# NTG for chest pain... even when you're thinking respiratory.



## Shishkabob (Dec 2, 2011)

So this has been a point of contention between me and my FTO.


He is of the thought process "If they're complaining of chest pain, even if I think it's respiratory in nature, they get a nitro SL just to test it out".  I'm of the opposite view... I'm not against trialing NTG if I deem it worthy, but if I think something is "solely" respiratory in nature (IE pleuritic chest pain for a few days after severe coughing fits with a fever, specific point, non-radiating with no nausea, diminished sounds in a field, no cardiac history, no other factors) they probably won't get a nitro from me.

He admits that nitro can stop non-cardiac chest pain just as likely as it is to not do anything for cardiac pain, but still questions my not doing nitro for chest pain "just to check".  If he backed it up by saying "I do it for the pain", that'd be one thing, but that's not his reasoning.



Views on nitro for chest pain, even when not convinced it's cardiac in nature?


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## Brandon O (Dec 3, 2011)

Relief from nitro is, at best, a weak supporter of cardiac etiology.

A 12-lead is a great one though, so unless you guys don't have that capability I'm not sure why you'd have to resort to anything else.


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## AlphaButch (Dec 3, 2011)

Sometimes it's difficult to nail down whether it's cardiac or non-cardiac in nature, and giving it for pain would be an option. However, doing it to "test" whether it's cardiac or non-cardiac seems poor reasoning for administration (particularly given the studies done on the matter).


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## DV_EMT (Dec 3, 2011)

Linuss said:


> Views on nitro for chest pain, even when not convinced it's cardiac in nature?



As taught by the Los Angeles EMT Expanded scope, "If it dosent DIICE out, you dont give it"

DIICE

Drug/Dosage
Indication/Integrety
Contraindications
Expiration

If it presents as respiratory and isn't indicated as cardiac in nature (EKG and pain), don't give it. I went to the ER the other day for substernal chest pain that worsened with swallowing. Did it present as cardiac, maybe with the pain location, but the fact that my vitals were stable and that the pain worsened with swallowing made me think it was GI or Respiratory. they got an Xray, Labs, and EKG (all negative). Turned out to be esophagitis with refered chest pain. 

... And no, I didn't get any nitro ^_^ - instead I got some prilosec and a "don't eat too much turkey"


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## Smash (Dec 3, 2011)

Linuss said:


> Views on nitro for chest pain, even when not convinced it's cardiac in nature?



Does he give it to someone with sudden onset, severe, tearing pain radiating through the back and into the groin with pallor, diaphoresis, nausea and hypotension?  You know, just to check?

Lazy, not very bright, potentially dangerous and at best a waste of time.


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## mike1390 (Dec 3, 2011)

DV_EMT said:


> As taught by the Los Angeles EMT Expanded scope, "If it dosent DIICE out, you dont give it"
> 
> DIICE
> 
> ...


This has nothing to do with the question at hand...moving on.

If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. easy as that. Cardiac events mask themselves as many things,I had one where the lady complained of an itch in her back and her friends called for her, had another that was stomach pain both full blown STEMIs . Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.


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## Handsome Robb (Dec 3, 2011)

mike1390 said:


> This has nothing to do with the question at hand...moving on.
> 
> If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. easy as that. Cardiac events mask themselves as many things,I had one where the lady complained of an itch in her back and her friends called for her, had another that was stomach pain both full blown STEMIs . Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.



Because using a medication when it is not indicated is bad medicine.

If she is showing a STEMI on the monitor then treat it as such. If there's no STEMI present and the pain, after assessment, is deemed to be pleuritic in nature NTG is not indicated or appropriate.

So she is short of breath and having chest pain and showing a STEMI on the monitor, do you give albuterol to treat her SOB/diff breathing even though the albuterol will boost her myocardial O2 demand through it's beta 1 effects and worsen the ischemia to the heart? :wacko:


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## mike1390 (Dec 3, 2011)

could be angina not a STEMI, NTG will relieve that pain.And it is indicated she's c/o CP. Its a matter of opinion like giving MS for a paper cut, pt states 10/10 on the pain scale do I withhold cause its a paper cut? You treat your patients the way you want ill do it my way.


