Ruling out MI - Pressing on Patient's Chest

[usalsfyre]

Clare, I think you're getting hung up on terminology here. Not an unusual thing, but just understand "provisional" doesn't really offer any protection.

I practice medicine and make diagnosis every time I'm on the truck. It may have some warm a d fuzzy "provisional", "field", "working" ect in front of it but it is a diagnosis. A LOT of patients get admitted from the ED doc with a diagnosis as vague as "short of breath".

 

[Clare]

Is "provisional diagnosis" somehow not "rule in"? I wouldn't give ASA or NTG if I didn't "rule in" ACS. I'm not quite sure what you're trying to say here.

I guess I am agreeing with you that yes, you can "rule in" an MI but that you cannot rule one out just because the chest pain is only reproducable upon palpation.

Not an unusual thing, but just understand "provisional" doesn't really offer any protection.

I practice medicine and make diagnosis every time I'm on the truck. It may have some warm a d fuzzy "provisional", "field", "working" ect in front of it but it is a diagnosis. A LOT of patients get admitted from the ED doc with a diagnosis as vague as "short of breath".

I am not saying it does offer any protection; a provisional diagnosis is something I've made plenty of so no problem there; if you cannot find a cause of their chest pain that is very obviously not cardiac then they have myocardial ischaemia until proven otherwise and should be taken to the hospital for further evaluation.

 

[usalsfyre]

And if it isn't Delta traffic chest pain it is 6-D-1 because they're having trouble breathing...because they're puking...

Dispatch:"Are you having any problems breathing"

Caller:"Well my nose is a little stuffy..."

Dispatch "OMG DELTA LEVEL CALL"

Thank you EMD...

 

[Aidey]

Dispatch:"Are you having any problems breathing"

Caller:"Well my nose is a little stuffy..."

Dispatch "OMG DELTA LEVEL CALL"

Thank you EMD...

Urgh... Our main dispatch center doesn't use normal EMD. They have their own in house developed version, and all sorts of stuff gets coded as a delta that would be Charlie under normal EMD standards.

 

[Christopher]

I guess I am agreeing with you that yes, you can "rule in" an MI but that you cannot rule one out just because the chest pain is only reproducable upon palpation.

Yep.

"Ruling out" is a tricky subject. You have to talk about pre-test probabilities and likelihoods and risk assessments (PERC? EMS don't need no steenkin PERC) which we were never properly educated about.

Which unfortunately is why lots of seemingly obvious non-ACS "chest pain" patients still get 324mg ASA, an IV, and a "trial" of NTG in the field.

 

[Clare]

"Ruling out" is a tricky subject. You have to talk about pre-test probabilities and likelihoods and risk assessments (PERC? EMS don't need no steenkin PERC) which we were never properly educated about.

Which unfortunately is why lots of seemingly obvious non-ACS "chest pain" patients still get 324mg ASA, an IV, and a "trial" of NTG in the field.

I haven't heard of PERC?

For somebody to get GTN they should have no obvious non-cardiac cause for their chest pain as well as findings that are consistent with myocardial ischaemia. If I am seriously in doubt and it's 50/50 as to whether somebody has myocardial ischaemia then they will probably get 0.4 mg of GTN as a "tester".

You must not assume that a "good" response to GTN means it is cardiac chest pain as it might just be a placebo effect.

If somebody has "chest pain" or "chest tightness" but a normal ECG and no history that is significant for MI risk factors or prevoking events then they aren't getting GTN from me.

At the end of the day 0.4 mg of GTN is not going to kill them, might make them a bit light headed or give them a headache but it should not be given if not indicated.

In saying all of that I am not overly convinced there is a significant role for GTN in a MI; it is a treatment for angina and not MI. It might help a bit by reducing preload but certainly aspirin has been shown to be far more beneficial.

Now as for putting in an IV, I was once told to put an IV into everybody I thought was having a cardiac event to save having to do it when they arrested.

 

[Christopher]

I haven't heard of PERC?

Pulmonary Embolism Rule-Out Criteria usually thrown in with Wells' Score. Which are great tools...if the patient meets the appropriate pre-test probability of having a PE ;-) Often, simple clinical gestalt is as accurate; but that'd get you in trouble if you "miss" something.

For somebody to get GTN they should have no obvious non-cardiac cause for their chest pain as well as findings that are consistent with myocardial ischaemia. If I am seriously in doubt and it's 50/50 as to whether somebody has myocardial ischaemia then they will probably get 0.4 mg of GTN as a "tester".

You must not assume that a "good" response to GTN means it is cardiac chest pain as it might just be a placebo effect.

If somebody has "chest pain" or "chest tightness" but a normal ECG and no history that is significant for MI risk factors or prevoking events then they aren't getting GTN from me.

At the end of the day 0.4 mg of GTN is not going to kill them, might make them a bit light headed or give them a headache but it should not be given if not indicated.

In saying all of that I am not overly convinced there is a significant role for GTN in a MI; it is a treatment for angina and not MI. It might help a bit by reducing preload but certainly aspirin has been shown to be far more beneficial.

