# Did i mess up will.i get fired



## chickj0434 (Nov 15, 2016)

So als triaged us a call for a fall pt. 88 year old female. fell in the bathroom had bruising swellong on her left eye. shes on blood thinners. we get her in our truck. find out from her she fell due to 10 out of 10 chest pain. vitals all normal. shes complainong of the chest pain on her left side. i gave her 324 mg of aspiring she said it helped a little. now how much of a dumbass was i to give aspiring to an elderly woman on blood thinners.  once we got to the hospital she saod the pain was more on her side so looks like its prob muscular and not even cardiac related. no history of heart problems but been complainong of this chest pain for weeks but it was real bad tiday she said.


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## Qulevrius (Nov 15, 2016)

Bigbadwolf25 said:


> now how much of a dumbass was i to give aspiring to an elderly woman on blood thinners



<-------------------------------------------------------------------------------------------- that much -------------------------------------------------------------------------------------------->

But not as much as your medics, who turfed the call to people who treat a geriatric pt, s/p unwitnessed fall, with normal vitals, as a cardiac emergency.


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## chickj0434 (Nov 15, 2016)

So how much trouble am k gonna get in


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## Qulevrius (Nov 15, 2016)

You're already in trouble, mate. And its name is 'utter incompetence'. Have you ever considered that 'getting in trouble' for failing to make the right assessment and going on with a wrong treatment, should be the least of your worries ?


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## chickj0434 (Nov 15, 2016)

How bad does it affect the pt


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## chickj0434 (Nov 15, 2016)

Pt was on plavix and atorvastin


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## StCEMT (Nov 15, 2016)

This has to be some less funny version of punkd....


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## chickj0434 (Nov 15, 2016)

Can someone explain why. als told us she slipped. she said 10 out of 10 chest pain radiating down left arm so i thought the aspirin would do more good then harm.


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## Qulevrius (Nov 15, 2016)

Bigbadwolf25 said:


> Can someone explain why. als told us she slipped. she said 10 out of 10 chest pain radiating down left arm so i thought the aspirin would do more good then harm.



Explain what, why you won the Darwin Award, again ?


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## chickj0434 (Nov 15, 2016)

Qulevrius said:


> Explain what, why you won the Darwin Award, again ?



As to why it was so bad giving someone woth 10 out of 10 chest pain aspirin


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## NysEms2117 (Nov 15, 2016)

because.


Bigbadwolf25 said:


> shes on blood thinners.


and your not a doctor. and any EMT-B school ever has this as ground rule #1. you also made no mention of MC.


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## chickj0434 (Nov 15, 2016)

NysEms2117 said:


> because.
> 
> and your not a doctor. and any EMT-B school ever has this as ground rule #1. you also made no mention of MC.



We were taught thats not a contradicition but just something to be aware of.


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## Qulevrius (Nov 15, 2016)

Bigbadwolf25 said:


> We were taught thats not a contradicition but just something to be aware of.



Well, aside from the fact that your 88 y.o. pt had a fall, has a black eye as a result and complains of a sharp (CARDIAC-UNRELATED) pain - which is, rather safe to assume, trauma-symptomatic, and who's ALREADY taking antiplatelets ? You just gave her some more, thus significantly increasing the chances of internal bleeding.

You Mum's little genius you.


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## chickj0434 (Nov 15, 2016)

Qulevrius said:


> Well, aside from the fact that your 88 y.o. pt had a fall, has a black eye as a result and complains of a sharp (CARDIAC-UNRELATED) pain - which is, rather safe to assume, trauma-symptomatic, and who's ALREADY taking antiplatelets ? You just gave her some more, thus significantly increasing the chances of internal bleeding.
> 
> You Mum's little genius you.



So should i just be ready to get fired then


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## CALEMT (Nov 15, 2016)

You ignored like the one contraindication of aspirin. Big no-no, you gave a drug when it wasn't indicated. I'm starting to think with your posting history that you're not really cut out for this.


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## StCEMT (Nov 15, 2016)

I've been questioning if these are actually even serious.


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## chickj0434 (Nov 15, 2016)

CALEMT said:


> You ignored like the one contraindication of aspirin. Big no-no, you gave a drug when it wasn't indicated. I'm starting to think with your posting history that you're not really cut out for this.



Well guess thats that. guess ill just wait for them to call me in and fire me


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## Qulevrius (Nov 15, 2016)

StCEMT said:


> I've been questioning if these are actually even serious.



If it's a smurf, it isn't funny. And if it isn't, the level of stupid is overwhelming.


