# Typical Chest Pain Call



## LAS46 (Nov 25, 2010)

This was a call that we had a few months ago.

Dispatch: 58 yo female with chest pain
Arrive to find: female seated at kitchen table, SOB, pale, cool, clammy, radiating pain down left arm.

Assessment reveals:

Airway is patent but PT is SOB. Pupils are PERRL, Lung sounds are clear, Skin is pale, cool and clammy. Pain started 2 hours ago. PT was watching TV when the pain started. Any movement makes the pain worse. PT complains of crushing pain. Pain is 8 on a 10 scale. Pain has got worse over the last 30 min. Physical exam does not reveal any injuries.

Vitals are as follows:
Pulse- 100
Blood pressure-148/90

Alergies-NKA
Meds-nitro, lipitor, high BP meds
Past Medical History-angina, hypertension, stints

TX: Gave 3 Nitro, also gave 325mg Aspirin. 

Patient Response: no response to 3 nitro administration
ALS: Consideration

(Hospital is 15 minutes away. ALS Available if needed.)

*Follow-up with your comments and TX.*


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## TransportJockey (Nov 25, 2010)

Has she been doing any travelling or sitting for long periods of time?


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## EMT11KDL (Nov 25, 2010)

LAS46 said:


> This was a call that we had a few months ago.
> 
> Dispatch: 58 yo female with chest pain
> Arrive to find: female seated at kitchen table, SOB, pale, cool, clammy, radiating pain down left arm.
> ...



ALS! High Flow o2. 

BLS Side, Re do vitals, contact med control and ask for additional Nitro.. Go en-route to Hospital.  Lights with NO SIRENS!


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## LAS46 (Nov 25, 2010)

PT had not been traveling, and does sit for long periods.



jtpaintball70 said:


> Has she been doing any travelling or sitting for long periods of time?


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## Shishkabob (Nov 25, 2010)

Pulse ox?
Ekg?  Humor me
Capnography?
Temp?
Recent bout of sickness?
Smoker?
How are her legs?




Pain on movement drives me pfurther from a cardiac origin, so I wouldn't be pushing for MORE nitro.


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## EMT11KDL (Nov 25, 2010)

Also your in Colorado correct.. I know some agencies with the rule 500 allow you to do 12 leads and IV as a basic.. Did the strip say anything? Are you able to do IV and push front line cardiac meds per Med control?


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## TransportJockey (Nov 25, 2010)

Iv cert doesn't add cardiac meds, and I'm pretty sure ekg cert is just rythym interprets, not twelve lead interpretation.





EMT11KDL said:


> Also your in Colorado correct.. I know some agencies with the rule 500 allow you to do 12 leads and IV as a basic.. Did the strip say anything? Are you able to do IV and push front line cardiac meds per Med control?


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## EMT11KDL (Nov 25, 2010)

jtpaintball70 said:


> Iv cert doesn't add cardiac meds, and I'm pretty sure ekg cert is just rythym interprets, not twelve lead interpretation.



depends on ur agency.. you might be allowed to do a 12 and send it to the hospital for the doc.. With the meds side it also depends on your medical director and med control...


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## TransportJockey (Nov 25, 2010)

You might be right. I'll look over my old stuff from the agency I worked for in Denver... and I never actually took either class, so I'm a little fuzzy on just how that worked  I just know they had me marked down as iv and ekg certified while I was there. 





EMT11KDL said:


> depends on ur agency.. you might be allowed to do a 12 and send it to the hospital for the doc.. With the meds side it also depends on your medical director and med control...


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## LAS46 (Nov 25, 2010)

Pulse ox? 92% ra
Ekg? No EKG
Capnography?
Temp? 96.2
Recent bout of sickness? No Known
Smoker? No
How are her legs? Some swelling noted in ankles and feet.




EMT11KDL said:


> Also your in Colorado correct.. I know some agencies with the rule 500 allow you to do 12 leads and IV as a basic.. Did the strip say anything? Are you able to do IV and push front line cardiac meds per Med control?



Our QRT crew only had Basics w/o IV cert available. Basics are limited on what they can give via IV. I am certified to interpret basic 12 lead but our QRT unit does not have EKG on board.


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## EMT11KDL (Nov 25, 2010)

jtpaintball70 said:


> You might be right. I'll look over my old stuff from the agency I worked for in Denver... and I never actually took either class, so I'm a little fuzzy on just how that worked  I just know they had me marked down as iv and ekg certified while I was there.



its been two years since i was in colorado.. I was over on the west side of the state though.  I know we could hook up the 12 lead and send it to the Doc.  Also, with the meds.. we were able to push front line, but i am trying to remember if it was only if we had a medic with us or if we could do it per Med control..


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## EMT11KDL (Nov 25, 2010)

LAS46 said:


> Our QRT crew only had Basics w/o IV cert available. Basics are limited on what they can give via IV. I am certified to interpret basic 12 lead but our QRT unit does not have EKG on board.



never mind.. guess that is out of the question than. haha


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## LAS46 (Nov 25, 2010)

*Rule 500*

Colorado Rule 500: http://www.dora.state.co.us/medical/rules/500_non_emer.pdf



jtpaintball70 said:


> You might be right. I'll look over my old stuff from the agency I worked for in Denver... and I never actually took either class, so I'm a little fuzzy on just how that worked  I just know they had me marked down as iv and ekg certified while I was there.