My gripe was more with the lock-step protocol adherence I often see due to a lack of an education to make a better decision.

Now as for putting in an IV, I was once told to put an IV into everybody I thought was having a cardiac event to save having to do it when they arrested.

Meh, I fall into the Palin camp on this one...Drill baby! Drill!

 

[Clare]

Meh, I fall into the Palin camp on this one...Drill baby! Drill!

Given the progressive deemphasis of IV access and IV drugs in primary cardiac arrest (they are now a very low priority) I wouldn't be overly quick to put in an IO unless three IV attempts have failed, including the foot and external jugular.

For somebody who has arrested due to asthma, anaphylaxis or hypovolaemia and needs adrenaline or fluid very promptly then yes I would be a bit quicker.

 

[DrParasite]

And if it isn't Delta traffic chest pain it is 6-D-1 because they're having trouble breathing...because they're puking...

According to ProQA, it's not: it's a 6-C-1 or 2, because they are not breathing normally while puking.....

when asked of the instructor, the response was "we would rather over dispatch than under dispatch."

As for the OP, check out these articles by reputable people:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC549654/

http://www.aafp.org/afp/2005/1115/p2012.html

http://jama.jamanetwork.com/article.aspx?articleid=201900

http://sfghed.ucsf.edu/Education/Lectures/Syllabus/ChestPain.pdf

I know many paramedics that still do the reproducible chest pain = not cardiac related, and have done it myself. that being said, the studies show it isn't as accurate as the providers seem to think.

 

[Shishkabob]

You can make a provisional diagnosis of MI yes but such a diagnosis is subject to confirmation.

I make a diagnosis. I don't make a 'provisional diagnosis'. I don't make a 'working diagnosis'. I don't make a 'field diagnosis'. I may have a differential diagnosis to get to my decision, but I diagnose.

Just because it may end up changing in the end doesn't make it any less of a diagnosis.




You have a patient with an angulated piece of solid white material sticking out of their leg after an MVC. Is it a compound fracture? A patient's arm is separated from the rest of the body. Is it an amputation? CAREFUL! That would be diagnosing something!

 

[KellyBracket]

Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?

Google wasn't as helpful as it usually is!

 

[Clare]

Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?

Google wasn't as helpful as it usually is!

I have no idea, I've never heard that.

A Physician makes a medical diagnosis,
A Nurse makes a nursing diagnosis,
A Paramedic makes a provisional diagnosis,
A Mechanic makes a mechanical diagnosis ...

Each of those is a diagnosis but they may be different than each other depending upon the type of diagnosis being made; certainly a medical and nursing diagnosis differ but the Paramedics provisional diagnosis and the Physicians medical diagnosis may be the same or differ too depending on what is found but they are both for all intents and purposes a diagnosis.

 

[Aidey]

Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?

Google wasn't as helpful as it usually is!

No idea, but some people will defend that myth until they hyperventilate themselves out.

 

[RocketMedic]

Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?

Google wasn't as helpful as it usually is!

Poorly trained EMS leadership, doc. Poorly trained and undereducated leadership.

 

[TomB]

Incidentally, does anybody know where the myth/dogma about "only doctors diagnose" first came up? An old textbook, or a quotation from some long-gone luminary?

Google wasn't as helpful as it usually is!

Generally speaking (and I know this view isn't popular) I do not believe that paramedics diagnose. We treat a "field diagnosis" at best. You could argue that every diagnosis is a "working diagnosis" subject to change based on new information but the reality is that a paramedic's education is not based on developing a differential diagnosis. It's a technician education and while I wish it was different we just don't have enough education to "know what we don't know" unless we've done a huge amount of aftermarket education or self study. If we could really diagnose then we wouldn't see so many studies showing we can't even predict who needs to be seen in the emergency department and who can be left on scene safely (one of the most glaring failures of paramedic education in the United States). After 15 years in the field full time and 17 years as a paramedic (including one year in a stepdown unit and experience working in 2 different emergency departments) there are some things I can diagnose but many other situations where I'm happy to leave the definitive diagnosis and treatment to physicians. It doesn't bruise my ego in the slightest. I really don't care if we're technicians. I just want us to be really good ones and do the right thing for the patient. I actually think you can be a technician who exercises sound clinical judgment (what should I do, what should I not do).

 

[mycrofft]

I skimmed the comments and many had merit, but I liked this one best

I have no idea, I've never heard that.

A Physician makes a medical diagnosis,
A Nurse makes a nursing diagnosis,
A Paramedic makes a provisional diagnosis,
A Mechanic makes a mechanical diagnosis ...

Each of those is a diagnosis but they may be different than each other depending upon the type of diagnosis being made; certainly a medical and nursing diagnosis differ but the Paramedics provisional diagnosis and the Physicians medical diagnosis may be the same or differ too depending on what is found but they are both for all intents and purposes a diagnosis.

And every one except the top one is based on a protocol rooted in the top one. ANy valid protocol below MD which starts with the name of a diagnosis instead of a sign or anatomic area (e.g., "MI", instead of "Chest Pain" or "Chest" or "Thorax") is also invalid as it presupposes the practitioner has already made a medical diagnosis.
===============================================
Back on track:

OP: any question which relates one s/s as THE certain indicator of a condition, especially for protocol-driven practitioners, is invalid.