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## chickj0434 (Nov 15, 2016)

Coumadin and aspirin do two different things. of you look at any medical artlicle it says a patient on coumadin is not a contradiction to give aspirin. the chest pain was before the fall the reason she fell so i thought id play it safe and give aspirin


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## CALEMT (Nov 15, 2016)

Bigbadwolf25 said:


> Coumadin and aspirin do two different things. of you look at any medical artlicle it says a patient on coumadin is not a contradiction to give aspirin. the chest pain was before the fall the reason she fell so i thought id play it safe and give aspirin



A blood thinner is a blood thinner is a blood thinner. While yes they do different things you think of it for a bit. You have a blood thinner to a 88 yo fall that's already on blood thinners. What's wrong with this picture. If you can't think of a answer then I'm sorry. You're going to severely injure or kill someone some day.


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## akflightmedic (Nov 15, 2016)

I am still in awe that this was turfed to a BLS crew....lazy *** medics for sure.


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## chickj0434 (Nov 15, 2016)

From my assessment she didnt seem to have any trauma other than just the bruising on the eye. had no complaints of pain besides the chest pain which wasnt due from the fall becasue she stated its what made her fall. i am very disapointed in myself and very upset with my descision. what kind of trouble can i be expected to get in for this


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## akflightmedic (Nov 15, 2016)

Your reply is so horrific, I am unsure if I should reply back and tell you everything wrong with what you just said.


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## chickj0434 (Nov 15, 2016)

akflightmedic said:


> Your reply is so horrific, I am unsure if I should reply back and tell you everything wrong with what you just said.



Pls do


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## NysEms2117 (Nov 15, 2016)

you should not be worried about what work will do to you... you should be worried about what you will do to a patient. Im not being overly critical or mean either. Just think about if this lady had an internal injury, you gave blood thinners, so now no OR. go back REVIEW your material, and have that count as your "punishment"


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## chickj0434 (Nov 15, 2016)

NysEms2117 said:


> you should not be worried about what work will do to you... you should be worried about what you will do to a patient. Im not being overly critical or mean either. Just think about if this lady had an internal injury, you gave blood thinners, so now no OR. go back REVIEW your material, and have that count as your "punishment"



I agree. pretty much hate myself right now


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## VentMonkey (Nov 15, 2016)

Bigbadwolf25 said:


> I agree. pretty much hate myself right now


I love how honest people can be on this forum.

Op, slow down, talk to your supervisors about it if you haven't already. Be as forthcoming with them as you have been on here.

One last bit of advice: can I suggest you change you username?
@Bigbadworrywort25, or @Bigbadgermaphobe25

Ligthen up a little, bud, ok a lottle.


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## chickj0434 (Nov 15, 2016)

VentMonkey said:


> I love how honest people can be on this forum.
> 
> Op, slow down, talk to your supervisors about it if you haven't already. Be as forthcoming with them as you have been on here.
> 
> ...



So i should go see my supervisor and tell them? or should i just take ot as a learning mistake and see if i get called in.


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## VentMonkey (Nov 15, 2016)

Bigbadwolf25 said:


> So i should go see my supervisor and tell them? or should i just take ot as a learning mistake and see if i get called in.


If you're being serious and this isn't a troll pranking, then yes, be honest and perhaps remediation is all that will result. Best of luck...in life in general, laterz.


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## RocketMedic (Nov 15, 2016)

So, here's the reply from an honest EMS educator.

1) This is _not_ a basic patient. The timeline you report is suggestive of several acute pathologies, to include cardiac dysrhythmia, ischemia, infarct and a few other things that are not easily identifiable in a prehospital environment. 
2) You actually sound like you did a decent job of gathering a history, but your decision to use aspirin was ill-informed. Aspirin is an anti-platelet agent that impedes further clot formation to some degree. With a fall that caused bruising and other blood thinners already aboard, she is at an increased risk of suffering a head bleed from the fall; but on the flipside, there isn't much danger either in dropping in aspirin. It's not really going to matter one way or another.
3) This patient needs both a cardiac assessment and a trauma assessment. As stated, those medics are lazy, but you can't fix that. It's on _you_ to be a patient advocate and push this data forward to the receiving facility, especially the timeline reported.

As for you, you're not going to get fired unless you're a total goober. Use this as a learning opportunity and keep networking and asking these questions to get better.


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## medichopeful (Nov 15, 2016)

akflightmedic said:


> I am still in awe that this was turfed to a BLS crew....lazy *** medics for sure.