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## DV_EMT (Dec 3, 2011)

mike1390 said:


> This has nothing to do with the question at hand...moving on.



Uh, yes it does



			
				Linuss said:
			
		

> He is of the thought process "If they're complaining of chest pain, *even if I think it's respiratory in nature, they get a nitro SL just to test it out". *I'm of the opposite view... I'm not against trialing NTG if I deem it worthy, but if I think something is "solely" respiratory in nature (IE pleuritic chest pain for a few days after severe coughing fits with a fever, specific point, non-radiating with no nausea, diminished sounds in a field, no cardiac history, no other factors) they probably won't get a nitro from me.



If its not indicated (see the DIICE pneumonic I used) then why would you give it. Linuss states that he wouldn't give it for a person without a HX of cardiac issues. You wouldn't just give a drug just cause you want to test the waters... especially if you can't reverse it. 

Example - I had substernal Chest Pain w/ some shortness of breath on inspiration. I had been down with a cold x2 days prior to onset. I have no Cardiac History, but a Hx or Pneumonia...and I'm 22 y/o. My vitals were stable. If a paramedic had tried to give me Nitro prior to getting an EKG and a set of vitals, I would have refused it because I - the patient - knew that there was no way in hell that i was having angina pectoralisis or an MI given my HX. 

Why give a drunkard or diabetic with slurred speech & loss of motor coordination a clot buster when they don't have an active stroke.


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## mike1390 (Dec 3, 2011)

right cause everyone who is having an MI knows they have a cardiac condition :glare:. Go work in the field dude and tell me how many times you run on new onset cadiac symptoms.... things dont always start when your getting a check up at the doctors. what would I need to reverse? .4 NTG isn't going to bottom this pt out, but in the rare case it does happen, Iv got fluids and dope. If you've never had a cardiac event before how would you know you arnt having one. hence why out in the field everyone who is having a panic attack and has no cardiac HX thinks their having a MI. I see it at least once a shift. And I would hope no medic would give NTG before a 12-lead.


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## Handsome Robb (Dec 3, 2011)

mike1390 said:


> could be angina not a STEMI, NTG will relieve that pain.And it is indicated she's c/o CP. Its a matter of opinion like giving MS for a paper cut, pt states 10/10 on the pain scale do I withhold cause its a paper cut? You treat your patients the way you want ill do it my way.



That's fine. Everyone has opinions and I respect that. I agree, NTG will help CP secondary to angina but that isn't the question presented in this thread. The question was do you trial NTG in a patient with CP that, after assessment, is presumably not of cardiac origin to rule out cardiac etiology.

All I will say is last time I checked, which was recently seeing as I'm in school, NTG is indicated for chest pain with *suspected cardiac origin* not just chest pain.


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## Smash (Dec 3, 2011)

Thousand Oaks is in California right?  Well, I guess that explains things.  One more place to add to my Never Get Sick Here List. 

Lazy, not very bright, potentially dangerous and at best a waste of time.  That could describe so many things...


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## usafmedic45 (Dec 3, 2011)

Smash said:


> Lazy, not very bright, potentially dangerous and at best a waste of time.



I've seen several people suspended without pay for that approach and one of them actually had a complaint filed with the state by our medical director for doing it again after two prior reprimands for it.


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## usafmedic45 (Dec 3, 2011)

mike1390 said:


> This has nothing to do with the question at hand...moving on.
> 
> If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. easy as that. Cardiac events mask themselves as many things,I had one where the lady complained of an itch in her back and her friends called for her, had another that was stomach pain both full blown STEMIs . Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.


You scare the crap out of me and make me want to pray for your patients.


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## usafmedic45 (Dec 3, 2011)

Smash said:


> Thousand Oaks is in California right?  Well, I guess that explains things.  One more place to add to my Never Get Sick Here List.



Couldn't have said it better myself.


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## mike1390 (Dec 3, 2011)

yep im lazy and very dangerous, not to mention the biggest waste of time....when in the OP stated that his FTO (the person training him) gives it just to check. Thats not?


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## Handsome Robb (Dec 3, 2011)

mike1390 said:


> yep im lazy and very dangerous, not to mention the biggest waste of time....when in the OP stated that his FTO (the person training him) gives it just to check. Thats not?



