daedalus (Feb 17, 2009)

Sasha said:


> Oooh. Someone can use wiki.



Quite a useful little website


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## VentMedic (Feb 17, 2009)

How many are not relevant at all to this patient?  Maybe he didn't disclose he was HIV postive.

Again, going with the known:

70 y/o
IDDM
3 stents that are at least 5 years old

Actually, the majority of problems on that list can cause severe complications to a patient with the above history and should be taken seriously.


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## chute43 (Feb 17, 2009)

Maybe it wasn't that you didn't treat the pt as ALS, downgrading his level of care could appear as not being in the pts best interest. 

How many MIs have typical signs?

Was BLS therapy in the pts best interest?

Did the pt have the potential to be having a silent MI?

 The pt has all the prior Hx for a silent MI. 

Dont most LAD coronary blockages present without CP? 

I believe the Nurse felt you as the higher qualified provider should have provided a higher level of care even if that higher level of care was just monitoring the pt with the skill of a paramedic.

I don't believe the pt deserved a 12 lead? I would have treated the pt was ALS, with O2, EKG, and IV access. I am ofcourse in a different region with different protocals. 

Ask yourself did you treat the pt with the highest level of care? Did you treat the pt in regard to treating worst case? In court could you truely justify your actions of sending the patient in BLS especially after ALS had been established?

I am not really trying to monday morning quarterback your actions but you asked the question "what I missed", and respectfully that is my thought on the subject.

kary


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## Ridryder911 (Feb 17, 2009)

Bottom line. 

Yes, your honor I was taught nausea and even associated vomiting can be an associated sign of an AMI. Yes, as well your honor I was also taught that those with DM and in particular those with a know positive cardiac hx. can present to be mildly symptomatic.

As well, yes a simple little thing such as ECG could had help rule out an underlying issue. 

Does one not also perform an twelve lead ECG on any person that also has a hx of event of diaphoresis, unknown etiology of vertigo, confusion, falls not associated w/tripping, heaviness in arms, jaw, associated pleuritic pain, severe abdominal pain, history of direct chest wall trauma and basically any associated symptom that can be linked to a potential AMI? Anyone that has a known history of coronary occlusion or positive history of an AMI with any associated or link symptom should be at least assessed for a AMI. 

or 

Look at this way. Did you hook them up to the monitor? Then why? You then obviously thought of potential cardiac and if you thought of that, a diagnostic ECG should had been performed. 

Remember a twelve lead is just one more vital sign. Three leads does not mean poop. Monitoring leads does present nothing more than an occurrence (lethal) has to occur before your eyes. 

Yes, nausea can be associated with tons of other illnesses, so can chest pain but have we not been taught to assume the worse? A simplistic and non invasive test that can save ones career better yet potentially someones life for an additional thirty five seconds... is worth it. 

I have highlighted those with nausea should as well be considered to have a twelve lead performed.



daedalus said:


> Nausea Differential:
> 
> *Adverse drug reaction*
> *Addison disease*
> ...



Many of those can be associated with dangerous electrolyte, hormonal imbalances, or associated symptoms that can be linked with associated coronary syndromes or before making diagnoses to rule out CAD a ECG should had been performed. 

Alike taking a set of vital signs, an ECG is just another assessment tool. Simple monitoring lead does not cut it, especially if you have a twelve lead on hand. 

R/r911


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## VentMedic (Feb 17, 2009)

chute43 said:


> I believe the Nurse felt you as the higher qualified provider should have provided a higher level of care even if that higher level of care was just monitoring the pt with the skill of a paramedic.


 
Excellent point...

Who did the Patient Care Report? Is there a record of an "ALS" assessment? 

If an EMT-P performed and "ALS" assessment to determine it was a "BLS" patient, that assessment should be documented with the Paramedic's signature. As well, if an EMT-B cared for the patient during transport there should be documentation of their observations during transport. If our FD Paramedics assess a patient in the field and then hands off to a BLS truck, their report accompanies the patient. The BLS truck will then have their report for what happens from that point on. 

In the hospital, there is not a "BLS" or "ALS" mentality. The RN is responsible for giving any reports about the patient, not the CNA. The RN would not do an assessment and determine that it is okay for the CNA to pass on the report to the next RN or doctor. In this situation, the RN probably had specific questions about how the patient was assumed to be BLS and what assessment was done to make that determination.

I would also include from the list posted for N/V:

Exercise - Some people are out of shape and don't know what their health status is. Many people have dropped dead while excercising, including children. 

