Chest pains

[trauma1534]

Here is yet another call that I had recently, try this one out. Tell me if you think this is cardiac related... if not what do you think.... also what is your tx plan for this patient????

You are dispatched to a 21 year old male patient having chest pains, pain down BOTH arms, difficulty breathing and nausea.

Upon arrival, you find a healthy looking 21 year old male, down on the ground beside of his car in the yard, vomiting and crying from pain. Family reports to you that he has no medical history... no allergies... has been otherwise health, fresh out of marine boot camp. Upon assessment you see no signs of trauma. When you ask patient what is going on, he states that his chest feels like something is setting on it, both arms are radiating with pain. He also states that he is having problems catching his breath. On a pain scale of 0-5, he says it is a 4. Vitals are as follows: Resp. rate: 36, Pulse: 120, B/P 210/114. Lungs: clear bilateral, no JVD, no Treachea Deviation, PERL. You load him into the truck on the stretcher. In the back of the truck, he now tells you that the pain is getting worst, but is feeling different. The chest pain is now a sharp stabbing pain, radiating to us LUQ.

What are you thinking... what is your plan of action? I will then tell you what I did and what the diagnosis was from the ER doctor.

Have fun!

[daemonicusxx]

You said BLS providers, but i want a strip. O2, IV. not sure what it is though, i guess diesel therapy would work too.

[ndilley]

tough one...well first things first, O2 is a must. another set of vitals, consider nitro, if not cardiac would help with b/p, even though bls; might hook up to a monitor (if avaliable) just to see anything completely abnormal...
also thinking possible pancreatitis b/c of LUQ pain... and of course when all else fails consume copious amounts of fuel and run L&S to hospital

[Jon]

I can't really say weather or not it was cardiac until I've seen an EKG, preferably a 12-lead.

Sounds like the kid has something going on, but don't know what - he needs to go to the hospital is for sure.

Jon

[Chimpie]

Was he smoking "anything" or taking any drugs?

I didn't think they came home after boot camp. Where was he serving prior to coming home?

(okay, I've been watching too much House lately)

[Jon]

Ok . I thought you were just asking "cardiac or non-cardiac"

here is my full answer (on 7 hours of sleep in 72 hours :rolleyes: ).

I'm thinking apendicitis is a possibility - often happens to young, otherwise healthy folk.

Also, could be fractures or bruising from "something" at boot camp (Hazing can still be part of military life, and the guy JUST got through boot camp)


Treatment - transport in a position of comfort, higfh-flow O2 and Class III to the closest ED. If transport will be greater than 5 minutes, consider an ALS intercept for both the cardiac monitor, and possibly pharacological analgesia.

Jon

[emtbuff]

I would agree with the others with the High flow O2, and diesel therapy. And depending on if I could determine cause I would alert the hospital to consider having the chopper crew come in.

It could be either something internal like the appendix or pancrease. Or it could be trauma of some sort.

For those that are ALS I would start a line, nitro, an analgesic, and a strip.

[AnthonyM83]

I'd be thinking appendix or as Jon said, broke something. Something floating around in there (shrapnel?) poking at stuff.

O2, position of comfort, calm & soothing voice.

What's diesel therapy? Pedal to the metal?

[ndilley]

hey trauma when you going to post what the doc said??? the suspense is killing me :ph34r:

[TTLWHKR]

Originally posted by MedicStudentJon@Nov 26 2005, 07:27 AM
Appendicitis
:blink: Left Upper Quadrant
Maybe RUQ, mid naval, possible even LLQ..


Cx Pn. LUQ. Gets worse when sitting, possibly laying.

Broken rib, punctured lung, partial pneumothorax, pleurisy, descending colon obstruction, kidney stones, internal bleeding from a fall, ulcer, pancreatitis, Splenic injury or rupture, Aneurysm, renal failure, Diverticulitis ?

People who have lost a fair amount of blood internally, weather into the abdomen, or bowels often complain of pain in the chest, neck, and arms from lack of perfusion. As the body is trying to compensate for the loss of fluids, electrolytes, and cells.