I'd love a response seeing as I didn't attack you directly


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## mike1390 (Dec 3, 2011)

well rob because you seem to not be a pompous douche like others who sit in the holy EMS Heaven that is EMTLIFE which is like being the coolest kid on the short bus.

to answer your question. If after my lazy and my I add not very bright assessment, we pin pointed exactly what type of pain and where it is, if i was lead to believe that it was due to a cough then no I wouldnt just try NTG out. At no point did I say that I try drugs on pts just for kicks. If this lady was adamant that she was having chest pain... not pain when she coughs but actual chest pain, Then I would go down the chest pain route.


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## DV_EMT (Dec 3, 2011)

mike1390 said:


> right cause everyone who is having an MI knows they have a cardiac condition :glare:. Go work in the field dude and tell me how many times you run on new onset cadiac symptoms.... things dont always start when your getting a check up at the doctors.



Paragod

10char


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## Smash (Dec 3, 2011)

Linuss said:


> * (IE pleuritic chest pain for a few days after severe coughing fits with a fever, specific point, non-radiating with no nausea, diminished sounds in a field, no cardiac history, no other factors) *





mike1390 said:


> If someone uses the words "chest" and "pain" together Im treating a chest pain with sob. Why take a chance at guessing what it is when we have the tool to treat both CP and SOB.



Which is the opposite of:



> to answer your question. If after my lazy and my I add not very bright assessment, we pin pointed exactly what type of pain and where it is, if i was lead to believe that it was due to a cough then no I wouldnt just try NTG out.



So why change your tune?




mike1390 said:


> yep im lazy and very dangerous, not to mention the biggest waste of time....when in the OP stated that his FTO (the person training him) gives it just to check. Thats not?



Yes it is.  That's why I said it is.



mike1390 said:


> well rob because you seem to not be a pompous douche like others who sit in the holy EMS Heaven that is EMTLIFE which is like being the coolest kid on the short bus.



Of course you are above all of that...



> This has nothing to do with the question at hand...moving on.





> right cause everyone who is having an MI knows they have a cardiac condition :glare:. Go work in the field dude...


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## the_negro_puppy (Dec 3, 2011)

What about using your clinical judgement and assessments to try and narrow down most likely diagnosis?

Sure, we always lean towards treating CP as cardiac in nature as benefits outweigh the risks of an aspirin, GTN and perhaps even IV MS.

However if the call iis seemingly pleuretic/resp in nature i.e febrile 50 y.o basal rales/crackles, decreased Sp02, mild tachycardia with recent hx of chest infection and mild CP on inspiration, are you really going to start treating with aspirin, GTN etc? particularly if they have no risk factors or cardiac hx?


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## T1medic (Dec 3, 2011)

I dont post often, mostly just read and absorb info. But I'd like to chime in on this one.

Ok first off, yea I know I have a cliche username. I made it back when I was a squirrel a few years ago.

It sucks that US EMS has brought everyone to think like this and all the sue happy people in this world don't help but most medics hear "chest pain"and automatically give NTG as a CYA. In school w are taught, "you see A,B,C you do X,Y,Z" not "you see A,B,C, you assess the pt,do X if appropriate, re-assess, do Y if appropriate, but revert to W if assessment deems appropriate, etc". So as soon as most hear the magic chest pain its straight to NTG. There is also the type that is constantly in fear of the "well my protocol says so." Who wants to be sitting in court trying to justify why you withheld NTG from a pt complaining of chest pain? I don't.

Having said that, I don't throw medications out without having a reason. If the pt complains of chest pain but presents as respiratory, I'm witholding NTG for the time being.


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## Medic Tim (Dec 3, 2011)

Just finished a run where the cc was chest pain. With a little investigation we found it to be respiratory in nature and a few updrafts took care of the problem.


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## EMSrush (Dec 3, 2011)

Linuss said:


> He is of the thought process "If they're complaining of chest pain, even if I think it's respiratory in nature, they get a nitro SL just to test it out".



Fascinating. Does he do a 12 lead or any other type of assessment first?


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## usafmedic45 (Dec 3, 2011)

> well rob because you seem to not be a pompous douche like others who sit in the holy EMS Heaven that is EMTLIFE which is like being the coolest kid on the short bus.



