NTG for chest pain... even when you're thinking respiratory.

[triemal04]

here is the problem, you have the mentality that just because you think its one thing, you shouldn't treat it as is, but the thing is, you're not out there to diagnose anything. If somebody, after questioning, still states chest pain, even if they have pain on palpation/inspiration, etc, you're more than likely going to give nitro than to not give it, because the point is you're still treating the chest PAIN, not trying to diagnose out in the field. Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because i think its pleuritic.... yeah, but the pt still has pain. and btw, where do you know that gives fibrinolytics out in the field prior to a ct scan to confirm stroke?

Thank you for illustrating in a nice, concise way exactly what is wrong with EMS in this country. It is much appreciated.

And if I bring in someone with non-cardiac chest pain, 1-it won't be me that's talking to the ER staff, exept in rare cirumstances, and 2-the responce to not giving ntg or aspirin would be, "ok," followed by...nobody giving ntg or aspirin for quite some time, if at all.

I'll pass over the "we don't diagnose" BS. But, I do want to just be sure that what you are saying is that everyone who complains of chest pain, no matter the cause, get's ntg and aspirin without any thinking on the providers part. Which would include that 25 year old with a rib fracture, or anyone else with chest trauma. I mean, if you aren't going to think, then that is what you should be doing.

maybe you can call base and see how they feel about you not wanting to give ASA/nitro, but i highly doubt any base is going to say withhold on everything if the pt states there is pain

Well, neither I or anyone I work with (which includes EMT-Basic's) would be calling in to give ntg or apirin, or to withhold it. And I can gaurentee that even if someone did, the answer would be "ok, don't give it." That would be the glory of working in a system that requires the providers to not only think, but think independently.

but then again, it all goes down to where you're working at, protocols, and who your micns are

I don't answer to a nurse, but, in the long term, to my medical director, and in the short term to the recieving ER doctor. Again, the glory of working in a halfway decent system.

You are right though, not everybody is this lucky, some are stuck in a worthless system. But even in those places, there is no requirement that you can't use a little bit of your brain, educate yourself beyond what you were taught in class, and apply that in the field. Blindly following protocol when you KNOW it is wrong without even trying is ridiculous. And using the fallback of "well, they won't let me do it and I'll look stupid if I ask" is truly stupid.

How about this, next time you have someone with right sided chest pain that increases on inspiration, a low grade fever, productive cough with green/yellow thick sputum and maybe some rhonchi, call, CLEARLY EXPLAIN what is happening, and then don't even ask to give ntg or aspirin. Bet you don't get questioned.

 

[usalsfyre]

So much fail to address...

but the thing is, you're not out there to diagnose anything

because the point is you're still treating the chest PAIN, not trying to diagnose out in the field.

The protocols I work under specifically state they are diagnostically based. If your giving drugs you better darn well be making a diagnosis, even if a nutless instructor clings to this, it's not true.

Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because i think its pleuritic.... yeah, but the pt still has pain.

I'll be looked at like an idiot (or a certain large FD medic) if I gave NTG and ASA to that patient. How about an NSAID or narcotic for the muscoskeletal pain instead of NTG which is not going to come close to helping.

maybe you can call base and see how they feel about you not wanting to give ASA/nitro, but i highly doubt any base is going to say withhold on everything if the pt states there is pain

Right, let's punt the decision off. I'd say "follow your protocol" too.

but then again, it all goes down to where you're working at, protocols, and who your micns are

The majority of paramedics in the US don't take orders from mere nurses (putting on my asbestos undies for that one)

 

[themooingdawg]

i dont disagree with you guys with the fact that if its obvious pleuritic cp or traumatic chest pain that giving asa or nitro obviously will not do anything, thats why i said "after a thorough assessment" obviously traumatic chest pains has no need for any medications, same with pleuritic, but, the thing is I'm going to let base, at least with us in la county, know whats going on with the pt and let them guide it and see if they want to administer. outside of trauma related cp, if its cp with a medical origin, I'm not going to withhold medications that i think might help the pt just because i think its so and so. and what happens if we get in the ER, i say i didn't give anything because i had thought it was so and so, and then there is something underlying wrong with the pt? its not a great system, but unfortunately paramedics in la county are severely protocol driven

 

[themooingdawg]

we don't have as much freedom as most other ems systems unfortunately

 

[themooingdawg]

Thank you for illustrating in a nice, concise way exactly what is wrong with EMS in this country. It is much appreciated.

And if I bring in someone with non-cardiac chest pain, 1-it won't be me that's talking to the ER staff, exept in rare cirumstances, and 2-the responce to not giving ntg or aspirin would be, "ok," followed by...nobody giving ntg or aspirin for quite some time, if at all.

I'll pass over the "we don't diagnose" BS. But, I do want to just be sure that what you are saying is that everyone who complains of chest pain, no matter the cause, get's ntg and aspirin without any thinking on the providers part. Which would include that 25 year old with a rib fracture, or anyone else with chest trauma. I mean, if you aren't going to think, then that is what you should be doing.

