# Scenerio 3



## Chris EMT J (Apr 6, 2022)

This Case is based off a really recent case that is broad and a few details different like not exact vitals. 

Dispatched to a male late 60s CC of chest pain. 
Vitals: 
HR low 100s 
BP 165/95 
O2 93%
RR 18 
BGL 110 
Temp 98.6f
SAMPLE:
Chest pain, no allergies, Diltiazem & albeterol, history of hypertension and COPD (early stage), last oral intake was a cup of coffee, and events leading was just sitting. 

I established a IV, gave aspirin and nitro, ran a ECG and had a paramedic interp it as having ST depression possible NSTEMI. 

Patient chest sounded clear with no wheezing or chest tightness, or even no sob. 

Social history:
3+ cups of coffee a day, 6+ smokes a day last 4 years. No alcohol.
Patient was transported to closest facility in around 20 minutes ETA. "Call was out of coverage area"


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## Tigger (Apr 6, 2022)

Are you looking for feedback or…?


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## Chris EMT J (Apr 6, 2022)

Tigger said:


> Are you looking for feedback or…?


Yes I actually have a question. Would you have given a inhaler since the 02 was board line? Patient reported his O2 is normal 99-97% also if you have any feedback I would love to hear it


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## mgr22 (Apr 6, 2022)

ChrisEMTA said:


> Yes I actually have a question. Would you have given a inhaler since the 02 was board line? Patient reported his O2 is normal 99-97% also if you have any feedback I would love to hear it


Can you think of something safer and more basic than an inhaler to administer to a cardiac patient with a relatively low sat?


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## Chris EMT J (Apr 6, 2022)

mgr22 said:


> Can you think of something safer and more basic than an inhaler to administer to a cardiac patient with a relatively low sat?


I was just curious because he wasn't having symptoms related and he did have a slightly elevated heart rate so didn't know if I should at the risk of a heart rate increase. But do you think I should have? For future reference?


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## ffemt8978 (Apr 6, 2022)

mgr22 said:


> Can you think of something safer and more basic than an inhaler to administer to a cardiac patient with a relatively low sat?


Oxygen?  Didn't see it listed anywhere in original post.


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## mgr22 (Apr 6, 2022)

ChrisEMTA said:


> I was just curious because he wasn't having symptoms related and he did have a slightly elevated heart rate so didn't know if I should at the risk of a heart rate increase. But do you think I should have? For future reference?


You left out O2. You sound like you're focusing on less important things.

I'm asking again about QA. Does anyone besides you review your calls?


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## Chris EMT J (Apr 6, 2022)

mgr22 said:


> You left out O2. You sound like you're focusing on less important things.
> 
> I'm asking again about QA. Does anyone besides you review your calls?


What? I said in the post that oxygen saturation was 93%. And not really. Our company sends surveys with rare replies. My partner a EMT basic does the call and the doesn't care anymore about them so really I am the only one who brings back old cases for testing my quality.


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## CCCSD (Apr 6, 2022)

ChrisEMTA said:


> What? I said in the post that oxygen saturation was 93%. And not really. Our company sends surveys with rare replies. My partner a EMT basic does the call and the doesn't care anymore about them so really I am the only one who brings back old cases for testing my quality.


Uhhh…quality is lacking in the basics.


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## Chris EMT J (Apr 6, 2022)

CCCSD said:


> Uhhh…quality is lacking in the basics.


Could you elaborate so I can improve?


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## MMiz (Apr 6, 2022)

ChrisEMTA said:


> Could you elaborate so I can improve?



It seems like a lot of people are replying that you probably should have put the patient on oxygen.


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## Chris EMT J (Apr 6, 2022)

MMiz said:


> It seems like a lot of people are replying that you probably should have put the patient on oxygen.


Oh ok. I thought maybe oxygen or a inhaler but wasn't too sure. But I was really thinking about NC 3lpm to start. Just didn't because.... Well I am not sure. While I was with the patient they acted like they had a O2 of 100% they didn't feel like a 93%. But I do see that I should have started oxygen and I will apply oxygen for any O2 below 94 for now on. Thank you for elaborating I really appreciate this opportunity to learn from others that a O2 speaks for itself not to trust just exam and history.


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## MMiz (Apr 7, 2022)

Lots of cryptic responses and non-answers in this thread. 

I remember as an EMT requesting an ALS unit for a patient with a low BP and weak pulse. As I rode along with the Paramedic he was quizzing me, and I don’t think I got a single question right. 

Every situation is a learning experience. Never stop learning, no matter how uncomfortable it may be.


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## akflightmedic (Apr 7, 2022)

So you are an Advanced...with a Paramedic on scene...and you are wondering whether you should have given albuterol for a chest pain patient with absolutely nothing related to the need for a bronchodilator?

