Did i mess up will.i get fired

[Alan L Serve]

Wait what?

What wait!

 

[Alan L Serve]

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.

 

[medichopeful]

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.

 

[Summit]

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.

 

[ERDoc]

Made me think of Hickam's Dictum.

That sounds dirty, but yes, it does.

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.

 

[FLdoc2011]

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.

 

[medichopeful]

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.

 

[MackTheKnife]

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.

 

[MackTheKnife]

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.

 

[MackTheKnife]

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.

 

[StCEMT]

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

 

[NysEms2117]

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.

 

[Say G]

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.

 

[Qulevrius]

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...

 

[Say G]

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?

 

[Qulevrius]

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.

 

[Say G]

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.)

 

[VentMonkey]

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.

 

[Qulevrius]

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.

 

[StCEMT]

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.