Who cares?
I think it is important to remember to see the forest from the trees.
Tree #1: acute trauma patient
Tree #2: potential MI
Forest: you can't do anything to accurately diagnose and treat these things in combination. Rapidly extricate and drive safely to the place that can.
Let's keep this in perspective.
high speed crash.
restrained
70 years old
long bone fracture
How do you call that a traumatic chest pain?
Even if by some miracle, the patient describes crushing substernal chest pain radiating to the arm and jaw with nausea prior to crashing, how do you rule out a cardiac contusion, pulmonary contusion, early tamponade, or aortic tear with just the information given?
These pathologies can occur in this case even if the patient also had an MI.
Let's talk about this MI. Could EKG changes be caused by trauma?
Could this be a non STEMI MI?
Ruling out angina with nitro in this case is also problematic.
First, if there is bleeding somewhere, nitro is going to decrease venous return to the heart, which is exactly the main life threatening problem in hemorrhage.
Second, endogenous opioid, endorphines, are shown to cause subendocardial capilary constriction. (appearing as a Qwave infarct on EKG sometimes) so his "nontraumatic chest pain" might not even be responsive to anything you have. Decreasin venous retun may actually make the problem worse.
In a controlled environment, playing with ASA in a bleeding patient is reasonable when you have a more accurate Dx.
But you have to be rather sure, especially in an elderly trauma patient. Forget bleeding in to the closed compartment of his distal extremity, how did you determine he didn't rupture bridging veins in his sub arachnoid space?
Giving ASA to that would be a far more serious problem than some blood in his leg.
From the stanpoint of protocol, you will probably be required to suspect a spinal injury. Which in an elderly person in a high speed accident is probably a good idea. The actual method of (supposed)immobilization might be a factor. This person may have other issues that preclude a longboard with head blocks and a bunch of straps.
Despite what is taught in trauma in EMS, it is in my not always humble opinion one of, if not the most complex disease in humans. It involves every system in the body, from skin to endocrine. Trauma has multiple phases. It also requires a combination of surgery and medicine in order to treat. (Incidentally the only other medical specialty that shares these characteristics is OB/Gyn)
Once this patient gets to a trauma center, many very tough decisions are going to have to be made. Like what is treated first, what is neglected, minimally invasive, maximumly (is that even a word?) aggresive with potentially multiple maybe simultaneous surgeries. Perhaps sequential. Not to mention the details of things like anesthesia, surgical techniques, etc.
Complex patients like this require an ivory tower, multispecialty trauma center.
If you delay that, especially monkeying around with community facilities, the only thing that will happen is delaying the patient the care they need.
If this was a scenario given in class, the only thing your instructor should require of you is: "this patient may be beyond EMS, let's just go."
Discretion is sometimes the better part of valor. Don't play games when you are in over your head.