This ^


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## chickj0434 (Nov 15, 2016)

RocketMedic said:


> So, here's the reply from an honest EMS educator.
> 
> 1) This is _not_ a basic patient. The timeline you report is suggestive of several acute pathologies, to include cardiac dysrhythmia, ischemia, infarct and a few other things that are not easily identifiable in a prehospital environment.
> 2) You actually sound like you did a decent job of gathering a history, but your decision to use aspirin was ill-informed. Aspirin is an anti-platelet agent that impedes further clot formation to some degree. With a fall that caused bruising and other blood thinners already aboard, she is at an increased risk of suffering a head bleed from the fall; but on the flipside, there isn't much danger either in dropping in aspirin. It's not really going to matter one way or another.
> ...





RocketMedic said:


> So, here's the reply from an honest EMS educator.
> 
> 1) This is _not_ a basic patient. The timeline you report is suggestive of several acute pathologies, to include cardiac dysrhythmia, ischemia, infarct and a few other things that are not easily identifiable in a prehospital environment.
> 2) You actually sound like you did a decent job of gathering a history, but your decision to use aspirin was ill-informed. Aspirin is an anti-platelet agent that impedes further clot formation to some degree. With a fall that caused bruising and other blood thinners already aboard, she is at an increased risk of suffering a head bleed from the fall; but on the flipside, there isn't much danger either in dropping in aspirin. It's not really going to matter one way or another.
> ...




I know i will.never make this mistake again. so there isnt too much danger i put the patient in? she was a&ox3  seemed on good spirits just the chest pain. in the back before goving the aspirin i even googled because i thought you shouldnt but then i read articles saying it was fine so just a ****ty job on my end. we brought her to a major hospital on the city. what are the chances this gets back to me


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## medichopeful (Nov 15, 2016)

OP, you are right in that the patient may have been having a cardiac event.  The problem, though, is that there was a major contraindication to the ASA (potential head bleed, possibly other trauma).



Qulevrius said:


> <-------------------------------------------------------------------------------------------- that much -------------------------------------------------------------------------------------------->
> 
> But not as much as your medics, who turfed the call to people who treat a geriatric pt, s/p unwitnessed fall, with normal vitals, as a cardiac emergency.



Although we can all agree that the ASA was a bad call in this situation, keep in mind that many geriatric fall ARE due to a cardiac emergency.  In addition, you can have "normal" vitals while having a STEMI.  Just a thought.


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## Qulevrius (Nov 15, 2016)

medichopeful said:


> Although we can all agree that the ASA was a bad call in this situation, keep in mind that many geriatric fall ARE due to a cardiac emergency.  In addition, you can have "normal" vitals while having a STEMI.  Just a thought.



Of course. But based on the situation described, I personally would be more worried about an evident s/p fall *trauma* as my 1st priority, rather than a *possible* STEMI scenario. Especially since it's a BLS crew (yickes) turfed by ALS, whose 1st priority should've been sticking the leads on. Overall, this entire thing is just bad right, left and centre...


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## akflightmedic (Nov 15, 2016)

BigBadWolf....do you know WHY you gave Aspirin?

There is a lesson here. Please humor us and tell us why you give ASA to a Chest Pain patient...do not google. There is no shame here. Plenty of learning if you want it and are sincere.


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## AllGoode (Nov 15, 2016)

Flipping through your posting history, OP, I'm seeing some very telling symptoms of WorryWortitis. It's not an uncommon condition among new workers, and is fortunately often managed with a simple administration of job experience. If you find that experience isn't helping and it's affecting your day-to-day life or ability to work, consider sitting down with a therapist once a week for a while. My guess is that this job isn't the only aspect of your life that gives you anxiety, and it could be a huge load off of shoulders- yours, your partner's, and your patients' shoulders, that is.


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## EpiEMS (Nov 15, 2016)

Bigbadwolf25 said:


> From my assessment she didnt seem to have any trauma other than just the bruising on the eye. had no complaints of pain besides the chest pain which wasnt due from the fall becasue she stated its what made her fall. i am very disapointed in myself and very upset with my descision. what kind of trouble can i be expected to get in for this



For one, this is poor ALS management and delegation - I would suggest that in the future, you should refuse to accept such a patient from ALS, if at all possible. This patient needs an ALS assessment, because of the possible cardiac (among other possibilities) origin of the fall.

At a minimum, BLS care for this patient includes cervical motion restriction (more for protocol compliance than anything else), trending vital signs (HR, RR, BP, SpO2, hemorrhage control, an ice pack, and a nice warm blanket.

What made you think that this was an ACS patient?



RocketMedic said:


> This patient needs both a cardiac assessment and a trauma assessment. As stated, those medics are lazy, but you can't fix that. It's on _you_ to be a patient advocate and push this data forward to the receiving facility, especially the timeline reported.



This, this, this! Also, you should strongly consider refusing to take a patient you're not comfortable with - especially if you can identify a reason why you need an ALS assessment or intervention.


