# Medical interventions on scene



## billycorgi (Jul 23, 2013)

Hello,

I am  relatively new to the EMT scene in Alberta.  I had a question regarding medications and on scene delivery.  If a patient needs a medical intervention say nitro for chest pain or epi for anaphalaxis or salbutamol for SOB, would an EMT provide the medical intervention on scene along with vitals, AMPLE, and an IV or would you wait until you are in back of the ambulance like school teaches in scenarios?  Any info would be great!


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## TransportJockey (Jul 23, 2013)

Depends. Where I work with 30-90 minute transports, pretty much everything gets done en route to the facility unless its something that is immediate life threats like a chest dart or airway. If I was urban I'd start treatment on scene and continue en route 


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## Anjel (Jul 23, 2013)

We have 3-5 minute transport times so everything is usually done on scene. Med pushed not so much, but IV, 12 lead, stuff like that. There are 4 of us in scene so while someone is doing the IV, one is doing a 12 lead, and the other getting meds ready. 


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## billycorgi (Jul 23, 2013)

so there would be nothing wrong with doing vitals/IV/AMPLE along with a shot of nitro on scene with a cardiac chest pain as long as it is done within 10 mins on scene with a load and go


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## hogdweeb (Jul 23, 2013)

in my area, it depends. We have nursing homes within 5 minutes of the hospital, amongst 95% of our calls in that same area. Have a little more time to stay and play, if we can afford it. We also have runs that are easy half an hour away. Thos we just load and go, everything we need to do can be done in that time. If it is anaphlyaxis, there is absolutely no reason to withhold epi so long as systolic BP is >100 and patient is in fact in anaphlyaxis.


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## Medic Tim (Jul 23, 2013)

billycorgi said:


> Hello,
> 
> I am  relatively new to the EMT scene in Alberta.  I had a question regarding medications and on scene delivery.  If a patient needs a medical intervention say nitro for chest pain or epi for anaphalaxis or salbutamol for SOB, would an EMT provide the medical intervention on scene along with vitals, AMPLE, and an IV or would you wait until you are in back of the ambulance like school teaches in scenarios?  Any info would be great!



Assessment and treatment of these pts usually starts on scene and then leads to the truck. For cardiac my partner gets a 12 and vitals while I do an assessment/ history. Will start Asa and nitro on scene and from there it depends how serious the pt is and how far we have to go.

Just because these pts may be labeled load and go.... Take it easy driving. It can be hard to do things in the back when you are being thrown around. It also adds a lot of unnessisary anxiety to the pt. 

Smooth is fast.


Welcome to emtlife


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## billycorgi (Jul 23, 2013)

Thanks Medic Tim!

I assume that an IV would be established on scene as well before the nitro is given regardless of what the systolic BP states? Or could you give the nitro without the IV as long as the systolic reading is above 100? Would it be better to wait to establish an IV in the ambulance or would your partner be all over that on scene as he or she is doiing vitals and ECG etc?


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## Medic Tim (Jul 23, 2013)

billycorgi said:


> Thanks Medic Tim!
> 
> I assume that an IV would be established on scene as well before the nitro is given regardless of what the systolic BP states? Or could you give the nitro without the IV as long as the systolic reading is above 100? Would it be better to wait to establish an IV in the ambulance or would your partner be all over that on scene as he or she is doiing vitals and ECG etc?



The cut off for nitro in AB is a sys of 90 and per policy I believe we are required to have IV access prior to its administration(though I am not sure)

As for who does the IV, It depends on my partner, the pt and what the scene is like. 

After some time you will develop a rhythm or flow to your assessments and they will get easier.


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## errey (Jul 23, 2013)

billycorgi said:


> Thanks Medic Tim!
> 
> I assume that an IV would be established on scene as well before the nitro is given regardless of what the systolic BP states? Or could you give the nitro without the IV as long as the systolic reading is above 100? Would it be better to wait to establish an IV in the ambulance or would your partner be all over that on scene as he or she is doiing vitals and ECG etc?



Always get the IV done before nitro, you could possibly tank their pressure


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## chaz90 (Jul 23, 2013)

errey said:


> Always get the IV done before nitro, you could possibly tank their pressure



Always is a strong word. Thousands of people take NTG daily without "tanking their pressure." Just something to think about.


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## EpiEMS (Jul 23, 2013)

Assessment and immediate life threats on scene. If it's not a "load-and-go," do as much on scene as need be, no?