Bulimia - The constant purging definitely takes a toll on the electrolytes and CV system. 

Norovirus, flu - Monitoring may be necessary for at risk populations especially the elderly. Usually the ED will do an EKG and use a cardiac monitor to determine if the patient needs further monitoring on tele especially if the correction of the electrolytes is still being done. 

Tobacco smoking/second hand smoke - Many patients presenting with N/V will get a 12-lead which even if it doesn't show an AMI, it may show cor pulmonale. This will then get the patient a work up for COPD or some other disease. Often the first steps toward diagnosing COPD and other pulmonary diseases are through EKG changes. This is especially true for the spouses of smokers.

Chronic Fatigue Syndrome - Closer attention is now being paid to the cardiac status of those with this disorder, especially women as the many recent new articles have stated from the research. Cardiomyopathy has been missed by doctors who blew off the symptoms. There are numerous articles from Cardiac and Exercise labs that indicate an inability for the patient reach their max or low cardiac output levels have been noted. There are those that do have evidence of poor wall motion and old infarctions found on their EKG but the etiologies is still being investigated. 

There are also many other diseases of the heart and chest that can cause N/V and can be extremely serious. Some may not be readily apparent on an EKG but may have abnormal heart sounds. These patients may still benefit from the inital and continued assessment of an ALS provider. Any observations made by someone who is well trained/educated in assessment may be valuable to making a diagnosis or giving the doctor a good starting point when passed on to the ED staff. *This shouldn't be just a ride to the hospital. EMS providers should realize their role and responsibilty they have to patient care in the healthcare system.*

Some of the situations played out in the TV show HOUSE are not that far fetched. It many take several days to make a true diagnosis and one may not be made as to the cause of some symptoms. However, it may take just one observation made by some healthcare provider that solves the mystery.


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## vquintessence (Feb 17, 2009)

Sorry to jump into the tail end of the conversation... but what exactly is wrong with performing diagnostic testing?  Hospitals do this all the time to gain an almost 95% understand with a good certainty of what exactly is happening to their pt.

<<<warning: paragraph long, relevant, personal story>>>
When I was a pre-teen, I had an anaphylaxis reaction to several wasp stings to my chest while mowing the lawn.  The allergy was known, and hell I'm allergic to all bee's except honey bees, but ground wasps give me the worst reaction.  Instantaneous urticaria and started to develop SOB/chest tightness in a couple min.  No personal stranger to experiencing allergic reactions, and my mum, an RN, was home and gave me my epi-jr shot and rushed me herself to the hospital (8min drive).  She didn't call EMS because of a horrible experience involving my grampa, an AMI, and the medic completely trivializing AND missing the STEMI.  Thank god the receiving hospital had an accredited cath lab... my family could have easily settled the 200K municipal lawsuit should they have sought it.

Anyways, get to the hospital, and end up with more epi, benadryl, zantac, neb, O2, NS (no idea how much, probably KVO?).  After the slew of crap they threw at me, a pre-teen with obvious anaphylaxis c known culprit (wasp and pmhx bee allergy), I still got these "weird stickers across my chest put on by some old lady"...

Now, pre-teen still experiencing chest tightness obviously secondary to anaphylaxis reaction... and they still gave the 12 lead.  Were they wrong in doing so?  Or were they just ensuring I received full care?

It is obvious the situation between this and the OP's are drastically different; sick vs not sick, let alone interventional medicine, but the similarity lies in this:  What is wrong with performing diagnostic testing?  A 12 lead takes 2 minutes MAX during the winter with a jacket and layers.  I am not Dr Ambulance, and even if I were, I'm sure Dr Ambulance would run a slew of tests before deciding on a definitive diagnosis.


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## BLSBoy (Feb 17, 2009)

vquintessence said:


> Anyways, get to the hospital, and end up with more epi, benadryl, zantac, neb, O2, NS (no idea how much, probably KVO?).  After the slew of crap they threw at me, a pre-teen with obvious anaphylaxis c known culprit (wasp and pmhx bee allergy), I still got these "weird stickers across my chest put on by some old lady"...
> 
> Now, pre-teen still experiencing chest tightness obviously secondary to anaphylaxis reaction... and they still gave the 12 lead.  Were they wrong in doing so?  Or were they just ensuring I received full care?



Its not so much the "Chest tightness" that caused them to do a XII lead on you, it was the fact that you recieved several doses of Epi, which puts strain and increased workload on the heart.


