InterFacility Transfer - Chest Pain

BobBarker

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Actual call here. Not super exciting but figured I would post more IFT calls since we don't get a ton in the scenario section. Keep in mind, we are a CCT truck in LA County which means we have a CCT-RN and 2 EMT's on board.

You are called for a non-emergent transfer of a 84yo female with a diagnosis of NSTEMI around 1AM. She is being transferred from a telemetry bed at one hospital to a telemetry bed at a hospital her insurance plan wants her at after they deemed her "stabilized". She was going to be transferred for a cardiac catherization the day before but the patient initially refused however has stated that she will talk it over with her family in the next couple days and make a decision.

C/C: Chest pain on/off 2-3 days, dull, left and right side with a 6/10 score. Non-radiating and no pain upon palpation. States she has not had chest pain recently, this is new.
Hx: Hypertension, hyperlipidemia and a left adrenal adenoma. No major or recent surgeries and no allergies
Home medications: Lisinopril and Atorvastatin.
Diagnosis: NSTEMI and Diverticulitis.
Tx: Aspirin 325mg, nitro x2 and a Heparin GTT. Noted to have no chest pain after treatment started and has remained on the Heparin drip at 850 units/hr with no pain since while on the telemetry floor.
Vitals after on our gurney: HR 80 NSR, BP 101/62, SP02: 95% on RA and R 16. No pain and has not had pain since being treated in the ER 2 days prior.
Plan: Transfer her to her insurance accepted hospital, continue heparin, treat her diverticulitis while she decides if she wants to have a cardiac cath, which the cardiologist recommended.

Halfway through transport, your patient states that she has 6/10 left sided dull chest pain and a "slight" discomfort in her chest. Her vitals at this time are: HR 84, BP 99/66, SPO2 90% and R 14 and she is still on the Heparin GTT. You place her on 2L NC which bumps her SP02 to 96% but provides no other relief. You perform a 12lead EKG that is below. What is your next move?

1. Continue the 10min transport to the destination hospital which is not a STEMI receiving center to her inpatient room.
2. Continue the 10min transport to the destination hospital but divert to the ER instead of the telemetry floor so she can be seen by a Dr immediately.
3. Divert your destination to the STEMI receiving center which is 16min away.

You do not have 12lead transmit capabilities and CCT does not work under a base hospital so you don't have the luxury of calling for advice.

I will try to post more IFT calls because it's different than 911 and we definitely get some interesting ones lol
 

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DesertMedic66

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Continue with the transport as normal. I’m not seeing a STEMI on the 12-lead. She has already been Dx with NSTEMI which can cause chest pain and she has been having pain off and on during her hospital stay.

I would have liked to get a 12-lead on patient contact as a baseline and then get another one while she is having this pain so I can compare and trend.

Being CCT you should have the ability to give the patient some NTG or Fentanyl for pain relief. I would go for the NTG first as it sounds like she has had relief with that in the past.
 

Tigger

Dodges Pucks
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Hopefully they sent an EKG with you so you can compare to see if there are any changes. While I am concerned that there is marked ST depression in I and AVL, I do not see any reciprocal elevation in the inferior leads.

She is going to a telemetry floor for a cardiac complaint. I assume there is still a cardiologist following her and I would be surprised to learn that this patient would be transferred to a facility with no cath lab at all, even if they are not a STEMI receiving hospital.

I would treat this patient's pain. I would do another 12 lead EKG. If there were really significant/STEMI type changes, I would call the receiving facility's unit charge and ask what they would like. Not sure how it goes in California, here when doing transfers we could call the receving for orders, or medical direction. I am surprised to learn you have no medical direction to consult.
 

DesertMedic66

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Hopefully they sent an EKG with you so you can compare to see if there are any changes. While I am concerned that there is marked ST depression in I and AVL, I do not see any reciprocal elevation in the inferior leads.