The normal stuff.. He's a too hypertensive for a young, fit male. ECG, IV 120xhr, 3xASA, 2xNstat, no pain management. If you get rid of the pain, how will the er doc be able to determine what is causing it, if it is a soft tissue injury? Pn on inspiration/expiration? pnt tenderness?
Since it's LUQ, I'd want to know if he's ingested anything unusual, or what he has eaten in the past 48 hours. I.e. fish, peanuts, clams, anything with bones or bone fragments, last BM, any blood? check for bowel sounds. Any problems urinating, color, etc. Could the pain be in his back, and just feels like the chest, i.e. kidney stones. Febrile? Abdominal tenderness, rigidity, distension?

[bravofoxtrot]

Taking another shot in the dark, possibly a pulmonary embolism? But with that BP it doesn't really sound like that either.

I really would not go with appendicitis, but I wouldn't rule it out either. Appendicitis is usually umbilicus to RLQ. LLQ pain usually goes with diverticulitis.

Give O2, get a strip on him. (Even if it's only Lead II.) Diesel.

[bravofoxtrot]

BTW, was he coughing up anything?

Could be cardiac, maybe even an MI, but for his age and shape I doubt it. Who knows, could be a genetic problem with his heart. Some family history enroute might reveal something. That LUQ pain could just be associated pain from the rest of the chest.

[MedicPrincess]

High Flow O2, get'em to the ER.

I am going for Pancreatitis or Gall Bladder.

[CaptainPanic]

OK, Im going to ignore everyone elses answeres and take a stab at it... so here goes, WEEEEEEEEEEEEEEE!!!

OK I have 21 y/o male c/c of pain in his chest bilaterally and pain raidiating down his arms. He his vomiting and appears nauseated. (This is my initial asessment)

You said his V/S were as follows:
BP: 210/114
Pulse: 120
R/R: 36
Lungs: clear bilateral, no JVD, no Treachea Deviation, PERL
He has pain in his LUQ (Left Upper Quadrant).
Also other V/S I need to make a better asessment:
Pulse Ox (I know this doesnt say a whole lot - but it does tell me if hes getting enough oxygen saturation.)
Skin: Is the skin normal, is it abnormal? (tell me cold, hot, dry, moist, clammy, pale, cyanosis,etc)
Pupils: are his pupils equal and reactive? (This might tell me if the kid is on some sort of drugs that the family doesnt know about - crack-cocaine use has a side effect of nuasea) :ph34r:


Im going to use SAMPLE and OPQRST to find my Hx.
S- Severity: You used the 0-5 scale, pt said it was rated as 4
A- Allergies: He has no known allergies
M- Medications: You never said if he was on any type of medication. Please give me this info.
P- Pertinent Medical Hx: You said the family said he has been otherwise healthy.
L- Last Oral Intake: What was the last thing he took by mouth (food, meds, liquids)
E- Events leading to illness: What was he doing before the onset? Was he doing strenous activity such as basketball, running, mowing lawn??? Please give us this info.

Now for my OPQRST
O- Onset: What was the onset- what caused it, when did it happen??
P- Provokes: What makes it worse? (Now that hes lying down on the stretcher and is c/o his pain becoming stabbing, Im going raise him to semi-fowlers/fowlers position, maybe even lay him on his left side if he is still nauseated. I'll be prepared suction at this point)
Q- Quality: What type of hurt is it? (Pt said stabbing after we got him in the truck)
R- Radiate: The pt said that he had pain radiating down both arms in the initial assessment, now after loading in the truck, he said it radiates to LUQ.
S- Severity - Pt said it is now a stabbing pain. In the initial assessment he rated at 4 (0-5) scale, I want to know if it is worse now.
T- Time: What time was it when it started?

Now for the rest of my asessment:
Im going to palpate his abdomen, focusing on his LUQ looking for tenderness, distension, pain upon palpation, also is the pt guarding his abdomen?

With his pain becoming worse and a high BP for his age Im going to contact Med Control to get the OK to administer NTG sublingually to bring his BP down. I will also administer 02 via NRB @ 15lpms - if unable to handle the NRB I will use cannuala at 4lpms.