Think of it as Venn diagrams (intersecting circles? Remember?). Each sign and symptom is a circle (list of s/s), and where most of them intersect indicates the likely diagnosis, or the applicable protocol/action. Remember it is not certain, and pts often have more than one problem, plus historians can influence histories.

OK, you're a day's hike from help at an expensive rental and your significant other c/o chest pain. You can instantly drop everything and carry them to help, or consider the following:

1. VS including rate, regularity and quality of apical and palpated pulses and respirations; plus chest auscultation.
2. Palpate costochondral areas firmly but not hard to elicit tenderness, malformation or crepitus; ditto thoracic spine . If you don't know what costochondral area is, skip it, and tend towards transport.
3. Observe for bruising, lumps, foreign objects, asymmetries, shifts.
4. Observe for SOB, pallor or cyanosis, air hunger, guarding.
5. Observe for level of energy and affect (tired/discouraged/scared?).
6. Ask about hx of indigestion, belching, similar earlier episodes, any earlier dx. If so, do these episodes get better with eating, antacids, sitting up? Worse with swallowing? Worse or better with position of neck/head, arms? Worse with a deep breath?
7. ASK what the pain felt like: zipping, tearing, electric shock, sudden or slow onset, sudden or slow recession, or is it ongoing?

And some others. NO mention of a pulse ox, labs, ekg.

These presume you have the knowledge base (didactic and practical), the confidence to use your senses, and are not in a situation where you are bound by protocol to act in a certain manner.

And you could STILL have your loved one keel over and die in your arms.

Tenderness of the chest does not rule-out MI. Tenderness reproducing the exact sensation plus normal s/s and VS means it makes the picture look more optimistic. Follow your protocols and learn.:angry:

EDIT: Well, I thought of one; absence of breathing for over three minutes is presuptive for respiratory failure. The differential gets sticky, but safety, airway and BVM is indicated STAT.

 

[Clare]

And every one except the top one is based on a protocol rooted in the top one. ANy valid protocol below MD which starts with the name of a diagnosis instead of a sign or anatomic area (e.g., "MI", instead of "Chest Pain" or "Chest" or "Thorax") is also invalid as it presupposes the practitioner has already made a medical diagnosis.

This makes absolutely no sense to me whatsoever.

A medical diagnosis is made by a Doctor, a nursing diagnosis is made by a Nurse, a provisional is made by a Paramedic. They are all inherently the same but inherently different and serve different purposes but are made after collecting a history, signs and symptoms, results of investigations etc and drawing upon a base of knowledge which may be anatomical, physiological, pathological, microbiological, psychological and/or a few others or likely all of them.

You cannot use a "protocol" to make a diagnosis.

A Nurse does not need a Doctor to make a nursing diagnosis, a Doctor does not need a Nurse to make a medical diagnosis, a Paramedic does not need a Doctor to make a provisional diagnosis and a Mechanic does not need a Vet to make a mechanical diagnosis. They are completely independent of one another.

To say that only a Doctor makes a diagnosis is very narrow minded. If the patient is immediately referred to a Doctor then the Doctor will make his medical diagnosis however that has no bearing on what the provisional diagnosis of the Paramedic was or how or if the Paramedic will treat the patient, the two are for all intents and purposes totally separate.

 

[VFlutter]

But what about PA/NP do they make semi medical diagnosis? lol

 

[Aidey]

This makes absolutely no sense to me whatsoever.

A medical diagnosis is made by a Doctor, a nursing diagnosis is made by a Nurse, a provisional is made by a Paramedic. They are all inherently the same but inherently different and serve different purposes but are made after collecting a history, signs and symptoms, results of investigations etc and drawing upon a base of knowledge which may be anatomical, physiological, pathological, microbiological, psychological and/or a few others or likely all of them.

You cannot use a "protocol" to make a diagnosis.

I'm pretty sure what he is saying is that in order to pick a protocol to follow you have to have come up with a diagnosis.

 

[TheLocalMedic]

I personally feel that a lot of people get "hung up" on making a diagnosis on a call. Often there's a lot of glaringly obvious evidence that points to a diagnosis, but even if there isn't, then so what? I can just as thoroughly diagnose a patient as a doctor can, but the difference I see is that I just don't have the same tools to use to confirm the said diagnosis. And I caution people about being too quick to try and diagnose, or to make symptoms try and fit what you are leaning towards. Trying to diagnose everyone can quickly lead you to putting on blinders about other symptoms that might point to multiple problems or shift your entire diagnosis.

But I digress...

As to the original question about palpating a chest to rule out MI: I feel that, in general, if someone has a vague complaint of chest pain that's tender to palpation and there are no other symptoms or clinical findings that may indicate ischemia, then it's a pretty safe bet that what they are experiencing isn't an MI. Granted, if you push hard enough you'll elicit a reaction in just about anyone, but a reasonable amount of pressure producing pain seems to almost certainly to rule the problem as musculoskeletal.