# Party like it's 1999!



## Summit (Sep 14, 2017)

Let's time-warp back to hypothetical 1999... 

"MAST4 Respond to 67 yom c/o chest pain."

A lady in a bathrobe leads you to the bedroom where you find a naked old dude pale, cool, and diaphoretic.

CC: during intercourse (first time in decades) 10/10 crushing substernal chest pain radiating to arm 

Shiny new-fangled LP12 says:
HR112 
Sinus Tach c PVCs + borderline ST elevation in anterior leads
BP102/66
SpO2 87%

Patient states a friend gave him some new miracle pill called Viagra that just came out last year. Guess that is why you are supposed to, "ask your doctor if your heart is healthy enough for sex."

Protocol says MONA... and time for NTG... but wait...  

Last night you read this article: https://www.ncbi.nlm.nih.gov/pubmed/10078539?access_num=10078539&link_type=MED&dopt=Abstract 

It said that phoshodiesterase 5 inhibitor within the last 24hrs is a STRICT contraindication for NTG due to synergistic hypotension... which super sucks in a MI. 

Your MI protocol was last updated in 1997. 

Protocol says NTG.  Radio is out. 23 minutes to hospital with a cath lab...

Give the NTG?


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## phideux (Sep 14, 2017)

No


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## EpiEMS (Sep 14, 2017)

Probably not, nope. I'm not sure if professional ethical standards (and notions of our duty to patients) have changed since then, but I sure as heck am expected to *not* do something that may be actively harmful.


*Also, I was 8, so I don't know if I would have been allowed on the ambulance.


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## E tank (Sep 14, 2017)

You'd probably be pretty sorry...was the Viagra still....working?


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## DrParasite (Sep 15, 2017)

Other than "because protocol says so," why would you give NTG?  

He isn't hypertensive, and he has already taken a vasodialating ED drug.

The question I have for you is could you defend your actions to your medical director if he called you into his office and asked for an explanation of your actions?  I think I could.


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## Summit (Sep 15, 2017)

DrParasite said:


> Other than "because protocol says so," why would you give NTG?
> 
> He isn't hypertensive, and he has already taken a vasodialating ED drug.



Is the purpose of the NTG in MI to treat htn? If not, what is its purpose?

What type of htn does the drug he take work best for?

(Please don't confuse this as me arguing for the NTG)


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## DrParasite (Sep 15, 2017)

Summit said:


> Is the purpose of the NTG in MI to treat htn? If not, what is its purpose?


MI + NTG = vasodialation with increased bloodflow, which is usually a good thing during an MI.  It can also reduces cardiac preload and further decreases myocardial wall stress, which is also a good thing.  Studies have also shown it to have a positive effect on restoring the equilibrium of oxygen and nutrients supply-demand in the ischemic heart.

However, MI + NTG + Viagra = synergistic hypotention, which can often lead to death.

I think the bad outweighs the good here.  

So I ask the same question to you, knowing that death can outweigh the positives of NTG, why would you give NTG, other than because protocol says to?


Summit said:


> What type of htn does the drug he take work best for?
> 
> (Please don't confuse this as me arguing for the NTG)


since you didn't list his current meds or history, I'm not sure if the scenario provides enough information to give a proper answer to that questions


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## GMCmedic (Sep 15, 2017)

Summit said:


> Is the purpose of the NTG in MI to treat htn? If not, what is its purpose?
> 
> What type of htn does the drug he take work best for?
> 
> (Please don't confuse this as me arguing for the NTG)


Pulmonary hypertension

Sent from my SAMSUNG-SM-G920A using Tapatalk


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## Summit (Sep 15, 2017)

EpiEMS said:


> Probably not, nope. I'm not sure if professional ethical standards (and notions of our duty to patients) have changed since then, but I sure as heck am expected to *not* do something that may be actively harmful.
> 
> 
> *Also, I was 8, so I don't know if I would have been allowed on the ambulance.



I was in highschool, so they wouldn't have let me on the ambulance either.

You've identified the crux of the question that I was trying to present: an ethical one.

Do you follow protocol, to the detriment of your patient, given an unusual circumstance where you know better than the protocol?

I was struggling to come up with an analog to the lightning strike scenario where the question was, as I saw it, "do you follow protocol (START) when you know it is bad for your patients?" (and not just a little bad)

The answer here, as there, is unequivocally, not only no, but HELL NO, screw the protocol, do the right thing for the patient and certainly don't harm them!

I find it interesting in this thread said "well yea I'd give the NTG while some were willing to follow a catastrophic protocol in the other thread. Is it because of the time warp? Because we are all familiar with the PDE5i/NTG interaction vs when it was brand new and novel? Because here we'd be taking potentially harmful action vs potentially harmful inaction? How many paramedic programs include a 3 credit healthcare ethics class? Do any require philosophy/ethics/logic as a prereq or co-req? Healthcare Ethics is part of BSN programs and one or more of the latter is typically a prereq.