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## RocketMedic (Nov 15, 2016)

(Refusing to accept care from the medics, _*NOT*_ refusing to transport!)

In my system, this would be a "let's chat" with clinical for the medics. The aspirin onto a potential head bleed certainly isn't good, but isn't terrible either- it won't make a clinical difference.


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## EpiEMS (Nov 15, 2016)

RocketMedic said:


> (Refusing to accept care from the medics, _*NOT*_ refusing to transport!)



Yes, yes, absolutely - totally necessitates a transport (heck, I'd make sure QA/QI and my medical director were aware that medics dumped a clear ALS patient on me without doing a real assessment and went back in service).


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## MRE (Nov 16, 2016)

Just a point of interest - after reading this thread and seeing the vehement opposition to ASA for a patient on blood thinners, I couldn't remember that being a contraindication in my state.  I checked the MA protocols on ASA and found that the only contraindication listed is an active GI bleed. 

So by the numbers, a patient on blood thinners with suspected cardiac related chest pain would get 324mg of aspirin, so long as they didn't have a GI Bleed.  Sounds like we are an outlier here.


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## ERDoc (Nov 16, 2016)

W1IM said:


> Just a point of interest - after reading this thread and seeing the vehement opposition to ASA for a patient on blood thinners, I couldn't remember that being a contraindication in my state.  I checked the MA protocols on ASA and found that the only contraindication listed is an active GI bleed.
> 
> So by the numbers, a patient on blood thinners with suspected cardiac related chest pain would get 324mg of aspirin, so long as they didn't have a GI Bleed.  Sounds like we are an outlier here.



But common sense should tell you that someone who potentially has a head bleed and is at an increased risk of a head bleed shouldn't get something that would make bleeding worse.


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## StCEMT (Nov 16, 2016)

W1IM said:


> Just a point of interest - after reading this thread and seeing the vehement opposition to ASA for a patient on blood thinners, I couldn't remember that being a contraindication in my state.  I checked the MA protocols on ASA and found that the only contraindication listed is an active GI bleed.
> 
> So by the numbers, a patient on blood thinners with suspected cardiac related chest pain would get 324mg of aspirin, so long as they didn't have a GI Bleed.  Sounds like we are an outlier here.


Why would it be contraindicated for a GI bleed but not a potential head bleed in your area?


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## Qulevrius (Nov 16, 2016)

StCEMT said:


> Why would it be contraindicated for a GI bleed but not a potential head bleed in your area?



Because that's way too much information for poor lil Basics. After all, why consider MOI plus underlying conditions such as age, Hx and existing medications if you can just do it by the book ?


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## NysEms2117 (Nov 16, 2016)

Just thinking outloud here... As an EMT-B and EMS in general, it's a very logical process.. Somebody is bleeding stop the bleeding, not make the bleeding worse. If they can't breathe, we try to get them to breathe or breathe for them... we don't suffocate them. Giving anything that would thin the blood makes 0 sense in the EMS setting. Let the docs figure out what they want to do. AT A VERY MINIMUM call the doctors and ask. This logic must be present even if you disregard history(which you should not do for the record*)


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## chickj0434 (Nov 16, 2016)

ERDoc said:


> But common sense should tell you that someone who potentially has a head bleed and is at an increased risk of a head bleed shouldn't get something that would make bleeding worse.



I understand what everyone os saying. to me she did not seem to have a head bleed based on what i saw. she had no naseau, was alert and oriented wasnt stuttering or sluring words. she was all in all fine beside her grabbing her chest. gonna go back and review all the aspects of aspirin. i did not think that 4 baby aspirins would cause that much damage when her problem was her chest. but thats my fault. i was always taught that aspirin does not thin the blood but just makes it "slippery"


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## Bullets (Nov 16, 2016)

Couple of things

OP said the chest pain caused the fall. So that would be atraumatic pain. However, the contusion over her eye would be a contraindication based on NJ protocols:

Known hypersensitivity
325mg ASA taken in last 24 hours
Bleeding or active bleeding disorder
Pregnancy
Suspicion of thoracic or abdominal aortic aneurism
ASA is expired

Third, this is  a trauma patient in my system. Patient over 65 on blood thinners with evidence of head injury + bleeding gets a trauma activation


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## chickj0434 (Nov 16, 2016)

Bullets said:


> Couple of things
> 
> OP said the chest pain caused the fall. So that would be atraumatic pain. However, the contusion over her eye would be a contraindication based on NJ protocols:
> 
> ...