This is a load and go. With his pain progressively getting worse and depending on what the ETA is to the nearest hospital is I may request for ALS intercept.

At the ER Id like to see fluids via IV and a cardiac workup just to be on the safe-side, given the pulse and BP. According to my texts, stabbing pain in the LUQ could mean Liver, spleen, kidney, stomach, colon, pancreas. With the nausea, Im going to lean towards stomach/colon/kidney problems.

Now whats the Dx Doc???? ;)

-CP

[TTLWHKR]

Originally posted by CaptainPanic@Nov 28 2005, 10:19 AM
OK, Im going to ignore everyone elses answeres and take a stab at it... so here goes, WEEEEEEEEEEEEEEE!!!

OK I have 21 y/o male c/c of pain in his chest bilaterally and pain raidiating down his arms. He his vomiting and appears nauseated. (This is my initial asessment)

You said his V/S were as follows:
BP: 210/114
Pulse: 120
R/R: 36
Lungs: clear bilateral, no JVD, no Treachea Deviation, PERL
He has pain in his LUQ (Left Upper Quadrant).
Also other V/S I need to make a better asessment:
Pulse Ox (I know this doesnt say a whole lot - but it does tell me if hes getting enough oxygen saturation.)
Skin: Is the skin normal, is it abnormal? (tell me cold, hot, dry, moist, clammy, pale, cyanosis,etc)
Pupils: are his pupils equal and reactive? (This might tell me if the kid is on some sort of drugs that the family doesnt know about - crack-cocaine use has a side effect of nuasea) :ph34r:


Im going to use SAMPLE and OPQRST to find my Hx.
S- Severity: You used the 0-5 scale, pt said it was rated as 4
A- Allergies: He has no known allergies
M- Medications: You never said if he was on any type of medication. Please give me this info.
P- Pertinent Medical Hx: You said the family said he has been otherwise healthy.
L- Last Oral Intake: What was the last thing he took by mouth (food, meds, liquids)
E- Events leading to illness: What was he doing before the onset? Was he doing strenous activity such as basketball, running, mowing lawn??? Please give us this info.

Now for my OPQRST
O- Onset: What was the onset- what caused it, when did it happen??
P- Provokes: What makes it worse? (Now that hes lying down on the stretcher and is c/o his pain becoming stabbing, Im going raise him to semi-fowlers/fowlers position, maybe even lay him on his left side if he is still nauseated. I'll be prepared suction at this point)
Q- Quality: What type of hurt is it? (Pt said stabbing after we got him in the truck)
R- Radiate: The pt said that he had pain radiating down both arms in the initial assessment, now after loading in the truck, he said it radiates to LUQ.
S- Severity - Pt said it is now a stabbing pain. In the initial assessment he rated at 4 (0-5) scale, I want to know if it is worse now.
T- Time: What time was it when it started?

Now for the rest of my asessment:
Im going to palpate his abdomen, focusing on his LUQ looking for tenderness, distension, pain upon palpation, also is the pt guarding his abdomen?

With his pain becoming worse and a high BP for his age Im going to contact Med Control to get the OK to administer NTG sublingually to bring his BP down. I will also administer 02 via NRB @ 15lpms - if unable to handle the NRB I will use cannuala at 4lpms.

This is a load and go. With his pain progressively getting worse and depending on what the ETA is to the nearest hospital is I may request for ALS intercept.

At the ER Id like to see fluids via IV and a cardiac workup just to be on the safe-side, given the pulse and BP. According to my texts, stabbing pain in the LUQ could mean Liver, spleen, kidney, stomach, colon, pancreas. With the nausea, Im going to lean towards stomach/colon/kidney problems.

Now whats the Dx Doc???? ;)

-CP
Know what would suck?


If he didn't come back with the answer to our pondering... :blink:

[bravofoxtrot]

That would...watch, he probably won't come back now.