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## DesertMedic66 (Sep 16, 2017)

Considering an MCI or a multiple patient incident is vastly different from a single patient encounter like this one is like trying to compare apples to a basketball, yes the are both kinda round but that’s about it.


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## Summit (Sep 16, 2017)

DesertMedic66 said:


> Considering an MCI or a multiple patient incident is vastly different from a single patient encounter like this one is like trying to compare apples to a basketball, yes the are both kinda round but that’s about it.


The ethical issue is minimally different...  Maybe more lack of beneficence in the mci vs lack of nonmalfeasance here... 

You giving the ntg?


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## DesertMedic66 (Sep 16, 2017)

Well I was only 7 at the time...

I honestly can’t say back in 1999 what I would have done. We all know now not to give NTG or in some areas to just be cautious if giving it. However i feel it would be very dangerous to start treating patients from an abstract (that doesn’t include sample size) on a single study...

In my current system our treatment protocols allow us to use clinical judgment, that is why we do not have a chest pain protocol for example. On the other side of the coin we do have a policy that states we must at all times follow any legal order that the IC gives us.


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## Summit (Sep 16, 2017)

DesertMedic66 said:


> In my current system our treatment protocols allow us to use clinical judgment, that is why we do not have a chest pain protocol for example. On the other side of the coin we do have a policy that states we must at all times follow any legal order that the IC gives us.


You think your medical director and your state EMS board give a crap about an employer policy if you interpret it to mean, "follow orders given by someone who has equal or less training and knowledge, even to the detriment of your patient."

Please explain in detail what ethical principles bind you to follow that policy?

At least the protocol was written by physicians with consideration and review!


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## VentMonkey (Sep 16, 2017)

Even at the ripe old age of 19 (1999) I would have been apprehensive. Still, I'm reluctant with RV involvement of STEMI's, and yes I am aware of current literature. I just don't want to be the one responsible for the refractory "dump" in blood pressure.

It reminds me of when all we had was MS for pain management, and were faced with a patient with a borderline blood pressure according to our protocols, but who was clearly in pain. A fluid bolus followed by a transient improvement in blood pressure, and an appropriate dose of MS worked fine.

Adding a potent vasodilator on top of another that may further impair venous return? No thanks.


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## DesertMedic66 (Sep 16, 2017)

Summit said:


> You think your medical director and your state EMS board give a crap about an employer policy if you interpret it to mean, "follow orders given by someone who has equal or less training and knowledge, even to the detriment of your patient."
> 
> Please explain in detail what ethical principles bind you to follow that policy?
> 
> At least the protocol was written by physicians with consideration and review!


This is not a company policy. This is a county protocol that is set by the medical director...


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## Gurby (Sep 16, 2017)

Summit said:


> You've identified the crux of the question that I was trying to present: an ethical one.
> 
> Do you follow protocol, to the detriment of your patient, given an unusual circumstance where you know better than the protocol?



I guess this is a cop-out to the ethics question, but you probably have time to call medical control in a lot of these cases if you're really torn up about it.


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## Summit (Sep 16, 2017)

Gurby said:


> I guess this is a cop-out to the ethics question, but you probably have time to call medical control in a lot of these cases if you're really torn up about it.


I agree. That is why I broke the radio for this hypothetical. In the other thread, there was no contacting medical control, it was "I follow orders like a robot medic *beep boop*"


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## Summit (Sep 16, 2017)

DesertMedic66 said:


> This is not a company policy. This is a county protocol that is set by the medical director...


HAHAHAHA

I suggest you pose this to your medical director. Ask what they think of your espoused willingness to follow orders you know to be stupid to the detriment of your patient without question. Ask your medical director if that was his/her intent? Please post his/her response here...

In the meantime, I am still waiting for your ethical basis for "just following orders" when you know they are wrong (and not just a little bit wrong)... 

And if i reprise the scenario in this thread so it is an MCI (say a viagra fueled orgy where everyone is having an MI) and the IC orders you to give the NTG all around, are you suddenly going to do it now because it is a "legal order"?


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## DesertMedic66 (Sep 16, 2017)

Summit said:


> HAHAHAHA
> 
> I suggest you pose this to your medical director. Ask what they think of your espoused willingness to follow orders you know to be stupid to the detriment of your patient without question. Ask your medical director if that was his/her intent? Please post his/her response here...
> 
> ...


I’d imagine their intent was to make a protocol for the realistic and the most likely MCIs. As I stated before I have never had nor heard of anyone in my county or any nearby county ever having a lightning strike patient let alone a multiple patient or MCI one. 

