Chest pain in the young and tiered EMS

[medichopeful]

Correct on Lowell. I agree with the term aggressive. Massachusetts is pretty limited on scope of practice for most EMS regions unfortunately. The exception being Boston, Worcester, Lowell, and Lawrence. They are also pretty selective in whom they hire, especially per diem/part time. As a full time buckethead that is all I can commit to. I see you have you critical care certification. I've been studying for a few weeks with one text book and Anthony Baca's crash course. I am mainly trying to get the cert to make myself look better on the resume. I also have CT certification and have been considering applying at Windham Hospital whom requires their medics to have CCP-C. Not sure if you know anything about that system. You seem very knowledgeable. Any advice for the test and preparation for it?

I worked EMS in Lowell for a while (not for LGH), if you have any questions about them let me know. LGH runs a solid service, one of the best in MA.

Edited to delete something I didn't mean to say.

 

[Tigger]

Well said Rocketman, I agree. Rescue1 transport times would be 5-20minutes. I understand that s1q3t3 is not very specific for PE. But back to my original question. It sounds like Tigger is not comfortable triaging a chest pain to BLS regardless or age, onset, history, risk factors, vital signs ect where as Rocketman seems okay with it based risk stratification and the patient being low risk.

Hardly ever. Realistically in my service area I'm not getting a lot of young people with chest pain anyway. There are of course exceptions, but generally I won't because I have the ability not to in my system. I can't call a BLS car to take the patient. I either or ride it or my EMT does. In the event of their being a bad outcome, what is my defense? I have nothing. I was present for the entire call and failed to intervene. Doesn't matter if there isn't actually anything I can do, it's still my ambulance and I am responsible for clinical outcomes. I can't justify going back into service because we have a scarcity of ALS resources, if I put my EMT in back I am still not available for other calls.

Which begs the question, if in our system (and nearly all of the front range of Colorado where there aren't tiered systems), chest pain nearly always goes ALS, can we prove a clinical benefit? I have no idea, but it would be nice to know. Unfortunately, as stated these patients are not going to affect M&M outcomes and that's primarily what we (sadly) measure.

 

[wdballer2431]

Hardly ever. Realistically in my service area I'm not getting a lot of young people with chest pain anyway. There are of course exceptions, but generally I won't because I have the ability not to in my system. I can't call a BLS car to take the patient. I either or ride it or my EMT does. In the event of their being a bad outcome, what is my defense? I have nothing. I was present for the entire call and failed to intervene. Doesn't matter if there isn't actually anything I can do, it's still my ambulance and I am responsible for clinical outcomes. I can't justify going back into service because we have a scarcity of ALS resources, if I put my EMT in back I am still not available for other calls.

Which begs the question, if in our system (and nearly all of the front range of Colorado where there aren't tiered systems), chest pain nearly always goes ALS, can we prove a clinical benefit? I have no idea, but it would be nice to know. Unfortunately, as stated these patients are not going to affect M&M outcomes and that's primarily what we (sadly) measure.

You make a great argument and some solid points Tigger. I appreciate the input on this thread.

 

[medicsb]

I'm speaking specifically on patients less than 40yo that activate EMS for chest pain. Example would be a 32yo male that presents with sharp non reproducible left sided chest pain associated with dyspnea. He has no cardiac risk factors, no medical hx, and is otherwise healthy. Vital signs are normal; no tachycardia, hypoxia, or respiratory distress, skin is p/w/d.

As a EM physician and former paramedic, I say if 12 lead EKG is not STEMI or grossly ischemic, or exhibiting an arrhythmia, then triage to BLS (if OK in your system, send along a copy of the 12 lead with BLS).

Treating this as ALS is a waste of resources and everyone's time, even in an all-ALS system. He may get a work-up in the ED, but I don't think that matters for you.

 

[wdballer2431]

As a EM physician and former paramedic, I say if 12 lead EKG is not STEMI or grossly ischemic, or exhibiting an arrhythmia, then triage to BLS (if OK in your system, send along a copy of the 12 lead with BLS).

Treating this as ALS is a waste of resources and everyone's time, even in an all-ALS system. He may get a work-up in the ED, but I don't think that matters for you.

Always good to hear what an ED MD and former medic has to say. I agree with you on this! Thanks

 

[DrParasite]

Hardly ever. Realistically in my service area I'm not getting a lot of young people with chest pain anyway. There are of course exceptions, but generally I won't because I have the ability not to in my system. I can't call a BLS car to take the patient. I either or ride it or my EMT does. In the event of their being a bad outcome, what is my defense? I have nothing. I was present for the entire call and failed to intervene. Doesn't matter if there isn't actually anything I can do, it's still my ambulance and I am responsible for clinical outcomes. I can't justify going back into service because we have a scarcity of ALS resources, if I put my EMT in back I am still not available for other calls.

define bad outcome. also define present for the entire call and failed to intervene.