Very good points. i should of treated it as a trauma pt more then a chest pain pt. just to clarify pt was not bleeding though


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## Qulevrius (Nov 16, 2016)

Bullets said:


> Patient over 65 on blood thinners with evidence of head injury + bleeding gets a trauma activation



^ Exactly. And it doesn't take a genius to understand. Incidentally, what the pt says is but a fraction of what should be considered. Any assessment is MOI + Hx + evidence based, regardless of C/C. In this case, the MOI is a traumatic fall, based on medications the pt has Hx of cardiac-related issues (HTN + high cholesterol -> potential for atherosclerosis, ischemia, etc) and the evidence is in favour of a head trauma. What she's complaining about is relevant to a degree, but not in presence of an overwhelming traumatic evidence. Especially since she's stating a '10/10 chest pain' on her LEFT side, has a LEFT eye bruised and has normal vitals.



Bigbadwolf25 said:


> just to clarify pt was not bleeding though



I'm sorry, does your system provide you with X-ray eyes ?


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## MRE (Nov 16, 2016)

ERDoc said:


> But common sense should tell you that someone who potentially has a head bleed and is at an increased risk of a head bleed shouldn't get something that would make bleeding worse.



Sure, but the way the protocols are written, you would be doing something wrong.  It would be nice if they allowed you to use some common sense.



Qulevrius said:


> Because that's way too much information for poor lil Basics. After all, why consider MOI plus underlying conditions such as age, Hx and existing medications if you can just do it by the book ?



Could be.  Don't mistake my statement for deferring to the protocol rather than using my head.  My point is that its written poorly and in such a way that we aren't supposed to be using our heads.


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## Qulevrius (Nov 16, 2016)

W1IM said:


> Could be.  Don't mistake my statement for deferring to the protocol rather than using my head.  My point is that its written poorly and in such a way that we aren't supposed to be using our heads.



This is where I completely disagree. What's being taught in school and written in protocols are just guidelines for marginal scenarios, and have very little to do with everyday's reality. It's the same as adhering to a speed limit of 65 mph, regardless of road conditions and/or traffic situation, just because the signs say so. If healthcare providers don't use their heads, they're not just incompetent - they're dangerous.


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## StCEMT (Nov 16, 2016)

Qulevrius said:


> Because that's way too much information for poor lil Basics. After all, why consider MOI plus underlying conditions such as age, Hx and existing medications if you can just do it by the book ?


I mean, I am pretty sure even the books would say this is a no no...


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## Qulevrius (Nov 16, 2016)

StCEMT said:


> I mean, I am pretty sure even the books would say this is a no no...



I think we all know how well that works. Reading & education, that is.


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## medichopeful (Nov 16, 2016)

W1IM said:


> Just a point of interest - after reading this thread and seeing the vehement opposition to ASA for a patient on blood thinners, I couldn't remember that being a contraindication in my state.  I checked the MA protocols on ASA and found that the only contraindication listed is an active GI bleed.
> 
> So by the numbers, a patient on blood thinners with suspected cardiac related chest pain would get 324mg of aspirin, so long as they didn't have a GI Bleed.  Sounds like we are an outlier here.



Head bleed (or potential for same), though maybe not listed, is a contraindication to ASA as well.


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## Bullets (Nov 16, 2016)

Bigbadwolf25 said:


> Very good points. i should of treated it as a trauma pt more then a chest pain pt. just to clarify pt was not bleeding though





Bigbadwolf25 said:


> had bruising swellong on her left eye



Bruising = contusion
Contusion = hematoma
Hematoma = bleeding

If the fall imparted enough force to rupture blood vessels, do you know where that rupture stops?

http://geri-em.com/wp-content/uploa...alls-in-the-Elderly-from-EmergMedClin_413.pdf

http://www.beaumont.edu/press/news-...in-for-people-on-blood-thinners-saving-lives/


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## ERDoc (Nov 16, 2016)

Bigbadwolf25 said:


> Very good points. i should of treated it as a trauma pt more then a chest pain pt. just to clarify pt was not bleeding though



Here is the problem.  You are so protocol driven that you don't see the pt and only see the protocol.  Most pts don't fit a nice, neat box.  This isn't a chest pain pt and this isn't a trauma pt.  It is a pt who has had ongoing chest pain who fell and hit her head and happens to be on blood thinners.  Pts have multiple problems so you have to be able to think about your protocols and combine several of them to treat the pt.

I will agree with others, the medics are the real problem in this scenario.


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## Alan L Serve (Nov 17, 2016)

ASA is an _antiplatelet_, not an _anticoagulant_. 324/325mg of ASA isn't going to kill this PT. If you loaded her up with UFH which is an actual anticoagulant I'd be concerned for bleeding but you didn't do that. Even if you gave her ASA + Clopidogrel you'd only be accomplishing dual antiplatelet which isn't the worst.