Aww...cut Rob some slack, he'll get there eventually.  

Seriously, if you're going to get into a debate on here, about the last two people you want to do it with are Smash and DV EMT.  Even I stop and think before wading into that.  Good luck man.


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## 18G (Dec 3, 2011)

Sometime ago (prob many years ago) I read that NTG has very little diagnostic ability. So giving it "just to see" if it lessens the pain (or not) doesn't carry a lot of weight in making the determination of etiology. 

Chest pain carries many etiologies and all chest pain is not cardiac. I don't believe in blanket treatment of all chest pain with NTG. Sometimes it is hard to distinguish cardiac or not in the field and I don't have a problem with erring on the side of caution if something is nagging at you on the cardiac side. A 12-lead that is negative DOES NOT rule out cardiac causes. But a good assessment and history can tell an obvious respiratory or musculoskeletal cause most of the time. 

The thing with NTG is that it is a pretty innocent drug and has a very short half life. Within 5-10mins the effects are gone. Same with ASA. If the FTO is giving NTG I hope he is giving ASA to or that makes the practice even more mindless.


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## Handsome Robb (Dec 3, 2011)

usafmedic45 said:


> Aww...cut Rob some slack, he'll get there eventually.



Shhh your going to get me into trouble h34r: I blame you for all my infractions :rofl:

NTG is pretty innocent like 18g said but I still don't think we should be using it as a diagnostic tool.


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## Veneficus (Dec 3, 2011)

18G said:


> The thing with NTG is that* it is a pretty innocent drug* and has a very short half life. Within 5-10mins the effects are gone. *Same with ASA*. If the FTO is giving NTG I hope he is giving ASA to or that makes the practice even more mindless.



If I am reading this right, you are saying ASA is a relatively benign drug?

ASA permanantly binds to and inhibits COX 1 and 2. 

That inhibits platelet aggregation, inhibits vasoconstriction via TXA2 (one of the more potent constrictors), prevents PGE 2 vasodilation, decreases the inflammatory response of neutrophils, decreases stomach mucosal barrier synthesis, and just for completeness but not important for discussion here decreases uterine contraction. 

It takes about 24-48 hours for the body to reconstitute these permanantly inhibited products. 

This has an impact on everything from clotting (in any pathology which causes bleeding) as well as reducing the acute immune response (which makes the patient more suseptable to infections).

Depending on your etiology (which I will limit to chest/GI pain) You could do everything from creating or enhancing a bleed to incite a severe infection or reactivate a chronic one.

I agree with you some times in the field you have to decide to give nitro and ASA based on less than perfect information or circumstances.

But that doesn't make it a benign decision. It makes it a prudent one based on risk/benefit analysis.


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## Rettsani (Dec 3, 2011)

I try sometimes to answers
whom also my English is not great and you can misunderstand me.

Here we give only nitro for heart attack and angina symptoms after a thorough medical history and blood pressure measurement. For the addition of nitro spray, blood pressure should be 110/80 mmHg at least.

I think Nitro is not a bad drug, it should only apply it correctly and note the risks.

Nitro reduces the preload of the heart and the oxygen consumption.
The decrease in preload leads to improved blood flow and a decrease of capillary pressure, which explains the effect in cardiac pulmonary edema.
Nitro is capable of to limit the ischemia zone during a Infakt.


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## Brandon O (Dec 3, 2011)

18G said:


> A 12-lead that is negative DOES NOT rule out cardiac causes. But a good assessment and history can tell an obvious respiratory or musculoskeletal cause most of the time.



Just want to add that the idea of a "negative" 12-lead is somewhat vague. There's this idea floating around that you can have a STEMI without any ECG changes, which IMO is largely wrong. (Okay, STEMI by definition has ECG changes, but we really mean any clinically significant coronary occlusion.) If what's meant is that you can have an occlusion without classic, textbook ST elevation, that is very true, but if you widen your net to encompass the many more subtle signs, you do approach 100% sensitivity.

The reason people are still unsure and fall back on things like biomarkers is that the _cause_ of the ECG changes they see may not be clear. But it's pretty reliable that there will be _some_ changes. I have never seen a confirmed MI with a properly-done 12-lead ECG that is truly textbook normal, or at least 100% unchanged from the patient's baseline.