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## frogtat2 (Feb 17, 2009)

*Epi*

I am an EMT-I on a small rural service.  After reading your initial question, here are my thoughts.

I don't think that you necessarily missed anything.  However, if this had been my patient I would have put him on a cardiac monitor.  I would have wanted to assess his cardiac status and that would require an EKG.  

Don't beat yourself up over this.  You did what you thought was appropriate at the time.  Use this experience as a stepping stool and learning tool.  We have all been there before, and will most likely be there again.  Just do the best you can for each patient and continue to study and learn.  Thats all any of us can do.


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## daedalus (Feb 17, 2009)

> Now, pre-teen still experiencing chest tightness obviously secondary to anaphylaxis reaction... and they still gave the 12 lead. Were they wrong in doing so? Or were they just ensuring I received full care?


Not to trivialize your horrible ordeal you went through as a child, but how is this relevant to preforming a 12 lead in a N&V patient? You were given epinephrine and nebulized medications, and those are potent on the heart. 

I will pose my question a different way;
Show me a study where preforming *field* 12 leads in patients with vomiting lead to something good instead of increased costs and unnecessary  testing.


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## Juxel (Feb 17, 2009)

I was writing a response to support not doing a 12-lead, but then I re-read the OP and saw the stomach pain that went away.  That, combined with the n/v and the past medical hx, would warrant a 12-lead in my opinion.

Studies have shown that n/v is the main (or only) presenting symptom in approximately 20% of STEMI's with no associated chest pain.  The study found the other non-pain symptoms to be dyspnea (50%), diaphoresis (18%), and syncope (12%).

Are there any others on that list that you would skip a 12-lead?  According to this study, n/v should be quite alarming and would certainly warrant a 12-lead.

Epi-do, if you brought me this patient with no 12-lead I wouldn't be upset as a hospital provider.  The standard of care for n/v when there is a clear history is not a 12-lead and I frequently see patients in the ER that I discharge without ever doing one.  However, given this patient's age and hx, it would probably be better to err on the side of caution.


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## daedalus (Feb 17, 2009)

> In the hospital, there is not a "BLS" or "ALS" mentality. The RN is responsible for giving any reports about the patient, not the CNA. The RN would not do an assessment and determine that it is okay for the CNA to pass on the report to the next RN or doctor. In this situation, the RN probably had specific questions about how the patient was assumed to be BLS and what assessment was done to make that determination.


This is a good point. Why do we do this in the field? Should the EMT be restricted to driving and assisting the paramedic on scene? Why is it okay to punt patients who we do not believe deserve paramedic care to EMTs? RNs do not get to punt "BLS" patients to CNAs, they take care of each patient at the same level with the advanced education they have.


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## daedalus (Feb 17, 2009)

> Studies have shown that n/v is the main (or only) presenting symptom in approximately 20% of STEMI's with no associated chest pain. The study found the other non-pain symptoms to be dyspnea (50%), diaphoresis (18%), and syncope (12%).



"The most common side effects with OsmoPrep [and others I looked up] are abdominal bloating, abdominal pain, nausea, and vomiting"
-Manufactures website

Pt with _anxiety_(causes nausea) before colonoscopy ingests _bowel prep_(common side effects include nausea, vomiting, and pain), and experiences an episode of isolated vomiting.

occums razor

Plus, while this patient may receive EKG in the hospital, we are talking about the field.


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## VentMedic (Feb 17, 2009)

daedalus,

I think we're getting somewhere now.

Think of doing the 12-lead as just another VS as Rid stated. EKG changes might be transient and EMS might be the providers that catches the changes. I can't tell you how many times I have watch a patient in the ICU with my finger poised on the 12-lead machine waiting for them to do what they did again. Ischemia or aberrancies vs VT are examples of something one can see but only momentarily. A Paramedic just might have the opportunity to capture something that will pull the puzzle together. 

I'm going to post this link again from another thread.
*Electrocardiographic Manifestations and Differential Diagnosis of Acute Pericarditis*

http://www.aafp.org/afp/980215ap/marinell.html

Look at the long list of etiologies for pericarditis. Now look at the list of differential diagnoses. Any clue that can be passed off in report might be very beneficial in narrowing down the process to start definitive care. I can not stress enough for good "ALS" assessments with a "medicine" point of view. Don't become just ambulance drivers and give the hospital staff a chance to view you as such because of your reports with the "we are different because we are in the field" mentality. The providers that get the most respect in the ED are those that do put a little extra effort to do a detailed assessment and be thorough with the histories or look for clues at scene. There are things that the ED staff do not have access to but the EMS providers may get first hand knowledge of. 