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## ERDoc (Nov 17, 2016)

Alan L Serve said:


> ASA is an _antiplatelet_, not an _anticoagulant_. 324/325mg of ASA isn't going to kill this PT. If you loaded her up with UFH which is an actual anticoagulant I'd be concerned for bleeding but you didn't do that. Even if you gave her ASA + Clopidogrel you'd only be accomplishing dual antiplatelet which isn't the worst.



So are you saying that platelets aren't important for clotting?


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## medichopeful (Nov 17, 2016)

Alan L Serve said:


> ASA is an _antiplatelet_, not an _anticoagulant_. 324/325mg of ASA isn't going to kill this PT. If you loaded her up with UFH which is an actual anticoagulant I'd be concerned for bleeding but you didn't do that. Even if you gave her ASA + Clopidogrel you'd only be accomplishing dual antiplatelet which isn't the worst.



Wait what?


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## Qulevrius (Nov 17, 2016)

ERDoc said:


> So are you saying that platelets aren't important for clotting?





medichopeful said:


> Wait what?



He must've forgotten that antiplatelets are fibrinogen/ADP inhibitors.


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## CALEMT (Nov 17, 2016)

Qulevrius said:


> He must've forgotten that antiplatelets are fibrinogen/ADP inhibitors.



You don't know what you don't know.


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## Alan L Serve (Nov 17, 2016)

medichopeful said:


> Wait what?


What wait!


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## Alan L Serve (Nov 17, 2016)

ERDoc said:


> So are you saying that platelets aren't important for clotting?


Rather important for clotting. In fact I don't know how you'd clot without them, but ASA isn't going to cause internal bleeding like an anticoagulant will.


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## medichopeful (Nov 17, 2016)

Alan L Serve said:


> Rather important for clotting. In fact I don't know how you'd clot without them, but ASA isn't going to cause internal bleeding like an anticoagulant will.



In this scenario though we're talking about a patient who may potentially already have a head bleed (or a bleed somewhere else) related to her fall.  So while ASA may or may not cause internal bleeding, it certainly can make internal bleeding worse.


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## Summit (Nov 17, 2016)

ERDoc said:


> Here is the problem.  You are so protocol driven that you don't see the pt and only see the protocol.  Most pts don't fit a nice, neat box.  This isn't a chest pain pt and this isn't a trauma pt.  It is a pt who has had ongoing chest pain who fell and hit her head and happens to be on blood thinners.  Pts have multiple problems so you have to be able to think about your protocols and combine several of them to treat the pt.



Made me think of Hickam's Dictum.


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## ERDoc (Nov 17, 2016)

Summit said:


> Made me think of Hickam's Dictum.



That sounds dirty, but yes, it does.




Alan L Serve said:


> Rather important for clotting. In fact I don't know how you'd clot without them, but ASA isn't going to cause internal bleeding like an anticoagulant will.



I think you mean intracranial bleeding.  No, ASA won't cause the bleeding to start but hitting your head on the floor will.  Now that you're bleeding you need those platelets to stop it.


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## FLdoc2011 (Nov 19, 2016)

I won't re-hash some of what's been said here,  but was she on plavix or an actual anticoagulant such as coumadin, Pradaxa, eliquis, or xarelto?   

I agree in that preceding CP can be worrisome but an elderly fall with some head trauma is also worrisome and a very reasonable reason to document why something like ASA was withheld, at least until she can be seen in the ER where I'm sure a CT will be obtained.


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## medichopeful (Nov 19, 2016)

FLdoc2011 said:


> I won't re-hash some of what's been said here,  but was she on plavix or an actual anticoagulant such as coumadin, Pradaxa, eliquis, or xarelto?
> 
> I agree in that preceding CP can be worrisome but an elderly fall with some head trauma is also worrisome and a very reasonable reason to document why something like ASA was withheld, at least until she can be seen in the ER where I'm sure a CT will be obtained.



Plavix per the OP.


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## MackTheKnife (Nov 24, 2016)

chickj0434 said:


> So als triaged us a call for a fall pt. 88 year old female. fell in the bathroom had bruising swellong on her left eye. shes on blood thinners. we get her in our truck. find out from her she fell due to 10 out of 10 chest pain. vitals all normal. shes complainong of the chest pain on her left side. i gave her 324 mg of aspiring she said it helped a little. now how much of a dumbass was i to give aspiring to an elderly woman on blood thinners.  once we got to the hospital she saod the pain was more on her side so looks like its prob muscular and not even cardiac related. no history of heart problems but been complainong of this chest pain for weeks but it was real bad tiday she said.