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## usafmedic45 (Dec 3, 2011)

> There's this idea floating around that you can have a STEMI without any ECG changes, which IMO is largely wrong. (Okay, STEMI by definition has ECG changes, but we really mean any clinically significant coronary occlusion.) If what's meant is that you can have an occlusion without classic, textbook ST elevation, that is very true, but if you widen your net to encompass the many more subtle signs, you do approach 100% sensitivity.



Hence the term "non-ST elevation myocardial infarction".


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## NomadicMedic (Dec 3, 2011)

Brandon Oto said:


> I have never seen a confirmed MI with a properly-done 12-lead ECG that is truly textbook normal, or at least 100% unchanged from the patient's baseline.



How often do prehospital providers in your area see a baseline 12 lead for comparison to the one obtained in the field?


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## Shishkabob (Dec 3, 2011)

Good... I'm not the only one with this reasoning.



Sad part is I can't really refute it without coming off as a knowitall new employee.  Meh.


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## Dwindlin (Dec 3, 2011)

In my limited time off I volunteer with a FD based system and I too have had some issues with my QA/QI officer dinging me for not doing some really archaic things.  While I die a bit inside every time I do them, I decided when I started it just isn't worth the headache to argue with him.


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## Shishkabob (Dec 3, 2011)

Dwindlin said:


> In my limited time off I volunteer with a FD based system and I too have had some issues with my QA/QI officer dinging me for not doing some really archaic things.  While I die a bit inside every time I do them, I decided when I started it just isn't worth the headache to argue with him.



And that's the decision I came to during my FTO period... but it was already too late and it's bit me.  



Thing is, this is a progressive system with a fairly robust QA/QI group and direct involvement with the MDs who are very evidence-based medicine... but alas...


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## DV_EMT (Dec 3, 2011)

usafmedic45 said:


> Seriously, if you're going to get into a debate on here, about the last two people you want to do it with are Smash and DV EMT.  Even I stop and think before wading into that.  Good luck man.



Thanks, I take that as a compliment


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## Brandon O (Dec 3, 2011)

usafmedic45 said:


> Hence the term "non-ST elevation myocardial infarction".



Yeah... but I find it to be less than useful terminology at times. What we really care about isn't whether there's ST elevation or not; what we care about is the severity and risk of the occlusion. That's why lots of NSTEMIs still get cathed.

So prehospitally, is there an acute occlusion causing injury? (STEMI or NSTEMI, really either way? Even UA that may deteriorate?) Or is there, well, anything else? (Baseline cardiac changes on the ECG, a non-cardiac event, an acute but non-ischemic cardiac event, etc.) If this is the decision you're trying to make, you can apply a pretty broad ischemia-minded filter, place the results in their clinical context, and otherwise forget about the labels. At least IMO.


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## themooingdawg (Dec 11, 2011)

DV_EMT said:


> Uh, yes it does
> 
> 
> 
> ...



here is the problem, you have the mentality that just because you think its one thing, you shouldn't treat it as is, but the thing is, you're not out there to diagnose anything. If somebody, after questioning, still states chest pain, even if they have pain on palpation/inspiration, etc, you're more than likely going to give nitro than to not give it, because the point is you're still treating the chest PAIN, not trying to diagnose out in the field. Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because  i think its pleuritic.... yeah, but the pt still has pain. and btw, where do you know that gives fibrinolytics out in the field prior to a ct scan to confirm stroke?


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## themooingdawg (Dec 11, 2011)

maybe you can call base and see how they feel about you not wanting to give ASA/nitro, but i highly doubt any base is going to say withhold on everything if the pt states there is pain


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## themooingdawg (Dec 11, 2011)

but then again, it all goes down to where you're working at, protocols, and who your micns are


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## triemal04 (Dec 11, 2011)

themooingdawg said:


> here is the problem, you have the mentality that just because you think its one thing, you shouldn't treat it as is, but the thing is, you're not out there to diagnose anything. If somebody, after questioning, still states chest pain, even if they have pain on palpation/inspiration, etc, you're more than likely going to give nitro than to not give it, because the point is you're still treating the chest PAIN, not trying to diagnose out in the field. Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because  i think its pleuritic.... yeah, but the pt still has pain. and btw, where do you know that gives fibrinolytics out in the field prior to a ct scan to confirm stroke?