She is going to a telemetry floor for a cardiac complaint. I assume there is still a cardiologist following her and I would be surprised to learn that this patient would be transferred to a facility with no cath lab at all, even if they are not a STEMI receiving hospital.

I would treat this patient's pain. I would do another 12 lead EKG. If there were really significant/STEMI type changes, I would call the receiving facility's unit charge and ask what they would like. Not sure how it goes in California, here when doing transfers we could call the receving for orders, or medical direction. I am surprised to learn you have no medical direction to consult.
I am not seeing any real ST depression in 1 or AVL. The monitor is only calculating them as -0.04 and -0.14 respectively. There is T wave inversion.
 
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BobBarker

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Continue with the transport as normal. I’m not seeing a STEMI on the 12-lead. She has already been Dx with NSTEMI which can cause chest pain and she has been having pain off and on during her hospital stay.

I would have liked to get a 12-lead on patient contact as a baseline and then get another one while she is having this pain so I can compare and trend.

Being CCT you should have the ability to give the patient some NTG or Fentanyl for pain relief. I would go for the NTG first as it sounds like she has had relief with that in the past.
Continue with the transport as normal. I’m not seeing a STEMI on the 12-lead. She has already been Dx with NSTEMI which can cause chest pain and she has been having pain off and on during her hospital stay.

I would have liked to get a 12-lead on patient contact as a baseline and then get another one while she is having this pain so I can compare and trend.

Being CCT you should have the ability to give the patient some NTG or Fentanyl for pain relief. I would go for the NTG first as it sounds like she has had relief with that in the past.
Exactly what we did, nitro and morphine (what we carry). Pain subsided and 12lead at the bedside was faxed to the Dr who wasn’t concerned enough to transfer to a stemi center
 
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BobBarker

Forum Lieutenant
170
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Hopefully they sent an EKG with you so you can compare to see if there are any changes. While I am concerned that there is marked ST depression in I and AVL, I do not see any reciprocal elevation in the inferior leads.

She is going to a telemetry floor for a cardiac complaint. I assume there is still a cardiologist following her and I would be surprised to learn that this patient would be transferred to a facility with no cath lab at all, even if they are not a STEMI receiving hospital.

I would treat this patient's pain. I would do another 12 lead EKG. If there were really significant/STEMI type changes, I would call the receiving facility's unit charge and ask what they would like. Not sure how it goes in California, here when doing transfers we could call the receving for orders, or medical direction. I am surprised to learn you have no medical direction to consult.
Original plan was to transfer to the hospital with cardiac cath and then send her to the hospital closest to her after. When she refused cath, they decided to send her to the non cath hospital closest to her with a plan to transfer her back and forth for the cath if she decided to do it.
In California, CCT operates off of orders from the sending physician as well as atanding orders.
We usually take MD’s with us on extremely critical calls if they are available in case we need multiple orders live.
We ended up continuing the transport to the destination with morphine and nitro with full relief. 12lead done by hospital at bedside was faxed to the hospitalist who was not concerned for a stemi
 

Akulahawk

EMT-P/ED RN
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Well, I'm seeing this with the "benefit" of having read the conclusion... but what I would have done was what was ultimately done. I would have treated the chest pain using nitro first, then morphine as needed. I didn't see anything that clearly screamed "STEMI" and the patient has already been diagnosed with NSTEMI. I would have wanted to at least see a relatively current 12-lead so that I might do a comparison later, which would have come in handy here.

I would have preferred that she be transferred to a facility that does PCI as they can presumably also care for NSTEMI patients too. However, that's a decision that was likely made jointly between the sending facility, insurance, receiving facility, and the patient. Of course that also means that she would need another transport to a PCI facility should she change her mind about the cardiac cath procedure....
 

Tigger

Dodges Pucks
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I am not seeing any real ST depression in 1 or AVL. The monitor is only calculating them as -0.04 and -0.14 respectively. There is T wave inversion.
Yup you’re right. Nonetheless, such a pattern would be concerning. But also possibly baseline for the patient right now.
 
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