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## EMT11KDL (Nov 25, 2010)

EMT11KDL said:


> its been two years since i was in colorado.. I was over on the west side of the state though.  I know we could hook up the 12 lead and send it to the Doc.  Also, with the meds.. we were able to push front line, but i am trying to remember if it was only if we had a medic with us or if we could do it per Med control..



Well according to the rule 500... Front line is out! ooppppsssss!!!! I miss spoke about the medications... 

ADDED: Medications are allowed under section 7.4 and a waiver... Sorry like I said earlier its been over two years since i was in colorado..


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## Shishkabob (Nov 25, 2010)

Well, since we can only run it as a BLS crew since that's what you are, and we have no way to get further objective information by way of ALS tools, there's not much to do.  

What does the rest of the physical assessment turn up?  Any abnormalities aside from the swelling to legs/feet?

How far is ALS intercept?  If it's further then 5-10 minutes, just bypass it headed for the ER.  Maybe have the patient on a couple of liters O2 via NC. Nothing else you can do.


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## Pittma (Nov 25, 2010)

Linuss said:


> Well, since we can only run it as a BLS crew since that's what you are, and we have no way to get further objective information by way of ALS tools, there's not much to do.
> 
> What does the rest of the physical assessment turn up?  Any abnormalities aside from the swelling to legs/feet?
> 
> How far is ALS intercept?  If it's further then 5-10 minutes, just bypass it headed for the ER.  Maybe have the patient on a couple of liters O2 via NC. Nothing else you can do.



This. With the swelling in the feet, any pain upon gently squeezing the calf of the swollen leg? How about pain upon foot flexion? Any active cancer or medical history I should know about? Yes to any of these, maybe DVTs?


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## fast65 (Nov 25, 2010)

As Linuss said, since we can only run as a BLS crew then there's not much else we can do at this point. 

Any JVD, jugular reflex, something along those lines? Respiratory rate? Any pain relief with nitro?


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## LAS46 (Nov 25, 2010)

fast65 said:


> As Linuss said, since we can only run as a BLS crew then there's not much else we can do at this point.
> 
> Any JVD, jugular reflex, something along those lines? Respiratory rate? Any pain relief with nitro?



No JVD or Jugular Reflex.

RR was 18

Nitro x3 was not effective for any relief of pain.

They physical assessment turned up no other abnormalities. No pain upon palp of legs or feet. Decreased ROM on both feet due to swelling, minor pain. The only recent medical Hx was surgery to place stints.


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## fast65 (Nov 25, 2010)

Hmmmm, well I can't really think of anything else that I would do, it seems like all the basics have been covered.


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## Aidey (Nov 25, 2010)

I'm going to get on my soapbox for a minute.

Stent, not stint.  

/soapbox


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## Shishkabob (Nov 25, 2010)

Aidey said:


> I'm going to get on my soapbox for a minute.
> 
> Stent, not stint.
> 
> /soapbox



I can buy you stilts for Christmas if you're so self-conscious about being short h34r:


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## 18G (Nov 25, 2010)

Given her presentation and history/risk factors of age, HTN, CAD and previous stent placement, I would definitely work her up for ACS. In the field, it's a safe bet to consider all chest pain to be of a cardiac etiology until proven otherwise. 

Is the swelling of the feet new onset or does she always have that? You mentioned "high BP meds"... was one of them a diuretic? Has the patient been compliant with her meds and diet?

Also, with the patient stating her chest pain worsened with movement.... did the patient grimace or appear with increased pain or did she just answer yes to your question? 

How has she been sleeping at night? 

What and when did she eat last?

The nitro that she took... was that from EMS or the patients? If the patients, was it old or still in date?

These are just a few things I would have investigated as well. I would have given ASA and nitro, started a line, performed serial 12-leads, and titrated oxygen to maintain saturation of at least 95% by nasal cannula and transported to local ED.


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## LAS46 (Nov 26, 2010)

Is the swelling of the feet new onset or does she always have that? You mentioned "high BP meds"... was one of them a diuretic? Has the patient been compliant with her meds and diet? *This is a regular PT and almost every time we have ran on her she has had swelling of the feet. The medication she is on for HTN is not a diuretic and she is compliant with her meds most of the time. She has forgotten to take her meds in the past.*

Also, with the patient stating her chest pain worsened with movement.... did the patient grimace or appear with increased pain or did she just answer yes to your question? *I was not there when her pain increased... but her answer was basically a yes answer.*

How has she been sleeping at night? *Did not ask.*

What and when did she eat last? *She at around 9am and had pancakes, eggs, and bacon with some juice.*

The nitro that she took... was that from EMS or the patients? If the patients, was it old or still in date? *The NTG was the PTs and was a recently filled Rx.*

These are just a few things I would have investigated as well. I would have given ASA and nitro, started a line, performed serial 12-leads, and titrated oxygen to maintain saturation of at least 95% by nasal cannula and transported to local ED. *We did have her on a cannula at 4lpm and she was transferred to ALS unit and transported to nearby ED. I am not sure what they did in route but I am sure they did a 12 lead. We also did give her 325mg of ASA at the scene from our unit.*


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## Aidey (Nov 26, 2010)

Linuss said:


> I can buy you stilts for Christmas if you're so self-conscious about being short h34r:



A friend of mine once gave me a step stool for Christmas, lol. 