Thank you for illustrating in a nice, concise way exactly what is wrong with EMS in this country.  It is much appreciated.

And if I bring in someone with non-cardiac chest pain, 1-it won't be me that's talking to the ER staff, exept in rare cirumstances, and 2-the responce to not giving ntg or aspirin would be, "ok," followed by...nobody giving ntg or aspirin for quite some time, if at all.

I'll pass over the "we don't diagnose" BS.  But, I do want to just be sure that what you are saying is that everyone who complains of chest pain, no matter the cause, get's ntg and aspirin without any thinking on the providers part.  Which would include that 25 year old with a rib fracture, or anyone else with chest trauma.  I mean, if you aren't going to think, then that is what you should be doing.


themooingdawg said:


> maybe you can call base and see how they feel about you not wanting to give ASA/nitro, but i highly doubt any base is going to say withhold on everything if the pt states there is pain


Well, neither I or anyone I work with (which includes EMT-Basic's) would be calling in to give ntg or apirin, or to withhold it.  And I can gaurentee that even if someone did, the answer would be "ok, don't give it."  That would be the glory of working in a system that requires the providers to not only think, but think independently.


themooingdawg said:


> but then again, it all goes down to where you're working at, protocols, and who your micns are


I don't answer to a nurse, but, in the long term, to my medical director, and in the short term to the recieving ER doctor.  Again, the glory of working in a halfway decent system.

You are right though, not everybody is this lucky, some are stuck in a worthless system.  But even in those places, there is no requirement that you can't use a little bit of your brain, educate yourself beyond what you were taught in class, and apply that in the field.  Blindly following protocol when you KNOW it is wrong without even trying is ridiculous.  And using the fallback of "well, they won't let me do it and I'll look stupid if I ask" is truly stupid.  

How about this, next time you have someone with right sided chest pain that increases on inspiration, a low grade fever, productive cough with green/yellow thick sputum and maybe some rhonchi, call, CLEARLY EXPLAIN what is happening, and then don't even ask to give ntg or aspirin.  Bet you don't get questioned.


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## usalsfyre (Dec 11, 2011)

So much fail to address...


themooingdawg said:


> but the thing is, you're not out there to diagnose anything





themooingdawg said:


> because the point is you're still treating the chest PAIN, not trying to diagnose out in the field.


The protocols I work under specifically state they are diagnostically based. If your giving drugs you better darn well be making a diagnosis, even if a nutless instructor clings to this, it's not true.



themooingdawg said:


> Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because  i think its pleuritic.... yeah, but the pt still has pain.


I'll be looked at like an idiot (or a certain large FD medic) if I gave NTG and ASA to that patient. How about an NSAID or narcotic for the muscoskeletal pain instead of NTG which is not going to come close to helping.



themooingdawg said:


> maybe you can call base and see how they feel about you not wanting to give ASA/nitro, but i highly doubt any base is going to say withhold on everything if the pt states there is pain


Right, let's punt the decision off. I'd say "follow your protocol" too.



themooingdawg said:


> but then again, it all goes down to where you're working at, protocols, and who your micns are


The majority of paramedics in the US don't take orders from mere nurses (putting on my asbestos undies for that one)


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## themooingdawg (Dec 11, 2011)

i dont disagree with you guys with the fact that if its obvious pleuritic cp or traumatic chest pain that giving asa or nitro obviously will not do anything, thats why i said "after a thorough assessment" obviously traumatic chest pains has no need for any medications, same with pleuritic, but, the thing is I'm going to let base, at least with us in la county, know whats going on with the pt and let them guide it and see if they want to administer. outside of trauma related cp, if its cp with a medical origin, I'm not going to withhold medications that i think might help the pt just because i think its so and so. and what happens if we get in the ER, i say i didn't give anything because i had thought it was so and so, and then there is something underlying wrong with the pt? its not a great system, but unfortunately paramedics in la county are severely protocol driven