[squid]

I guess I would treat him for pain because those symptoms might all be secondary to really intense pain -- saw a guy like that once with stomach ulcers. Of course, we were a couple hours from the hospital, not 5 minutes, so that might make a difference.

[CaptainPanic]

Great now that I did that entire speel, he aint gonna come back-

I guess someone else could step in and make up some stuff so we can finish the scenario at least----- perhaps do a role-playing thread. ;) :lol: :D

[squid]

Ow! Ow! Owwwwwwwww!

Huh, I think my acting's better IRL than here.

[TTLWHKR]

Originally posted by squid@Nov 29 2005, 06:26 PM
Ow! Ow! Owwwwwwwww!

Huh, I think my acting's better IRL than here.
Hits squid with a rolled up newspaper.

Someone email him...

[trauma1534]

;)
OK the moment that everyone has been waiting for!!! This is the rest of the story...

Ok, so we loaded him up. Gave him O2/15 LPM/NRB. Ran a strip, ST. Started an IV, hung a bag. Administered ASA, with no relief. Update on vitals, no change... he is starting to slow his breathing down... with doing that, his arm pain is now going away... by the way the arm pain is not really pain at all, it is comming from hyperventalating... we then preceded to give 1 Nitro 0.4/SL, B/P came down, but his pain is no better, it is now moving more towards his RUQ, still in the chest also... the pain is discribed as a stabbing pain now. We then administered 2mg Morphine... pain much more better now. Resps are normal again, B/P is stable acceptable at this time.

When doing the follow up on this patient, it was diagnosed as Gall Bladder rupture... he had surgury that night and did fine. Who would have ever guessed!

Great job you guys! I will keep posting more calls on this site. I won't wait as long next time before I come back with the rest of the story! Good Sports! Gotta run! :P

[CaptainPanic]

So I guess my pt lived afterall?? LOL.

Thanks for the update truama. I wish we had more scenarios. Im awful at the thinking up of good scenarios.

-CP

[Jon]

Good show... I went at it from the BLS side.

It is REALLY good to see an ALS provider not afraid to push drugs for patient comfort.


Jon

[nyc.ems]

i've would have ruled out ulcers or anxiety attack..

[CaptainPanic]

For my PAs, I usually try to ask questions that rule out things to narrow it down a little more and hopefully Im treating the ailment thats causing the pts discomfort.

-CP

[FFEMT1764]

I always get the pt to point with 1 finger to where it hurts then ask them to describe the pain....I do all this after they are calm-doesnt work if they have been hyperventilating for the past 30 minutes...everythings numb and hurts then!

[TTLWHKR]

Paper-Bag...

[FFEMT1764]

The paper bag is absolutely contraindicated per our protocols...we have to use the NR at 2lpm technique...as to not deprive the pt of oxygen!

[Wingnut]

The paper bag is absolutely contraindicated per our protocols...we have to use the NR at 2lpm technique...as to not deprive the pt of oxygen!


There's also a condition that some have in which breathing the carbon dioxide through the bag will kill them. Can't remember what it's called though. It's completely against our protocols because of this.

[MedicPrincess]

;)

When doing the follow up on this patient, it was diagnosed as Gall Bladder rupture...

Who would have ever guessed!
:P


SINCE you asked....I did. I guessed Gall Bladder. Yep, me. :P B) :)

[TTLWHKR]

There's also a condition that some have in which breathing the carbon dioxide through the bag will kill them. Can't remember what it's called though. It's completely against our protocols because of this.



I was being sarcastic. <_<

[Recruiting]

I know it's an old post but there are some recent posts sooooooo.

How did you assess the Chest Pain?
The fact the CP was pleuritic in nature could have been discovered with a directed verbal assessment. Sir, take a deep breath, does it get worse or better. (a RGB patient would surly say the pain got MUCH worse) pleuritic in nature right? The physical movement of the pt's trunk with each breath would have made the patient scream in pain, any movement would. Not a cardiac problem

PHYSICAL EXAM & Scene: Man down outside, awake, Scene safe, no trauma suspected on visual inspection, 21 year old "healthy" male patient AOx3?, PERLS, JVD?, no allergies, VITALS, in MOD resp distress(perceived as dyspnea), no pert medical hist, was he on any MEDS? (history or no), substernal CP with bilat arm pain, skin color?,Skin feel?, temp?, pulse ox reading? 0-70 -95%??. turger?, patients Grip strength, postural?...