You made a POTENTIAL medication error. However, pts are commonly on ASA and Plavix or Eliquis at the same time. ASA is not absolutely contraindicated and in this case, your treatment was probably appropriate. The ER might have given ASA as well upon arrival. Ignore those here that are blasting you.


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## MackTheKnife (Nov 24, 2016)

Qulevrius said:


> You're already in trouble, mate. And its name is 'utter incompetence'. Have you ever considered that 'getting in trouble' for failing to make the right assessment and going on with a wrong treatment, should be the least of your worries ?



Seriously? "Utter incompetence"? You are wrong. ASA and Plavix are given concurrently all of the time.


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## MackTheKnife (Nov 24, 2016)

So many here jumping on the OP. Yes, she should have called for guidance as to whether or not to give the ASA. As to the "sharp pain", that is a subjective comment given by the pt that might/might not be accurate. The pain did radiate down the left arm. Pt also on a statin which might be indicative of CAD. So the ASA might have been appropriate. And in the elderly, falls are usually caused by a precipitating cardiovascular event (approx 80%).  As for the "no OR" comment, not absolutely true. The pt, if surgery was needed, would have PT/INR checked and if out of therapeutic range (due to the coumadin), surgery might be delayed. As so many of you have said before, nothing is absolute without knowing all of the facts.


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## StCEMT (Nov 24, 2016)

At least for me, the problem with what I have read isn't just the asa....


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## NysEms2117 (Nov 24, 2016)

I am with st here. As a fellow basic, I am by no means a doctor, nurse or what have you. I do very little things to a patient without advanced approval. It seems the op is more concerned with getting himself in trouble as to a potentially fatal case. Which is were my problem is lying.


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## Say G (Nov 24, 2016)

http://tetaf.org/wp-content/uploads/2016/03/trauma-activation-guildelines.pdf
_
"Patients with coagulopathies or being treated with anticoagulants (warfarin, aspirin, etc.) are at *increased risk for intracranial hemorrhage*, increased severity of hemorrhage and associated morbidity and mortality."_

It may not be a contraindication per protocol but under trauma guidelines it clearly states that it can increase risks. We all make mistakes, some dumber than others, but hopefully this will be a lesson. As for your personal consequences, I would be more worried about the patient suing you than getting fired to be honest.


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## Qulevrius (Nov 24, 2016)

Say G said:


> http://tetaf.org/wp-content/uploads/2016/03/trauma-activation-guildelines.pdf
> _
> "Patients with coagulopathies or being treated with anticoagulants (warfarin, aspirin, etc.) are at *increased risk for intracranial hemorrhage*, increased severity of hemorrhage and associated morbidity and mortality."_
> 
> It may not be a contraindication per protocol but under trauma guidelines it clearly states that it can increase risks. We all make mistakes, some dumber than others, but hopefully this will be a lesson. As for your personal consequences, I would be more worried about the patient suing you than getting fired to be honest.



ASA is an antiplatelet, not an anticoagulant. That's the main issue therein. And the other issue is that @MackTheKnife is the 2nd medic, who jumped the gun without bothering to read the entire thread...


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## Say G (Nov 24, 2016)

Qulevrius said:


> ASA is an antiplatelet, not an anticoagulant. That's the main issue therein.



I am having a difficult time differentiating the two since they both have the same result through slightly different means. Would that really effect whether or not you can give it to someone that has a high risk of internal hemorrhaging?


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## Qulevrius (Nov 24, 2016)

Say G said:


> I am having a difficult time differentiating the two since they both have the same result through slightly different means. Would that really effect whether or not you can give it to someone that has a high risk of internal hemorrhaging?



They differ in the mechanism of action. In short, antiplatelet drugs inhibit the platelets from moving towards the site of injury whilst anticoagulants prevent the actual clotting. There's also the lengthy physiological explanation that involves all kinds of smart stuff (proteins, catalysts etc) but it's not very important.

And to answer your question - yes, giving antiplatelet drug to a pt with possible internal hemorrhage will potentially exacerbate the condition because factor I won't be able to convert to fibrin -> damaged blood vessels won't be repaired -> bad stuff will happen. Especially since there's a good chance that the pt *already *has fibrinogen inhibitors in their system.


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## Say G (Nov 24, 2016)

Qulevrius said:


> They differ in the mechanism of action. In short, antiplatelet drugs inhibit the platelets from moving towards the site of injury whilst anticoagulants prevent the actual clotting. There's also the lengthy physiological explanation that involves all kinds of smart stuff (proteins, catalysts etc) but it's not very important.