It is all about the medicine for the greater good of patient care regardless of what treatment you can provide from your findings.

Edit:
Okay forget my first remarks. Forget the Colonoscopy prep. That is a distraction for you. Many patients have conditions that can be exacerbated by tests or their prep which is why we may do an EKG before sending them home with the prep and another before they get the procedure as well as being on a cardiac monitor for the procedure which may get stopped because of EKG changes.


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## Ridryder911 (Feb 17, 2009)

daedalus said:


> I will pose my question a different way;
> Show me a study where preforming *field* 12 leads in patients with vomiting lead to something good instead of increased costs and unnecessary  testing.



Show me where it costs more and what is and who is determining what is unecessary? 

R/ r911


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## VentMedic (Feb 17, 2009)

daedalus said:


> "The most common side effects with OsmoPrep [and others I looked up] are abdominal bloating, abdominal pain, nausea, and vomiting"
> -Manufactures website
> 
> Pt with _anxiety_(causes nausea) before colonoscopy ingests _bowel prep_(common side effects include nausea, vomiting, and pain), and experiences an episode of isolated vomiting.
> ...


 
It seems you missed a few things about the OsmoPreP.



VentMedic said:


> *Oral sodium phosphate (OSP) solutions, including FLEET, Visicol and OsmoPrep, draw water into the gut to promote cleansing. They may be easier to tolerate, but can cause dehydration and electrolyte imbalances. A high phosphate load may also not be safe for patients with kidney, heart, liver, or certain intestinal diseases.*


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## Juxel (Feb 17, 2009)

Occam's razor may apply to some scenarios, but if you use it to dictate your practice of medicine you are going to have a very short career.  Please don't fall into that trap.  I've seen all too many EMS careers end prematurely due to people falling into traps like this.


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## Veneficus (Feb 17, 2009)

daedalus said:


> This is a good point. Why do we do this in the field? Should the EMT be restricted to driving and assisting the paramedic on scene? Why is it okay to punt patients who we do not believe deserve paramedic care to EMTs? RNs do not get to punt "BLS" patients to CNAs, they take care of each patient at the same level with the advanced education they have.



Daedalus,

While I see your point and respect your opinion I do not think having an EMT ride a call is “punting” in the traditional sense. Where I am from the idea of punting is to transfer not only care but the responsibility of care. 

If the medic is in the front of the truck, all the basic has to do is ask for help. If in a tiered response a medic defers to a basic a patient complaining of CP radiating to arm and jaw, SOB, N/V and impending doom, it is not the basic who will be answering for that. So it seems to me more like delegation of a task more than transfer of responsibility. 

In addition, both nurses and physicians (don’t know about others) have to delegate care on a regular basis, not only for logistical reasons, but to develop other providers.

Anecdotally I worked in a system as a medic where the highest level provider was required to ride calls, I am not sure who made the requirement,  and while there were exceptional individuals, most of the basics took exceedingly long to develop into a competent provider or partner. When they advanced to medic school their knowledge was often no better than somebody who never saw a patient before.

I *do NOT* (bold for the critics who accuse my advocacy of greater education as an attack on basics) support the idea of basics being a “go for” and a “driver.”


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## BLSBoy (Feb 17, 2009)

Before an EMT gets a pt when there is an ALS provider on scene, an ALS rule out assessment should be made. 
Vitals, ECG, XII lead if indicated, BGL. 

Period.


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## daedalus (Feb 17, 2009)

Veneficus said:


> Daedalus,
> 
> While I see your point and respect your opinion I do not think having an EMT ride a call is “punting” in the traditional sense. Where I am from the idea of punting is to transfer not only care but the responsibility of care.
> 
> ...


Actually, I am not convinced that punting to the EMT is a bad idea, I was just posing questions because VentMedic made a valid comparison to RNs and CNAs. We do have the ability to preform an ALS assessment and than BLS the call in Ventura County. 

VentMedic, I am starting to see what you mean, as in looking at a 12 lead as an opportunity to catch something. I am by far not the most experienced provider here, but I have rarely been failed by simplicity.


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## vquintessence (Feb 17, 2009)

BLSBoy said:


> Its not so much the "Chest tightness" that caused them to do a XII lead on you, it was the fact that you recieved several doses of Epi, which puts strain and increased workload on the heart.