The chest pain is now a sharp stabbing pain, radiating to his LUQ moving everywhere it seems. The GB sits just below the rib cage on the right of the pt's stomach. If the patient ABD was palped that area URQ would have presented VERY TENDER! With that being the case at that point your going in a new direction with your working diagnosis, aye. Thus ruling out a Cardiac event.

INTERVIEW:Was this asked? last time he went? what did it look like: dark tarry, "light chaulky"<--GB issues-->Constipation?, if so how long, pain: sudden onset? What were you doing just prior to this incident? You never said???

Was the patient unremarkable on the secondary survey?
How was the ABD? Acute, rigid, masses, pulsating? (besides what he told you) If so what did you suspect at that point? cardiac?

Acute Gall Bladder issue will sometimes present with right sided "Referred" chest pain and or back pain because of stones in the bile duct or inflammation. That would explain the refered pain in the chest and else where. We know the bilateral arm pain/numbness via hyperventilation is very common. In this case it's a non-issue.

TREATMENT IN THE FIELD: IV access yes, EKG yes, ASA why (standing orders?), Nitro why (standing orders? to lower BP?). Morphine ok maybe, BUT, without knowing what you were dealing with or having a good working diagnosis was administering it a good idea? Patient comfort is a wonderful thing, but not at the expense of making a good Dx. Masking the pain with drugs inhibits a good Dx..IMHO

What did medical control order? The EKG was normal in ST considering the severe pain he was in.

I guess my only question is what was your diagnosis before going ALS with this patient.. Angina? AMI?, "unknown" roving chest Pain and patient hysteria?<--BLS call. A Hypertensive, 21 year old male with a non traumatic Acute Abdomen? That guy goes with me.

A Cardiac event and like treatment could have been ruled out by the ALS crew on the scene.

DEPENDING on transport time: OUR TREATMENT: Assess LOC, vitals, take a good history, take into account patient presentation, conduct a strong secondary survey (enrout), cut through the patients pain with strong questioning (again). The surveys alone would have put this crew in the right directionMy "working" Dx, a non-traumatic, hypertensive patient w/an acute Adbomen, the end...

Given this, try to Calm/reassure the PT,monitor the airway and LOC, obtain IV access, hiflow O2 NRM, position of comfort, EKG, vitals again, No cardiac protocols or pain meds, Med control, continue rapid transport.

When doing the follow up on this patient, it was diagnosed as Gall Bladder rupture... he had surgury that night and did fine. Who would have ever guessed! Who??

But again, I could be wrong...:blush:

LOVE MY TYPO'S TOO!

[EMTK005]

Obviously everyone's treatment plan would vary based on their individual medical control protocols. FIRST off, ALS!!!! It's sad that we rely on ALS so much, but for this one, I want them. Prior to their arrival, O2 15 lpm NRB, position of comfort, see if they have their own ASA or nitro and if so, assist in administration. Other than that, gather as much of a history that you can.

[Wingnut]

I was being sarcastic. <_<


:P

Bite meh :)

[TTLWHKR]

No Thank You.

[ResTech]

Wingnut.. extend that invitation to me.. I'll bite ya..:)

[TTLWHKR]

.. .. :unsure:

[trauma1534]

Recruiting, While I appreciate your input, I would love to know what your certification level is... how long have you been in EMS?

Without lashing out, and with respect, I would like to reply with these few points.

You wrote; The physical movement of the pt's trunk with each breath would have made the patient scream in pain, any movement would. He did not do this.

First of all, not all patients can be treated "By the book". With that said, the key thing in EMS is that unfortunatly, we are NOT doctors (although I would love to make thier money!!!), therefore, we do not diagnose in the field, we simply treat the symptoms. I am not sure where you practice at, and really don't care, but if you were on this call with us, (which you obviously were not), you would know that our protocols were followed for a reason. If you are not up to par on your medications, here is a run down on pharmacology.