So if enough time has passed since a traumatic event occurred (e.g. 12-24 hours) and the pt complains of chest pain after the fact, is it possible to assume that clots have already formed and an antiplatelet would not affect them? (given that they are not taking any blood thinners.)


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## VentMonkey (Nov 24, 2016)

Say G said:


> So if enough time has passed since a traumatic event occurred (e.g. 12-24 hours) and the pt complains of chest pain after the fact, is it possible to assume that clots have already formed and an antiplatelet would not affect them? (given that they are not taking any blood thinners.)


If gamgam fell half a day to a day ago and is now complaining of unrelated (atraumatic) chest pain I see no reason not to give gamgam her ASA if she's in fact meeting ACS criteria.

Don't get in the habit of overthinking every call, I'm willing to bet that's part of the ops problem to begin with, that being said...those medics were lazy.

#beatingadeadhorse.


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## Qulevrius (Nov 24, 2016)

Say G said:


> So if enough time has passed since a traumatic event occurred (e.g. 12-24 hours) and the pt complains of chest pain after the fact, is it possible to assume that clots have already formed and an antiplatelet would not affect them? (given that they are not taking any blood thinners.)



As far as I know, the formation of clots can take as short as minutes and as long as hours, depending on location, age, state of health etc. Based on the given scenario, it's a geriatric patient (1st red flag) with a high risk of traumatic head injury (2nd red flag), who has a trauma-symptomatic hematoma + complaint of side-correspondent chest pain + side-correspondent UE pain. That alone should be enough to cue in the responders.


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## StCEMT (Nov 24, 2016)

The most basic way I can think to describe it.

Antiplatelet prevents things (platelets) from sticking together and anticoagulants prevent things from changing their physical form.


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## Summit (Nov 25, 2016)

@MackTheKnife the OP is receiving the responses seen here because of their overall established attitude and history in this thread and in others


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## MackTheKnife (Nov 26, 2016)

Summit said:


> @MackTheKnife the OP is receiving the responses seen here because of their overall established attitude and history in this thread and in others


Thanx. Not familiar with the poster. Appreciate it.


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## dutemplar (Nov 27, 2016)

So... did you get fired?  What happened?


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## FFEMT91 (Nov 29, 2016)

I do not understand why you think giving aspirin for chest pain is a bad thing, it is a blood thinner... However, I would leave it for ALS to administer anything else along those lines as you said pt is already on them. Chest pain would've been my first question, why did you not ask sooner? Also, how can you rule out cardiac issues? Can you interpret a 12 lead? I know I sure as hell can't, although I've never been formally taught.


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## CALEMT (Nov 29, 2016)

FFEMT91 said:


> I do not understand why you think giving aspirin for chest pain is a bad thing, it is a blood thinner... However, I would leave it for ALS to administer anything else along those lines as you said pt is already on them. Chest pain would've been my first question, why did you not ask sooner? Also, how can you rule out cardiac issues? Can you interpret a 12 lead? I know I sure as hell can't, although I've never been formally taught.



Have you read the original post? You might want to before you post on here. He gave ASA to a 88 year old female who fell and has swelling and bruising around her eye AND is guess what? On blood thinners. Not a good idea to give a fall patient who already is on blood thinners more blood thinners. Plus the type of chest pain he described doesn't even sound cardiac related, it sounds muscular related.


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## EpiEMS (Nov 29, 2016)

FFEMT91 said:


> I do not understand why you think giving aspirin for chest pain is a bad thing, it is a blood thinner...



Chest pain is an indication to administer ASA, if the chest pain seems to be (1) cardiac in origin and (2) not otherwise contraindicated. In this case, we can probably debate whether 1 is true or not (I would lean towards not), but 2 is clear - they're already anticoagulated and are bleeding...that would tend to mean aspirin is a bad idea.


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## Say G (Nov 29, 2016)

dutemplar said:


> So... did you get fired?  What happened?



I think they ran away...


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## Inspir (Nov 29, 2016)

Blood thinners are not a contraindication in our protocols for giving ASA for ischemic chest pain.

Excerpt:


ASA must be administered even when patient:
states that they have already taken their prescribed daily dose
is currently taking blood thinners(e.g. Plavix, warfarin)


I've seen its here a couple time so to be clear. ASA is not an anticoagulant, it's a antiplatelet.


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## Say G (Nov 29, 2016)

Inspir said:


> Blood thinners are not a contraindication in our protocols for giving ASA for ischemic chest pain.
> 
> Excerpt:
> 
> ...



Does it say anything about trauma patients that fit in the category of elevated risks (>65 yoa on anticoagulants) that could be suffering from internal hemorrhaging?


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## Qulevrius (Nov 29, 2016)




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