If you are driving, with your EMT in the back, and your patient crashes, and you failed to do anything ignoring your partner's requests for assistance and kept driving to the hospital, than you deserve to be drawn and quartered. plain and simple. that's negligence, laziness, and you deserve to be thrown out of this profession on your ***.

But if you are driving, with your EMT in the back, and in the hospital the patient has a bad outcome, what is your defense? well, what is the charge? did you fail to assess the patient? was there anything you would have done as a paramedic that would have prevented the bad outcome? did the prehospital interventions (or lack thereof) contribute to the bad outcome? or was it simply the patient's time to go, and nothing you could have done would have prevented it?

You're also on an ALS ambulance, and it doesn't sound like you have BLS ambulances in your system that are dispatched alongside you. so you really can't triage it to another unit that is on scene to transport the patient, allowing you to go back in service.

Which begs the question, if in our system (and nearly all of the front range of Colorado where there aren't tiered systems), chest pain nearly always goes ALS, can we prove a clinical benefit? I have no idea, but it would be nice to know. Unfortunately, as stated these patients are not going to affect M&M outcomes and that's primarily what we (sadly) measure.

Chest pain does not always equal cardiac emergency. I 'm sure you know this. So saying chest pain always goes ALS makes me wonder how many times you are treating based on mechanism, vs actual clinical findings (I know it's not a trauma, but I hope you get the analogy).

I would imagine shorter door to balloon times, better reports to cardiologists, IV access and MONA to make the patient more comfortable (and patient satisfactions, which is becoming as important if not moreso in healthcare), and faster identification that the patient is experiencing a cardiac emergency vs routine "chest pain" could all be quantified to provide a clinical benefit.

I've seen plenty of patients be treated by the medic on the crew vs the EMT "just because." Maybe the medic didn't like something he or she saw. Or even better, "this patient is super stable, but I'm going to ride this one in so I don't get flagged by QA." They get an IV lock, are kept on the monitor, and take a nice easy ride to the ER with the medic talking to them about the latest news. Could they have gone BLS? probably. VFlutter said it better than I could have:

You can't ALS everyone out of fear of "What if" and you can't turf everyone to BLS or you will get burned. This is where experience and assessment skills come into play but as already said it is very provider dependent.

 

[DrParasite]

The only reason we wouldn't BLS chest pain in a young person with a (-) EKG and normal vitals is since the medic on the truck already needs to write a report anyway, now you're just making the EMT write a report as well.

why does the medic and EMT need to write a chart? is the EMT incapable of providing proper documentation for the call? I'm sure the 12 lead is going to be attached to the ticket, as will the medic's name to explain the 12 lead should that be needed?

a decent EMT should know how to write a chart on a patient they treat, enough to explain why ALS wasn't used, and to allow for proper continuity of care.

 

[rescue1]

why does the medic and EMT need to write a chart? is the EMT incapable of providing proper documentation for the call? I'm sure the 12 lead is going to be attached to the ticket, as will the medic's name to explain the 12 lead should that be needed?

a decent EMT should know how to write a chart on a patient they treat, enough to explain why ALS wasn't used, and to allow for proper continuity of care.

It was just agency policy. If an ALS "intervention" was performed then it required an ALS level chart. I believe it was a combination of so it could be billed ALS 1 instead of BLS, and that the PA protocols were unclear on the ability of ALS to hand over care once an ALS intervention was performed.

 

[RocketMedic]

Most (if not all) tiered systems have QI expectations that are geared to guide these marginal patients. They're not crucifying people left-and-right for not ALSing a marginal, non-interventional patient.

Me personally? When deciding if it's a call to triage down to my partner, I ask myself what interventions are likely, reasonable, necessary, and whether or not we should or should not perform them; then I ask my partner if they're comfortable taking the call if the answers are something they can handle, and then we keep our ears open and reassess. For example: geriatric "weakness" patient with a room-air SpO2 of 91%, to 97% on 4L, no need for prehospital fluid/IV access, stable and unremarkable. Could that go ALS? Sure, and if something catches my eyes, maybe...but it could just as legitimately go BLS.

Another thing to remember here too is that these patients are how our EMTs gain confidence and experience. Allowing them to see, learn, assess and decide what to do is a critical part of professional development.

 

[DrParasite]

It was just agency policy. If an ALS "intervention" was performed then it required an ALS level chart. I believe it was a combination of so it could be billed ALS 1 instead of BLS, and that the PA protocols were unclear on the ability of ALS to hand over care once an ALS intervention was performed.

Maybe it's just me, but I don't consider a 12-lead to be an ALS intervention... more like an ALS assessment tool.... but that's just me.

If it's agency policy, than I completely understand why the medic rides in with the patient. doesn't make much sense to write two charts for the same call.