ASA - first line drug for chest pains (after 02 ofcourse)
Nitro - Nitro is given to relieve chest pains, providing that we have an IV started and the B/P is above 90 systalic.
Morphine - Chest pains, and pain management in general

It was a 25 - 35 min. transport from the best of my recolection. I can tell you from personal experience, not from the book, and this is what they don't teach you in class, Gall Bladder attacks, weather or not it is ruptured, however mine did rupture, can mimic a cardiac event. There is not always tenderness present in the RUQ, I too did not have that. The cardiac protocols were gone through for process of elimination. It did not hurt him to take an ASA, nitro did not hurt him, but it did not help him. This varified that there was no cardiac event going on. Morphine was used for pain management... if you were there, you would understand that something had to be done to help him tolorate the pain. All of the above treatment is the plan of action set up by our OMD to rule out a cardiac event. We don't have to call in for anything, although sometimes it helps us feel better to get the go ahead from the ER doc on drug choices. All of our drugs are on standing orders. The only reason we usually call in is to give report. By the way, You said that the cardiac event could have been ruled out at the scene... I AM ALS, and I don't claim to be a doctor!!!! I had another ALS provider with me also.

We are a very agressive squad, and region for that matter. Our OMD wants us to be agressive. Alot of the treatment differences come from protocol differences... and EXPERIENCE IN THE FIELD. Listen to your patient, evaluate your symptoms, treat the symptoms... don't try to play doc! It is impossable to compleatly diagnose in the field!!!!!!!!!!!! Never reasure the patient in the field... this is outlined in the 2003 Mosby edition of "The Basic EMT". We can try to keep them calm, but it is discouraged these days to reasure. This gives the patient false hope.

It is ok to work out a scenario, but do not try this "I know all and you know nothing attitued". You will not make many friends here. You don't have to try to impress anyone here. We all get together on here, we don't bash eachother, or try to make people look or sound stupid, we get together to discuss our experiences in the field and talk out calls with other providers. You might want to consider reading other entries before you post another "know it all" reply. Try learning more about what you are talking about before you try to quote treatment plans in the way that you did on here. With respect! I hope others will agree with me.

[Jon]

Wingnut.. extend that invitation to me.. I'll bite ya..:)
me too... me too

[Ridryder911]

Reasurement is a form of keeping the patient calm... what you can't say.. I am here to help you ?... geez . false hopes, it is not like we are saying.. your fine .. ignore it..

Second thing .. YES you do diagnose in the field.. short & simple..patient does not have a pulse .. you treat, from what guessing... nope, you made a clinical impression (pc word for diagnosing). Truthfully, only physicians, and certain other healthcare workers can offficially dx.

Third : Morphine Sulfate is STRICTLY contraindicated in biliary cholic (galbladder) Want to make a simple diagnostic test ... give them morphine and the pain increases.. it's gall bladder. Morphine causes the sphincter of oddi & other bile ducts to constrict more, causing spasm and pain. Fluids, analgesics such as Demerol, Nubain, etc... is recommended. oh by the way it is usually shoulder tip pain, as the refferred pain.

Be safe,
R/R 911

[dhpd9807]

When did we start treating pts based on "it's not gonna hurt 'em" NTG is not something used to R/O cardiac, it is used to treat cardiac c/p and on very rare occasions, hypertension. I would love to hear what this guy's problem was but as far as I can tell he'll get a line, some o2, and unfortunatly the monitor because that's what the powers that be think I should do. I think the chances of this kid having a cardiac event are pretty slim.

[Jon]

When did we start treating pts based on "it's not gonna hurt 'em" NTG is not something used to R/O cardiac, it is used to treat cardiac c/p and on very rare occasions, hypertension. I would love to hear what this guy's problem was but as far as I can tell he'll get a line, some o2, and unfortunatly the monitor because that's what the powers that be think I should do. I think the chances of this kid having a cardiac event are pretty slim.
The patient had Chest pain, and a blood pressure above 100 systolic. Pt. has no known cardiac problems, but neither did Jim Page.... Patients have MI's with no real warning all the time. Could also have been drug related.