Additionally, you use the word nSTEMI as if you a) know what it means, b) think it can be diagnosed without troponins and c) this indicates a higher understanding of medicine, yet oxygen was a revelation to you. 

I am just confused at the progression of this "scenario".


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## DrParasite (Apr 7, 2022)

ChrisEMTA said:


> This Case is based off a really recent case that is broad and a few details different like not exact vitals.
> 
> Dispatched to a male late 60s CC of chest pain.
> Vitals:
> ...





ChrisEMTA said:


> Yes I actually have a question. Would you have given a inhaler since the 02 was board line? Patient reported his O2 is normal 99-97% also if you have any feedback I would love to hear it


I'm just a dumb hose dragger who hasn't been on an ambulance in years.... what would your indications be for giving a Bronchodilator?   with no wheezing or SOB, how would an inhaler raise their O2 %?  I know my A&P was pretty light, but last I checked, albuterol isn't (typically) used to treat chest pain with no other ancillary symptoms.

Is this a case of "When all you have is a Hammer, everything looks like a Nail"?


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## Chris EMT J (Apr 7, 2022)

DrParasite said:


> I'm just a dumb hose dragger who hasn't been on an ambulance in years.... what would your indications be for giving a Bronchodilator?   with no wheezing or SOB, how would an inhaler raise their O2 %?  I know my A&P was pretty light, but last I checked, albuterol isn't (typically) used to treat chest pain with no other ancillary symptoms.
> 
> Is this a case of "When all you have is a Hammer, everything looks like a Nail"?


I was thinking that even if the bronchus wasn't closing it still may improve oxygenation if more air is able to get in via bronchial dialation. I also have asthma and I don't start wheezing until I feel like the worst. When my asthma starts to  exacerbate I just get chest tightness. My pulmonologist says some people don't experience anything warning them of a asthma attack until they start wheezing. It was just me asking if you guys thought it could help. Seems like a few people are already calling me out for being dumb for asking a question. Not the best learning but it will have to do.


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## DrParasite (Apr 7, 2022)

ChrisEMTA said:


> I was thinking that even if the bronchus wasn't closing it still may improve oxygenation if more air is able to get in via bronchial dialation.


That's a fair assumption... but that's also assuming that the cause of the low O2 is a bronchial restriction, which you have no proof of actually occurring.  we tend to treat based on what is there, and what we can see, not just in case something is occurring and this _might _fix is (which is why we don't do coma cocktails for patients who are unconscious with no known cause).


ChrisEMTA said:


> Seems like a few people are already calling me out for being dumb for asking a question. Not the best learning but it will have to do.


No one is calling you dumb, nor are they calling you dumb for asking a question.  However, several people are expressing concern about some of your treatment plans, because they aren't based on actual clinical indicators.  Not only that, but you are considering administering a treatment that can have negative side effects for the patient.  As the most educated provider on your ambulance, you are responsible for that patient, so people are concerned, which is why many have asked what your QA department thinks of your clinical decisions.

But no one has called you dumb for asking a question.

Like it or not, many of your clinical actions are questionable, which is why many have referred you to your department's QA team for guidance on your treatment plans.


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## Chris EMT J (Apr 7, 2022)

DrParasite said:


> That's a fair assumption... but that's also assuming that the cause of the low O2 is a bronchial restriction, which you have no proof of actually occurring.  we tend to treat based on what is there, and what we can see, not just in case something is occurring and this _might _fix is (which is why we don't do coma cocktails for patients who are unconscious with no known cause).
> 
> No one is calling you dumb, nor are they calling you dumb for asking a question.  However, several people are expressing concern about some of your treatment plans, because they aren't based on actual clinical indicators.  Not only that, but you are considering administering a treatment that can have negative side effects for the patient.  As the most educated provider on your ambulance, you are responsible for that patient, so people are concerned, which is why many have asked what your QA department thinks of your clinical decisions.
> 
> ...


Ok. I think I understand what I did wrong so I can apply the lesson to future cases.


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## Chris EMT J (Apr 11, 2022)

akflightmedic said:


> So you are an Advanced...with a Paramedic on scene...and you are wondering whether you should have given albuterol for a chest pain patient with absolutely nothing related to the need for a bronchodilator?
> 
> Additionally, you use the word nSTEMI as if you a) know what it means, b) think it can be diagnosed without troponins and c) this indicates a higher understanding of medicine, yet oxygen was a revelation to you.
> 
> I am just confused at the progression of this "scenario".


NSTEMI is a non ST elevated myocardial infarction which is a heart attack that doesn't have ST elevation. Meaning ether not enough blood or oxygen going to the heart muscle. Can be caused by a clot or really anything blocking blood or oxygen. Not even necessarily blocked. I don't think it can be diagnosed without a troponin but can say that it may be suspected based on symptoms and ST depression representing possible ischemia and or a myocardial infarction.


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