To the OP why wasn't ALS dispatched to this from the get go?


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## Cameron (Nov 26, 2010)

As you may or may not know, I am not certified as a EMT nor CFR. Only advanced First aid CPR... and the other basics.

I have a few questions, not sure if you guys are suppose to ask it.
But seeing that she is taking medications, would you ask:
• Has she just started taking one of the medications within the past week or so?
• If so, what were the signs/symptoms before taking it?
• Has the medication seemed to have helped with the signs/symptoms or have they been in-effective?

With my limited knowledge it seems like a heart attack, thinking about it, COULD it be a clot somewhere?

--Cameron


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## LAS46 (Nov 26, 2010)

Aidey said:


> To the OP why wasn't ALS dispatched to this from the get go?



ALS was dispatched but they arrive almost always when we are ready to load and go. Its the way the EMS system is set up here. They dispatch our county QRTs (Quick Response Teams) but the QRT from ALS personnel is not the best so we end up with only Basics. In this county they dont let EMT-I's use their ALS certs... they can only act as basics on the QRT. QRTs are located throughout the county and our county GOV ambulance service comes from the city which we have the 2nd largest county in the state so the response time for the county rig can be lengthy. QRTs can only transport if a intercept is needed or there is no ALS units available.


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## LAS46 (Nov 26, 2010)

Cameron said:


> As you may or may not know, I am not certified as a EMT nor CFR. Only advanced First aid CPR... and the other basics.
> 
> I have a few questions, not sure if you guys are suppose to ask it.
> But seeing that she is taking medications, would you ask:
> ...



Answers in bold in quote.


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## Akulahawk (Nov 26, 2010)

Given that I'd be functioning as a Basic here, I'd work her up as a cardiac chest pain patient. Being that she's on HTN meds, has had stents placed in the past, I imagine that she has experienced cardiac chest pain before. I'd want to know how this compares to previous episodes. O2, ASA and NTG if authorized. Being that I'm out in the boonies, I'd want to know how far out ALS is and package for transport.

This is NOT all of what I'd do or ask. My thought process would be to get her moving towards a facility that has a staffed cath-lab in an expeditious, safe manner. In the meantime, I would also do what I can to get her some pain relief. If that means that I transport or I turn her over to ALS, so be it...


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## LAS46 (Nov 26, 2010)

Akulahawk said:


> Given that I'd be functioning as a Basic here, I'd work her up as a cardiac chest pain patient. Being that she's on HTN meds, has had stents placed in the past, I imagine that she has experienced cardiac chest pain before. I'd want to know how this compares to previous episodes. O2, ASA and NTG if authorized. Being that I'm out in the boonies, I'd want to know how far out ALS is and package for transport.
> 
> This is NOT all of what I'd do or ask. My thought process would be to get her moving towards a facility that has a staffed cath-lab in an expeditious, safe manner. In the meantime, I would also do what I can to get her some pain relief. If that means that I transport or I turn her over to ALS, so be it...


*I really dont like the EMS system out here... all PTs unless authorized by online med control have to be seen at our Level 4 Trauma Center (Basically a URGENT care center) before they can be transferred to a Level II or Level I facility. If it was up to me all Serious Condition PTs would be transported directly to the Level II facility 80 miles from here and all Green PTs can be transported locally to the Level IV facility.*


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## TransportJockey (Nov 26, 2010)

I can sympathize with you there, as that's the way it is here too. Really sucks sometimes. 





LAS46 said:


> *I really dont like the EMS system out here... all PTs unless authorized by online med control have to be seen at our Level 4 Trauma Center (Basically a URGENT care center) before they can be transferred to a Level II or Level I facility. If it was up to me all Serious Condition PTs would be transported directly to the Level II facility 80 miles from here and all Green PTs can be transported locally to the Level IV facility.*


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## 18G (Nov 26, 2010)

A patient has the right to be transported to whichever facility they want (within reasonable distance) regardless of what medical command says.


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## TransportJockey (Nov 26, 2010)

18G said:


> A patient has the right to be transported to whichever facility they want (within reasonable distance) regardless of what medical command says.



True. But if patient has no preference, even if we think they need to go to the City, we still have to take them to the County ED


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## LAS46 (Nov 26, 2010)

18G said:


> A patient has the right to be transported to whichever facility they want (within reasonable distance) regardless of what medical command says.


*I agree with that. There are some exceptions made for those cases but 99% of our PTs dont ask to be taken to a different hospital. And a critical PT cant ask so we still have to do what med control says.*


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## 18G (Nov 26, 2010)

You could tell the patient which facility you think is most appropriate for their condition and allow them to make an informed decision. There are ways to play the game


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