I just looked at my County's ALS protocols... there is no contraindication of Nitro for "suspected ischemic chest pain" EXCEPT Viagra/Levitra/Cialis etc.

I think giving ASA and Nitro isn't a bad idea... but I would call the Doc before doing anything if I had any questions.

[mightymom7]

Wow, I just read this entire post....out protocols don't allow us to give anything for abd pain -- don't want to mask symptoms. CP however is treated with ASA, NTG, and morphine if pain not relieved by NTG. I would have definitely called med control about this one. And would have definitely been palpating the abd to try to locate where the pain was, especially since the pain was on the move. Didn't sound like classic CP, then however, not everyone has the "classic symptoms."

Thanks for sharing this call info....was definitely something to put into the ole memory banks for future reference. :)

[jewls]

:excl: -_- Recruiting, While I appreciate your input, I would love to know what your certification level is... how long have you been in EMS?

Without lashing out, and with respect, I would like to reply with these few points.

You wrote; The physical movement of the pt's trunk with each breath would have made the patient scream in pain, any movement would. He did not do this.

First of all, not all patients can be treated "By the book". With that said, the key thing in EMS is that unfortunatly, we are NOT doctors (although I would love to make thier money!!!), therefore, we do not diagnose in the field, we simply treat the symptoms. I am not sure where you practice at, and really don't care, but if you were on this call with us, (which you obviously were not), you would know that our protocols were followed for a reason. If you are not up to par on your medications, here is a run down on pharmacology.

ASA - first line drug for chest pains (after 02 ofcourse)
Nitro - Nitro is given to relieve chest pains, providing that we have an IV started and the B/P is above 90 systalic.
Morphine - Chest pains, and pain management in general

It was a 25 - 35 min. transport from the best of my recolection. I can tell you from personal experience, not from the book, and this is what they don't teach you in class, Gall Bladder attacks, weather or not it is ruptured, however mine did rupture, can mimic a cardiac event. There is not always tenderness present in the RUQ, I too did not have that. The cardiac protocols were gone through for process of elimination. It did not hurt him to take an ASA, nitro did not hurt him, but it did not help him. This varified that there was no cardiac event going on. Morphine was used for pain management... if you were there, you would understand that something had to be done to help him tolorate the pain. All of the above treatment is the plan of action set up by our OMD to rule out a cardiac event. We don't have to call in for anything, although sometimes it helps us feel better to get the go ahead from the ER doc on drug choices. All of our drugs are on standing orders. The only reason we usually call in is to give report. By the way, You said that the cardiac event could have been ruled out at the scene... I AM ALS, and I don't claim to be a doctor!!!! I had another ALS provider with me also.

We are a very agressive squad, and region for that matter. Our OMD wants us to be agressive. Alot of the treatment differences come from protocol differences... and EXPERIENCE IN THE FIELD. Listen to your patient, evaluate your symptoms, treat the symptoms... don't try to play doc! It is impossable to compleatly diagnose in the field!!!!!!!!!!!! Never reasure the patient in the field... this is outlined in the 2003 Mosby edition of "The Basic EMT". We can try to keep them calm, but it is discouraged these days to reasure. This gives the patient false hope.

It is ok to work out a scenario, but do not try this "I know all and you know nothing attitued". You will not make many friends here. You don't have to try to impress anyone here. We all get together on here, we don't bash eachother, or try to make people look or sound stupid, we get together to discuss our experiences in the field and talk out calls with other providers. You might want to consider reading other entries before you post another "know it all" reply. Try learning more about what you are talking about before you try to quote treatment plans in the way that you did on here. With respect! I hope others will agree with me.
I do agree with you totally! We are here to learn and share. I love your response! Very professional and right on!

[TTLWHKR]

I just looked at my County's ALS protocols... there is no contraindication of Nitro for "suspected ischemic chest pain" EXCEPT Viagra/Levitra/Cialis etc.