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## rmabrey (Jul 23, 2013)

I've yet to see a nitro tank anyones pressure.  But when in doubt CYA


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## Medic Tim (Jul 23, 2013)

to add to my previous post.
After ruling out RVI, If the pt has taken nitro before and they have a decent pressure....I am not to worried about getting the IV first.

people take nitro their own nitro all the time without checking their pressure.


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## Mariemt (Jul 23, 2013)

Chest pain with no allergies to aspirin and if they aren't on any kind of blood thinners I'll give aspirin and maybe nitro depending on their pressure. Protocol says I have to check pressure first. I would give that on scene . 
Vitals on scene as long as we are fast and can do it in our time window . I will out the leads on and get them sent ahead.  
History as we go. Load blah blah blah.


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## Mariemt (Jul 23, 2013)

rmabrey said:


> I've yet to see a nitro tank anyones pressure.  But when in doubt CYA



Yet is the key word. Be careful of the patient not admitting to Viagra use in front of his girlfriend etc.


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## Mariemt (Jul 23, 2013)

billycorgi said:


> Hello,
> 
> I am  relatively new to the EMT scene in Alberta.  I had a question regarding medications and on scene delivery.  If a patient needs a medical intervention say nitro for chest pain or epi for anaphalaxis or salbutamol for SOB, would an EMT provide the medical intervention on scene along with vitals, AMPLE, and an IV or would you wait until you are in back of the ambulance like school teaches in scenarios?  Any info would be great!


Our epi pens are in our jump bag and no I wouldn't wait to give that in the back. If they are needing it now, its time to give it now. 
Aspirin, nitro , glucose etc I give on scene.  Quicker the better. 

If it is a load and go I will get the rest in the ambulance.  Why wait to give something the patient needs while loading etc?


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## broken stretcher (Jul 23, 2013)

short of an arrest, i do absolutely nothing in the house... 
1) you can wait the 3 minutes it takes to load into the truck
2) have you seen the houses i go into when i work? you wouldn't wanna stay there either.
3) my truck is my sanctuary. i can set up everything how i want it where i want it. its a controlled environment (sometimes :rofl: ) 
4. the longer I'm in the house, the more likely something can go wrong. 


get in, get out, go


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## NomadicMedic (Jul 23, 2013)

Depending on how long it takes for the ambulance to get on scene. I'll do stuff in the house. Always the Priority One "if I don't do it now, they're gonna die" stuff or maybe some pain management and zofran if it'll make moving the patient more comfortable. 

However, I also have been in my share of nasty houses and I'm not above having a relatively stable patient come outside and sit on the porch for treatment while I wait for the ambulance, so I don't get marinated in cigarette smoke or covered with roaches. 

I also like to get a 12 lead early in any chest pain call, so I may elect to do that before we leave. 

It all depends on my mood, the severity of the patient, how close I am to the hospital and how nasty the house is.


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## Mariemt (Jul 23, 2013)

broken stretcher said:


> short of an arrest, i do absolutely nothing in the house...
> 1) you can wait the 3 minutes it takes to load into the truck
> 2) have you seen the houses i go into when i work? you wouldn't wanna stay there either.
> 3) my truck is my sanctuary. i can set up everything how i want it where i want it. its a controlled environment (sometimes :rofl: )
> ...


Um, I do a lot more than just CPR in the house. I can't make a patient having an asthma attack wait 3 minutes. I won't move the patient with a broken pelvis or hip/femur without splinting. 
3 minutes is a long time for certain conditions. 
A lot of calls, yeah I wait too, but I have had my share where I just couldn't make my patient wait. I put up with the smoke, the dog poop smell etc. I felt I had to treat in the house for their best interest.


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## DesertMedic66 (Jul 23, 2013)

There is no standard way. A lot of it depends on the call. The medics that I work with will get at least a set of vitals inside the house (12 lead if a CP call). If the patient doesn't need medication or treatments right away then we will load up inside of the ambulance and do everything there. 

If the patient needs a treatment immediately then we do what ever we have to do inside the house. 

Heck I've have 2 calls where we spent 45 minutes inside the ambulance with a patient and have them AMA.


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## broken stretcher (Jul 23, 2013)

ok maybe i was a little harsh, ill splint and if I'm in a good mood and you really could use it ill give you some O's while my partner straps you in to the stretcher


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## Mariemt (Jul 23, 2013)

broken stretcher said:


> ok maybe i was a little harsh, ill splint and if I'm in a good mood and you really could use it ill give you some O's while my partner straps you in to the stretcher



OK almost sounds obscene lol.

