Typical Chest Pain Call

[Shishkabob]

I'm going to get on my soapbox for a minute.

Stent, not stint.

/soapbox

I can buy you stilts for Christmas if you're so self-conscious about being short h34r:

 

[18G]

Given her presentation and history/risk factors of age, HTN, CAD and previous stent placement, I would definitely work her up for ACS. In the field, it's a safe bet to consider all chest pain to be of a cardiac etiology until proven otherwise.

Is the swelling of the feet new onset or does she always have that? You mentioned "high BP meds"... was one of them a diuretic? Has the patient been compliant with her meds and diet?

Also, with the patient stating her chest pain worsened with movement.... did the patient grimace or appear with increased pain or did she just answer yes to your question?

How has she been sleeping at night?

What and when did she eat last?

The nitro that she took... was that from EMS or the patients? If the patients, was it old or still in date?

These are just a few things I would have investigated as well. I would have given ASA and nitro, started a line, performed serial 12-leads, and titrated oxygen to maintain saturation of at least 95% by nasal cannula and transported to local ED.

 

[LAS46]

Is the swelling of the feet new onset or does she always have that? You mentioned "high BP meds"... was one of them a diuretic? Has the patient been compliant with her meds and diet? This is a regular PT and almost every time we have ran on her she has had swelling of the feet. The medication she is on for HTN is not a diuretic and she is compliant with her meds most of the time. She has forgotten to take her meds in the past.

Also, with the patient stating her chest pain worsened with movement.... did the patient grimace or appear with increased pain or did she just answer yes to your question? I was not there when her pain increased... but her answer was basically a yes answer.

How has she been sleeping at night? Did not ask.

What and when did she eat last? She at around 9am and had pancakes, eggs, and bacon with some juice.

The nitro that she took... was that from EMS or the patients? If the patients, was it old or still in date? The NTG was the PTs and was a recently filled Rx.

These are just a few things I would have investigated as well. I would have given ASA and nitro, started a line, performed serial 12-leads, and titrated oxygen to maintain saturation of at least 95% by nasal cannula and transported to local ED. We did have her on a cannula at 4lpm and she was transferred to ALS unit and transported to nearby ED. I am not sure what they did in route but I am sure they did a 12 lead. We also did give her 325mg of ASA at the scene from our unit.

 

[Aidey]

I can buy you stilts for Christmas if you're so self-conscious about being short h34r:

A friend of mine once gave me a step stool for Christmas, lol.


To the OP why wasn't ALS dispatched to this from the get go?

 

[Cameron]

As you may or may not know, I am not certified as a EMT nor CFR. Only advanced First aid CPR... and the other basics.

I have a few questions, not sure if you guys are suppose to ask it.
But seeing that she is taking medications, would you ask:
• Has she just started taking one of the medications within the past week or so?
• If so, what were the signs/symptoms before taking it?
• Has the medication seemed to have helped with the signs/symptoms or have they been in-effective?

With my limited knowledge it seems like a heart attack, thinking about it, COULD it be a clot somewhere?

--Cameron

 

[LAS46]

To the OP why wasn't ALS dispatched to this from the get go?

ALS was dispatched but they arrive almost always when we are ready to load and go. Its the way the EMS system is set up here. They dispatch our county QRTs (Quick Response Teams) but the QRT from ALS personnel is not the best so we end up with only Basics. In this county they dont let EMT-I's use their ALS certs... they can only act as basics on the QRT. QRTs are located throughout the county and our county GOV ambulance service comes from the city which we have the 2nd largest county in the state so the response time for the county rig can be lengthy. QRTs can only transport if a intercept is needed or there is no ALS units available.

 

[LAS46]

As you may or may not know, I am not certified as a EMT nor CFR. Only advanced First aid CPR... and the other basics.

I have a few questions, not sure if you guys are suppose to ask it.
But seeing that she is taking medications, would you ask:
• Has she just started taking one of the medications within the past week or so? This can be asked if you or the PT suspects that they are experiencing one of the side effects of the medication.
• If so, what were the signs/symptoms before taking it?
• Has the medication seemed to have helped with the signs/symptoms or have they been in-effective? This can be asked in this case because we need to know if the medication (in this case Nitro) has helped with the S/S.

With my limited knowledge it seems like a heart attack, thinking about it, COULD it be a clot somewhere?

--Cameron

Answers in bold in quote.

 

[Akulahawk]

Given that I'd be functioning as a Basic here, I'd work her up as a cardiac chest pain patient. Being that she's on HTN meds, has had stents placed in the past, I imagine that she has experienced cardiac chest pain before. I'd want to know how this compares to previous episodes. O2, ASA and NTG if authorized. Being that I'm out in the boonies, I'd want to know how far out ALS is and package for transport.

This is NOT all of what I'd do or ask. My thought process would be to get her moving towards a facility that has a staffed cath-lab in an expeditious, safe manner. In the meantime, I would also do what I can to get her some pain relief. If that means that I transport or I turn her over to ALS, so be it...

 

[LAS46]

Given that I'd be functioning as a Basic here, I'd work her up as a cardiac chest pain patient. Being that she's on HTN meds, has had stents placed in the past, I imagine that she has experienced cardiac chest pain before. I'd want to know how this compares to previous episodes. O2, ASA and NTG if authorized. Being that I'm out in the boonies, I'd want to know how far out ALS is and package for transport.

This is NOT all of what I'd do or ask. My thought process would be to get her moving towards a facility that has a staffed cath-lab in an expeditious, safe manner. In the meantime, I would also do what I can to get her some pain relief. If that means that I transport or I turn her over to ALS, so be it...

I really dont like the EMS system out here... all PTs unless authorized by online med control have to be seen at our Level 4 Trauma Center (Basically a URGENT care center) before they can be transferred to a Level II or Level I facility. If it was up to me all Serious Condition PTs would be transported directly to the Level II facility 80 miles from here and all Green PTs can be transported locally to the Level IV facility.

 

[TransportJockey]

I can sympathize with you there, as that's the way it is here too. Really sucks sometimes.

I really dont like the EMS system out here... all PTs unless authorized by online med control have to be seen at our Level 4 Trauma Center (Basically a URGENT care center) before they can be transferred to a Level II or Level I facility. If it was up to me all Serious Condition PTs would be transported directly to the Level II facility 80 miles from here and all Green PTs can be transported locally to the Level IV facility.

 

[18G]

A patient has the right to be transported to whichever facility they want (within reasonable distance) regardless of what medical command says.

 

[TransportJockey]

A patient has the right to be transported to whichever facility they want (within reasonable distance) regardless of what medical command says.

True. But if patient has no preference, even if we think they need to go to the City, we still have to take them to the County ED

 

[LAS46]

A patient has the right to be transported to whichever facility they want (within reasonable distance) regardless of what medical command says.

I agree with that. There are some exceptions made for those cases but 99% of our PTs dont ask to be taken to a different hospital. And a critical PT cant ask so we still have to do what med control says.

 

[18G]

You could tell the patient which facility you think is most appropriate for their condition and allow them to make an informed decision. There are ways to play the game