I think giving ASA and Nitro isn't a bad idea... but I would call the Doc before doing anything if I had any questions.


Ditto. I treat all CxPn patients on a case by case basis, no call is the same, unless it's BS... :P O2, monitor, NS IV, 4 Baby ASA, 1 squirt Nitro, possibly some MS, depending on the pain level and pressure.

Unless the patient is hypotensive, or has taken some sort of enhancement drug.. The Nitro will give them a headache, but one dose really won't hurt them. We're giving it pre-hospital, which will aid the MD in diagnosis, we are giving the patient medications to see if they will stop, reverse, or aleviate pain and damage to cardiac tissues. So the basic concept is, we're giving it to the guy and if it helps, great.. if it doesn't, it really won't hurt anything. So yes, that is the way we treat people. If it wasn't, it wouldn't be a standard of care.

[MecklenburgEMT_RS20]

I have had a similar call to this....it was for the same age group and same description of pains. It turned out when we got to the hospital it was gall stones. But it showed all the S/S's of cardiac related problems....he was vomiting...SOB....Cx. Pains in both arms....and then the abd. pains..
The doc told us when we went back up there that night that it was a gall stone....
So sometimes you just never know do you.

[emtbass]

with my als experience i would say O2, large boar IV, 12 lead, ASA, and nitro and rapid transport.

The 12 lead would help determine the cardiac portion of it.

[EMTMandy]

Could be a DVT/PE too.

[KEVD18]

well im glad we brought back an almost two year dead thread for that tid bit.

[TKO]

just for the confusion regarding abd quadrants, I offer this link with some good, basic information:

http://www.geocities.com/pcpsk/abs.html


FTR: I wouldn't have guessed gall bladder, but I knew it wasn't cardiac. Referred pain can also come from the abdomen as it is the same nerve moving up past the heart and into the shoulders and arms. The high BP suggested a blockage, so I thought spleen or even kidney (tho a lower back pain would have been more common for the kidney).

But hey, abdomen is a tough guess for anyone.

[lancymoor102]

Hi, I am only 22 years old female and a soccer player. I get really bad pains in my feet and ankles. Some times it affects my knees. I can’t seem to tell it the pain is in my bone or muscle but generally it feels like a deep dull pain. Also I find massaging and pushing down with my fingers into the areas where the joints/bone are help. Has anyone experienced this pain and can tell me what it is or what to do?

[Ridryder911]

It could be mulitple things from ranging from inflamed joints, tendonitis, athritis, gout, etc.. The only lodgical advice is to seek medical attention per your physician. Only they can truly assess and treat accurately.

Good luck,

R/r 911

[KEVD18]

wouldnt this be more suited for its own thread and not a post in a thread started years ago?

[Topher38]

i thought this was the BLS section?

[KEVD18]

and???

ever gotten an als intercept? so the call starts with a bls response and then at some point the medics jump in and do their thing? that happens on the bls board sometimes.

[MSDeltaFlt]

Hi, I am only 22 years old female and a soccer player. I get really bad pains in my feet and ankles. Some times it affects my knees. I can’t seem to tell it the pain is in my bone or muscle but generally it feels like a deep dull pain. Also I find massaging and pushing down with my fingers into the areas where the joints/bone are help. Has anyone experienced this pain and can tell me what it is or what to do?
Lancy,

Rid's right. Go see a doctor AND a physical therapist. For several reasons:

1. If you're a new athelete at 22, you're throwing your feet and joints into a state of shock. If you don't figure out what you're doing wrong, only one thing will happen.. it'll get worse. It won't go away by itself. Doctors can fix the problem. PT's can show you how to do it right so it won't happen again.

2. If you're still an athelete at 22, you've been here before. This ain't your first rodeo. You're still doing something wrong and it won't go away by itself. Doctors can fix the problem. PT's can show you how to do it right so it won't happen again.

3. Just because you're a young, healthy athelete, doesn't mean you automatically know how to do things right. It's OK. None of us know how to do things right. That's why God created doctors and PT's. Doctors can fix the problem. PT's can... need I go on?