How about epi pen? Albuteral inhaler assist? Bgl levels?  

I will do about anything in the home if the person is really in distress. I would prefer to get to the ambulance if I need to


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## chaz90 (Jul 23, 2013)

broken stretcher said:


> ok maybe i was a little harsh, ill splint and if I'm in a good mood and you really could use it ill give you some O's while my partner straps you in to the stretcher



How about hypoglycemic patients that turn into refusals 9/10 times? They're grouchy when woken up en-route to the hospital for a visit they don't need. If you're BLS, this still applies for oral glucose.


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## medic741 (Jul 27, 2013)

Mariemt said:


> Chest pain with no allergies to aspirin and if they aren't on any kind of blood thinners I'll give aspirin and maybe nitro depending on their pressure. Protocol says I have to check pressure first. I would give that on scene .
> Vitals on scene as long as we are fast and can do it in our time window . I will out the leads on and get them sent ahead.
> History as we go. Load blah blah blah.



My understanding is that ASA is safe to give with pt's on blood thinners as a one time administration. What I've read (correct me if I'm wrong) is that the ASA causes the Cuomadin (or other blood thinner) to become unbound and cause massive decrease in your pt's coagulability.  Pt's on blood thinners are told not to take ASA for this reason but during a cardiac event my understanding is that this is a safe tx. Thoughts?

Matt


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## abckidsmom (Jul 27, 2013)

medic741 said:


> My understanding is that ASA is safe to give with pt's on blood thinners as a one time administration. What I've read (correct me if I'm wrong) is that the ASA causes the Cuomadin (or other blood thinner) to become unbound and cause massive decrease in your pt's coagulability.  Pt's on blood thinners are told not to take ASA for this reason but during a cardiac event my understanding is that this is a safe tx. Thoughts?
> 
> Matt



Aspiring makes the platelets less sticky.  Less sticky platelets make clots less likely to form in areas with limited flow (like blocked coronary arteries).  Platelets are the first step in a long, complex cascade of events that lead to a strong clot.

Coumadin blocks another step, much further down that cascade.  

Patients on blood thinners with a high risk of coronary artery blockage aren't typically told not to take aspirin.  It's really personally driven, knowing that aspirin is a major preventer of clot formation in coronary arteries.


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## Mariemt (Jul 27, 2013)

abckidsmom said:


> Aspiring makes the platelets less sticky.  Less sticky platelets make clots less likely to form in areas with limited flow (like blocked coronary arteries).  Platelets are the first step in a long, complex cascade of events that lead to a strong clot.
> 
> Coumadin blocks another step, much further down that cascade.
> 
> Patients on blood thinners with a high risk of coronary artery blockage aren't typically told not to take aspirin.  It's really personally driven, knowing that aspirin is a major preventer of clot formation in coronary arteries.



If a person is on blood thinners already and has not already taken aspirin , I will call ahead if it is a longer transport. We are within 3 minutes usually,  but I have given it before. Its just some thing I was taught.


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## Carlos Danger (Jul 27, 2013)

medic741 said:


> My understanding is that ASA is safe to give with pt's on blood thinners as a one time administration. What I've read (correct me if I'm wrong) is that the *ASA causes the Cuomadin (or other blood thinner) to become unbound and cause massive decrease in your pt's coagulability*.  Pt's on blood thinners are told not to take ASA for this reason but during a cardiac event my understanding is that this is a safe tx. Thoughts?
> 
> Matt



That is interesting. Do you have a reference?

Warfarin and aspirin are both highly protein bound (>95%, IIRC), so if aspirin were to have a much greater affinity for the plasma protein binding sites than does warfarin, the bound warfarin would be displaced from the proteins, the free fraction of drug would be increased, and the net result would essentially be the same as giving a large bolus of warfarin.

That said, I've never heard of warfarin being an absolute contraindication to aspirin, and I've always assumed that the danger of co-administration was related more to syngergistic anticoagulant effects than any direct or indirect interaction between the drugs.


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## medic741 (Jul 27, 2013)

Halothane said:


> That is interesting. Do you have a reference?
> 
> Warfarin and aspirin are both highly protein bound (>95%, IIRC), so if aspirin were to have a much greater affinity for the plasma protein binding sites than does warfarin, the bound warfarin would be displaced from the proteins, the free fraction of drug would be increased, and the net result would essentially be the same as giving a large bolus of warfarin.
> 
> That said, I've never heard of warfarin being an absolute contraindication to aspirin, and I've always assumed that the danger of co-administration was related more to syngergistic anticoagulant effects than any direct or indirect interaction between the drugs.