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## themooingdawg (Dec 11, 2011)

we don't have as much freedom as most other ems systems unfortunately


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## themooingdawg (Dec 11, 2011)

triemal04 said:


> Thank you for illustrating in a nice, concise way exactly what is wrong with EMS in this country.  It is much appreciated.
> 
> And if I bring in someone with non-cardiac chest pain, 1-it won't be me that's talking to the ER staff, exept in rare cirumstances, and 2-the responce to not giving ntg or aspirin would be, "ok," followed by...nobody giving ntg or aspirin for quite some time, if at all.
> 
> ...



when i say cp, i mean cp with medical in origin, not cp due to some form of trauma


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## triemal04 (Dec 11, 2011)

themooingdawg said:


> i dont disagree with you guys with the fact that *if its obvious pleuritic cp or traumatic chest pain that giving asa or nitro obviously will not do anything*, thats why i said "after a thorough assessment" *obviously traumatic chest pains has no need for any medications, same with pleuritic*, but, the thing is *I'm going to let base, at least with us in la county, know whats going on with the pt and let them guide it and see if they want to administer*. outside of trauma related cp,* if its cp with a medical origin, I'm not going to withhold medications that i think might help the pt just because i think its so and so.* and what happens if we get in the ER, i say i didn't give anything because i had thought it was so and so, and then there is something underlying wrong with the pt? its not a great system, but unfortunately paramedics in la county are severely protocol driven


Well, you do work in hell I guess, so I could make some allowances for you...but...no.

You rather contradicted yourself above, you know that?  You know that ntg/aspirin will not help in non-cardiac chest pain...but you'll still give it anyway, or in the most cop-out kind of way, let someone else make your decision for you.  Cheers to you friend, thanks for helping to make EMS what it is today.

I understand that you work in a lousy place and that to a certain extent your hands are tied, so at least some of this you can't do anything about and it isn't your fault.  But the bolded parts of your above statement...come on, you should be striving to be a much better provider than that makes you appear.  Your hands may be a bit tied, but you can at least try and do what's right for your patients and think for yourself.

Seriously, next time you have a patient who has chest pain that is not cardiac, do what I suggested, report in detail what you have and then DON'T ASK for ntg/apirin.  If they order you to give it anyway...sucks, but at that point it no longer is your fault, you did what you could.  If they don't...congrats you just took your first step in becoming a better provider.

As far as liability...educate yourself.  Learn how to do a real, detailed, thorough exam, learn how to read a 12lead for yourself, not just the monitors interpretation and you'll be ahead of the pack.  At that point, if you are questioned on why you did/didn't do something, you can explain that because of A, B, C, and D, your assessment was E, which meant that F wasn't needed.

And, at some point, you will be wrong.  It'll happen,  But, contrary to what you see on TV and may have learned in school, delaying ntg and aspirin for a relatively short amount of time in someone having a subacute event is not going to kill them or generally even cause a poor outcome.  If you can, hang out in an ER sometime and watch how long most people who come in complaining of chest pain go before they get treated.  You'll probably be surprised.


themooingdawg said:


> when i say cp, i mean cp with medical in origin, not cp due to some form of trauma


No.  If you are going to be a mindless protocol monkey, then be a mindless protocol monkey.  If you can't tell what is cardiac and not cardiac chest pain, then you can't tell what is traumatic chest pain either.  Who's to say that nice 65 year old diabetic who fell, hit his chest on the arm of a chair and is now having right sided pain that increases on palpation and inspiration is not having atypical cardiac chest pain?  I mean, who could tell in that case, right?


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## STXmedic (Dec 11, 2011)

themooingdawg said:


> here is the problem, you have the mentality that just because you think its one thing, you shouldn't treat it as is, but the thing is, you're not out there to diagnose anything. If somebody, after questioning, still states chest pain, even if they have pain on palpation/inspiration, etc, you're more than likely going to give nitro than to not give it, because the point is you're still treating the chest PAIN, not trying to diagnose out in the field. Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because  i think its pleuritic.... yeah, but the pt still has pain. and btw, where do you know that gives fibrinolytics out in the field prior to a ct scan to confirm stroke?



I don't know whether to LMAO or SMH :unsure: As usals stated, so much fail... I may address later, too much to type to do it on the phone.


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