Right, and exactly.  The interventional medications in that instance were a significant part of needing the 12 lead, however my point (however poor it ended up being) was that it was done as another diagnostic to completely rule out complications and/or catch other etiologys at work for my present condition.

I was young, healthy/fit, and no pmhx (esp no cardiac hx).  Was probably slightly tachy from the epi and albuterol, but being that age as well as a healthy demographic within it, can certainly handle and metabolize rather effectively those doses and stressors on the vascular system.  The 12 lead was just another diagnostic to offer further assurance, _for my benefit (and my poor mum)_, that I was alright.

Someone already recently said it, but a 12 lead should just be considered part of vitals in situations where a grey area exists (ex: the N/V).  Sure, that can be trivialized by us in EMS as a "waste of effort", but that's what we've also done with temperature.  We all know the importance of having a temp for a pt with PNA or febrile sz or neurogenic insults or etc, but because we have trivialized requiring thermometers, a lot of EMS doesn't even allow their employees to use them.

What if we were to go so far as trivializing the need to get a BP for much of our "BLS" pts?  (lets leave aside the violent, the refusals and the impractical [e.g. airway issues])  I can look at a lot of pts and have a general idea of their BP based on HPI, PMHx, skin c/t/c, weight, race and sex.  Because I can guess based on experience and prejudices, doesn't mean I'm right and ergo should never do it.  Give the pt all ya got when there is a grey area.    Sure, setting up EKG's are repetitive and sometimes tedious, but it's our job.  We lose respect among healthcare when we give ourselves the ability to write off performing diagnostic tests for the grey area pts.


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## medic_chick87 (Feb 18, 2009)

BLSBoy said:


> Before an EMT gets a pt when there is an ALS provider on scene, an ALS rule out assessment should be made.
> Vitals, ECG, XII lead if indicated, BGL.
> 
> Period.



Exactly what I was going to say. As per my county protocol all pts get a full assessment, including a quickie ECG just to make sure you've covered all your bases before you can turn it over to your EMT partner. As many have all ready said, I would have done one just to rule out cardiac because of the age and hx. But since none of us were there, you are the only one who can say whether he was "Big Sick vs Little Sick" I'm sure you made the best judgment call. Just next time do a "quickie" ECG, even if you dont think it will help with your deferential.


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## Epi-do (Feb 18, 2009)

I appreciate all of the replies and insight.  I have definately taken a few different things away from what has been posted.  

Now, for the update I got from the nurse that had patient care at the hospital.  It was deteremined all of this patient's symptoms were as a direct result of drinking the Trilyte and the side effects from doing so.  He was released from the ER in time to make it to his colonoscopy and was rather upset with the nurse when he asked if they would call the ambulance back to take him home after the test and she told him no, but that a taxi could be called instead.


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## VentMedic (Feb 18, 2009)

Epi-do said:


> He was released from the ER in time to make it to his colonoscopy and was rather upset with the nurse when he asked if they would call the ambulance back to take him home after the test and she told him no, but that a taxi could be called instead.


 
This could also have been an error of the pre-admit and discharge instructions. We tell our patients they are not to drive themselves for any procedure where sedation, hypnotics and/or pain meds are given. Our hospital system has a courtesty van and also arranges for transport if the need a higher level of transportation. The patient may have been just following orders but didn't understand them and called for the wrong transport. I do try to give elderly people the benefit of the doubt even if it appears they are playing the system. Most just don't understand it. Anyone here try understanding the Medicare changes a couple of years ago? 

If you have ever tried you arrange for an ambulance transport from either a hospital or for one of your own loved ones, you will find it is a very complicated and confusing process even if you work in the system. Who to call for what is a huge area to cover. Before our hospital system started doing our own CCT or "ALS" IFT, we literally had menus for what each ambulance service could or could not do Often there was one thing missing from the list and someone from the hospital staff would end up going anyway. 

Sorry for the rambling since this is not the case for this patient. Just keep in mind how confusing and overwhelming the whole U.S. healthcare system is.


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## daughertyemta (Apr 5, 2009)

nurses being nurses.  They always wanna jump the EMTs for something they didn't do.  But they couldn't perform out in a squad.  Cardiac hx yea prob. shouldve had a monitor but that was your medics call and if he down graded it then so be it.  As long as you felt comfortable with it.  Thats all that matters.  Obsivously following your protocols and what not also.  It could have went either way.


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## JPINFV (Apr 5, 2009)

^
Can we leave the conspiracy theories to Coast to Coast AM?


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