Well, neither I or anyone I work with (which includes EMT-Basic's) would be calling in to give ntg or apirin, or to withhold it. And I can gaurentee that even if someone did, the answer would be "ok, don't give it." That would be the glory of working in a system that requires the providers to not only think, but think independently.

I don't answer to a nurse, but, in the long term, to my medical director, and in the short term to the recieving ER doctor. Again, the glory of working in a halfway decent system.

You are right though, not everybody is this lucky, some are stuck in a worthless system. But even in those places, there is no requirement that you can't use a little bit of your brain, educate yourself beyond what you were taught in class, and apply that in the field. Blindly following protocol when you KNOW it is wrong without even trying is ridiculous. And using the fallback of "well, they won't let me do it and I'll look stupid if I ask" is truly stupid.

How about this, next time you have someone with right sided chest pain that increases on inspiration, a low grade fever, productive cough with green/yellow thick sputum and maybe some rhonchi, call, CLEARLY EXPLAIN what is happening, and then don't even ask to give ntg or aspirin. Bet you don't get questioned.

when i say cp, i mean cp with medical in origin, not cp due to some form of trauma

 

[triemal04]

i dont disagree with you guys with the fact that if its obvious pleuritic cp or traumatic chest pain that giving asa or nitro obviously will not do anything, thats why i said "after a thorough assessment" obviously traumatic chest pains has no need for any medications, same with pleuritic, but, the thing is I'm going to let base, at least with us in la county, know whats going on with the pt and let them guide it and see if they want to administer. outside of trauma related cp, if its cp with a medical origin, I'm not going to withhold medications that i think might help the pt just because i think its so and so. and what happens if we get in the ER, i say i didn't give anything because i had thought it was so and so, and then there is something underlying wrong with the pt? its not a great system, but unfortunately paramedics in la county are severely protocol driven

Well, you do work in hell I guess, so I could make some allowances for you...but...no.

You rather contradicted yourself above, you know that? You know that ntg/aspirin will not help in non-cardiac chest pain...but you'll still give it anyway, or in the most cop-out kind of way, let someone else make your decision for you. Cheers to you friend, thanks for helping to make EMS what it is today.

I understand that you work in a lousy place and that to a certain extent your hands are tied, so at least some of this you can't do anything about and it isn't your fault. But the bolded parts of your above statement...come on, you should be striving to be a much better provider than that makes you appear. Your hands may be a bit tied, but you can at least try and do what's right for your patients and think for yourself.

Seriously, next time you have a patient who has chest pain that is not cardiac, do what I suggested, report in detail what you have and then DON'T ASK for ntg/apirin. If they order you to give it anyway...sucks, but at that point it no longer is your fault, you did what you could. If they don't...congrats you just took your first step in becoming a better provider.

As far as liability...educate yourself. Learn how to do a real, detailed, thorough exam, learn how to read a 12lead for yourself, not just the monitors interpretation and you'll be ahead of the pack. At that point, if you are questioned on why you did/didn't do something, you can explain that because of A, B, C, and D, your assessment was E, which meant that F wasn't needed.

And, at some point, you will be wrong. It'll happen, But, contrary to what you see on TV and may have learned in school, delaying ntg and aspirin for a relatively short amount of time in someone having a subacute event is not going to kill them or generally even cause a poor outcome. If you can, hang out in an ER sometime and watch how long most people who come in complaining of chest pain go before they get treated. You'll probably be surprised.

when i say cp, i mean cp with medical in origin, not cp due to some form of trauma

No. If you are going to be a mindless protocol monkey, then be a mindless protocol monkey. If you can't tell what is cardiac and not cardiac chest pain, then you can't tell what is traumatic chest pain either. Who's to say that nice 65 year old diabetic who fell, hit his chest on the arm of a chair and is now having right sided pain that increases on palpation and inspiration is not having atypical cardiac chest pain? I mean, who could tell in that case, right?

 

[STXmedic]

here is the problem, you have the mentality that just because you think its one thing, you shouldn't treat it as is, but the thing is, you're not out there to diagnose anything. If somebody, after questioning, still states chest pain, even if they have pain on palpation/inspiration, etc, you're more than likely going to give nitro than to not give it, because the point is you're still treating the chest PAIN, not trying to diagnose out in the field. Yeah, patient might be pleuritic in nature, but how are you gonna look when u come into the ER and say pt has chest pain, blah blah blah, pain of 9/10, oh but we didn't give any nitro because i think its pleuritic.... yeah, but the pt still has pain. and btw, where do you know that gives fibrinolytics out in the field prior to a ct scan to confirm stroke?

I don't know whether to LMAO or SMH :unsure: As usals stated, so much fail... I may address later, too much to type to do it on the phone.