My paramedic instructor mentioned this, one of the many things that I have no idea how she knows without having an MD... her lectures would go along the lines of "if the atmospheric pressure of Oxygen is 20.95%..." anyhow after some digging here's an article I came up with


"Medications such as aspirin and the NSAIDs, and high doses of penicillin and moxalactam can increase the risk of warfarin related bleeding by inhibiting platelet function. Aspirin posses the most significant risk due to its common use and its prolonged effect on platelets. The proposed mechanism of interaction involves the possibility that salicylates displace warfarin from plasma protein-binding sites. However, the transient nature of the interaction make the significance of this mechanism questionable as compared to aspirin's intrinsic effect on platelets. Aspirin and NSAIDs can also produce gastric erosions that increase the risk of serious upper gastrointestinal bleeding. Some of the available NSAIDs may have a lesser effect on coagulation than aspirin."

https://secure.pharmacytimes.com/lessons/200301-01.asp

Seems that the ASA has a higher affinity and displaces the Cuomadin, so in effect you are 'giving your pt' a bolus of anticoagulant AND causing the inhibitory A2 thromboxane effects intrinsic in the ASA... just how I remember it, think it might hold some merit?

Matt


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## Carlos Danger (Jul 27, 2013)

medic741 said:


> My paramedic instructor mentioned this, one of the many things that I have no idea how she knows without having an MD... her lectures would go along the lines of "if the atmospheric pressure of Oxygen is 20.95%..." anyhow after some digging here's an article I came up with
> 
> 
> "Medications such as aspirin and the NSAIDs, and high doses of penicillin and moxalactam can increase the risk of warfarin related bleeding by inhibiting platelet function. Aspirin posses the most significant risk due to its common use and its prolonged effect on platelets. The proposed mechanism of interaction involves the possibility that salicylates displace warfarin from plasma protein-binding sites. However, the transient nature of the interaction make the significance of this mechanism questionable as compared to aspirin's intrinsic effect on platelets. Aspirin and NSAIDs can also produce gastric erosions that increase the risk of serious upper gastrointestinal bleeding. Some of the available NSAIDs may have a lesser effect on coagulation than aspirin."
> ...



Well, I'm no pharmacist myself, so I just go by what I read. It sounds from this like the displacement of warfarin is a transient and likely minor effect. I have to review anticoagulants over the next couple weeks so I'll keep this in mind and see if I come across anything about it in my texts.

Good find.


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## Christopher (Jul 29, 2013)

Halothane said:


> Well, I'm no pharmacist myself, so I just go by what I read. It sounds from this like the displacement of warfarin is a transient and likely minor effect. I have to review anticoagulants over the next couple weeks so I'll keep this in mind and see if I come across anything about it in my texts.
> 
> Good find.



I'll add Dr. John Mandrola's take on this (if you don't read his stuff, it'd be worth checking out):


			
				DrJohnM said:
			
		

> My take home
> 
> Combining warfarin and aspirin increases the risk of bleeding. A review of the evidence reveals scant few groups of patients that enjoy a net clinical benefit from the combination. In patients with mechanical valves, acute coronary syndrome and recent coronary stents, the benefit (embolic prevention) seems to outweigh the burden (bleeding).
> 
> ...


This isn't a peer review article, but a practical look at the clinical implication of ASA + anticoagulants (both classical and novel).


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## unleashedfury (Aug 23, 2013)

On Topic. 

Its a variable situation. If the patient appears to be in little to no distress. They can wait to get to the buggy. If they are in need of immidiate life saving interventions based on my primary assesment. Its do what we can to get them stable, and roll. OTOH there are things that was mentioned earlier that can be non life threatening and beneficial. I.E. splinting a broken extremitiy before movement, using a antiemetic for the nauseated pt. 

Its really a situation based question. where some would say meh you got time do your thing here. Others will say lets just get rolling we'll get what we can along the way. My transport times at my primary service is about 5 minutes from most locations. So to spend a tremondous amount of time on scene is not for me. My general theory is what can't be done here the hospital can get done there. So usually I do a quick assesment triage my patient on scene. and go, as far as 12 lead monitoring goes. Yes its better to get a good capture in a house or parked outside before rolling to avoid excessive artifiact. 

So the the OP. if your still new, develop your own rapport and run with it. it comes down to what makes you most comfortable, without causing damage or fear to your patient.


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