I’m not going to try to lie and say I know everything about lightning strike patients because those subjects were never actually covered in any of my training (initial training, refresher courses, hospital courses, and CE courses). The subjects are covered very briefly in my EMT and paramedic textbooks and pretty much just say “they are usually not fatal and to follow current ACLS guidelines” and do not go into a multiple patient scenario for treatment plans. Since I have never had this topic covered or read about it, why would I with only an average of 300 patients being hit per year in the entire US, I can say that the majority of medics in my system or the nearby ones would not know either. Does that make it any better? No, however it is impossible to know everything or be able to treat anything. Would I get faulted at all in an MCI for following my county protocols about standard triage and what my education has taught me? I highly doubt it for several reasons. 

As for your second “scenario” that is a ridiculous scenario that deserves no response.


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## Summit (Sep 17, 2017)

You are getting the 3rd degree from me, not because you weren't an expert in lightning/electrocution (of which there are thousands per year combined), but because once informed and presented with evidence of the right treatment, you insisted that you would still do the wrong for your patient thing because surely you would be ordered to do the wrong thing... and orders are orders or some such tautological BS.

The viagra scenario (and the viagra MI MCI) is purely test of your internal consistency because in both the lightning and the viagra scenarios, you possess extra knowledge on how to do right by your patients. If you are going to leave the lightning victims to die "because orders" but can't unequivocally say that you'd give NTG in the Viagra MI MCI if so ordered, then you are a hypocrite as well as ethically dubious cookbook medic.


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## DesertMedic66 (Sep 17, 2017)

You must not understand how private EMS works during an MCI in my system. Unless we are the first or second piece of equipment on scene all we are going to do is pull up on scene and talk to either the IC, MedCom, and/or ground transport coordinator who will say “you are taking this patient to this hospital”. Unfortunately our fire department believes the RT in START stands for Rapid Transport and it Rapid Treatment which means get everyone off scene ASAP. 

If we show up on scene and they give us 2 greens then that is what we are taking. We are not told “hey, we have 4 red, 5 yellows, and 3 greens”.


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## VentMonkey (Sep 17, 2017)

I wonder how treatments would change if each person in the "orgy MCI" had cardiac involvement in opposing parts of cardiac muscle? Also, an orgy MCI just sounds gross.

When I did my internship in @DesertMedic66's county in 2007 it was almost a 50/50 split of engines staffed with paramedics to BLS engines. That said, IIRC fire still had a hold of MCI's and trying to take command of such incidents was both realistically unheard of, and cause for more confusion amongst them.

Having moved to a part of the state where it doesn't exactly operate this way in an MCI situation a few things have changed. If the paramedic arrives and finds that the call no longer warrants a med alert (MCI) they can call it off. A lot of the times the paramedics won't either because they lack the scene command, and/ or experience to do so, they're from a different county or state, or they're just lazy and let fire take "med group" control; med group is soley on the highest trained medical personnel in our county (i.e., the medic). Or, and this seems to be becoming more commonplace, they are in fact clock-punching cook books.

Fire won't typically argue one bit if our medic calls off an MCI. Many times they're too caught up in the rescue to even acknowledge the patients triage color, and what all resources they in fact do or don't need. Some batt chiefs are definitely more keen on wasting vs. efficient utilization of their manpower and resources, but way too many just remind me why California fire-based medicine is all sorts of haywire.

I kind of feel @DesertMedic66's pain, and if it were me still in that county I would personally be frustrated to no end. My experiences with ALS fire departments in my state is equivalent to giving the ball back to the schoolyard bully.

Don't believe us? Take a look at this forum on any given day and you'll find a thread that pertains to some sort of riff between some California EMS agency and their local FD.

Like I have already eluded to, my options are limited, as are many of my peers. The only way to get ahead in this state is to outsmart the schoolyard bully, and that really shouldn't be that hard to do.


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## CWATT (Nov 26, 2017)

DrParasite said:


> MI + NTG = vasodialation with increased bloodflow, which is usually a good thing during an MI.



My understanding is that coronary artery dilation occurs high in the therapeutic range and only to a maximum of 15%, but I don’t have a source to back me up at the moment.  I imagine this would occur long after resolution of ischemic chest pain, the point at which our protocols say we titrate to.  



DrParasite said:


> It can also reduces cardiac preload


. 

This.  I was literally looking at my lecture slides earlier today that described Nitro as “symptomatic relief” followed by the statement that it has not been proven to reduce mortality.   That said, it’s a pretty easy line to draw IMHO between relief of ischemic pain and reduction of cardiac workload and subsequent preservation of tissue.


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