Please tell me what I missed with this patient

[VentMedic]

You have caught me on a day I am sick unto death of knowitall armchair nurse "administrators" and especially nurses with no field experience who decide to add to the mix. Please don't anyone take this as a universal truth, but you have to know that many, many nurses think EMT's are basically moving men, know-it-all noobs and need to be kept in their place. Sorry, that's how it is in many places, if it is different for you, you have done an excellent job and the nurses are being allowed to work realistically and not prodded into senseless "fannyflage" (backside coverage) by their managers and administrators.

Vitals reveal cardiac signs? Pt anxious, in pain, SOB, or a little too keen to explain some chest pain away as "gas"? If your protocols call for an EKG, do it, but if we do EKG's (start IV's, do ABG's, etc.) on every person who is the equivalent of this patient who vomits and is a diabetic with a half-decade old hx of cardiac stent but has normal vital signs, what kind of professional autonomy/judgement is that? If the nurse bothers you, tell her to take it up with your manager and give that nurse your manager's card.

Some think I have an attitude but you are one bitter nurse. I don't know about your co-workers or if you even work with any other nurses, but there are many, many very good nurses and other professionals out there. This should not be a free for all to bash a profession or provide a negative mindset for those that do not have the opportunity to work with other professionals at any length to form an opinion except for heresay or an occasional rude remark encountered in the ED.

EMS providers do take things rather personally because they do not deal with many other professionals for very long. They see only a snippet of what life is like in the hospital. In 15 minutes that nurse may have been screamed at by 4 doctors, an RRT with an attitude stressed for time and maybe 5 patients. You can also include other departments and RNs as they are trying to get their patients moved through the system. So yes, maybe the nurse does not know your specific protocols in the field, but EMS providers probably do not know the ED staff's protocols either. But just keep adding to the flames that keep EMS isolated from the rest of the world of medicine with inciting the bashing of nurses and other hospital personnel.

In addition to that, the diagnostic suites send potential colonoscopy patients to the ED for further screening when their pre-procedure 12-lead ECG or cardiac monitor shows something suspicious. Even in the Pulmonary Labs which are considered outpatient, abnormal rhythms for which the patient has no history gets sent to the ED. N/V during a test may also get sent to the ED.

BTW, how long before a 3 stent 70 y/o with IDDM needs a CABG? More stents? Which has the longer survivablitiy rate? CABG? Or, 3 or more stents? A stent does not reduce the risk of another cardiac event and one patient can receive many stents as occlusions develop. However, a patient's body may eventually say no more and a CABG or death is the option.

How many women or older patients will present with the cardiac signs you described? Some elderly patients who come to the ED with the "flu" are surprised to learned they have had a heart attack. You might also remember how John Cougar Mellencamp was surprised when he found out he had an MI at 43. His symptoms were also not textbook.

 

[Margaritaville]

Amen, RR911!

 

[emtfarva]

This is only for Epi.

Everyone else can read this but this comment is for Epi.

Epi, I am at the Basic level, so what I say doesn't mean much to some peoples eyes. I once brought a sz Pt to the ER, well my partner did, she is a medic. When we got to the ER the nurse told us to put the Pt in the Hall. From my experience any sz Pt should be placed on at least a 3 lead. I am not saying that maybe they weren't busy and didn't have a telly bed available. But in my eyes this Pt should be on some type of ECG. Get to your case, maybe it wouldn't have hurt to put the limb leads on and check. But I think you were right to hand it off to the bls provider. I think sometimes Nurses forget things. I think they heard Cardiac hx and was expecting a 12 lead. Personally I would not have called for als for this Pt. I had a Pt one call with cc of n&v. The Pt was dierphratic and dry heaving when I found the Pt. My partner at the time wanted to walk the Pt down the stairs. I said no. The Pt, I found out later, was in a-fib. She wasn't a diabetic and she had no hx. In the back of my head I thought she has some kind of cardiac issue going on. I was right. so don't let one thing fool you. I guess what I am trying to say is, next time at least do a 4 lead. Don't beat up yourself about it, learn from it.

 

[Epi-do]

Wow! I swear even in first aid classes we teach one of the most ominous signs of an AMI (especially silent) is nausea? Especially those with a hx. of stent placement (oh by the way, stent re-occlusion is about 5 years) and diabetics as mentioned do present with even more silent conditions.

Want to make that a valid case and explain yourself upon why you did not? Since, you have a patient with a + cardiac history, s/s of an AMI. This is how many AMI's are missed.

R/r 911

Nausea and vomitting can be indicative of cardiac issues, but it can also be indicative of a laundry list of other things. That list can include food poisoning, gastritis, gastroenteritis, gall stones, DKA, drug overdose, intoxication, pancreatitis, the flu, various infections, GI bleed, etc, etc. Therefore, by itself, nausea and vomitting can't be considered indicative of anything in particular. PMHx, other signs/symptoms, VS, and pertinent positives/negatives all must be taken into consideration.

This patient's blood sugar was higher than I was expecting to see, but could be attributed to the vomitting. Otherwise his VS were all within normal limits. He had absolutely no other complaints and said the nausea/vomiting coincided with drinking the Trilyte. Everything did not add up to suspicion of a cardiac event, given the information I had before me.

Had I known that stent re-occlusion is in the ballpark of 5 years, or any of the other info Vent has provided about stents, I may have made different choices regarding this patient. Unfortunately, that is not something I have ever been taught. "I didn't know" is not an excuse, I have learned something new, and plan on doing some reading on my own to learn even more. That being said, I still do not believe the big picture for this particular patient added up to suspicion of a cardiac event.

I do plan on following up on this patient to find out exactly what the ER determined. I will be sure to pass along what I find out.

 

[daedalus]

Nausea Differential:

Adverse drug reaction
Addison disease
Alcoholism
Anxiety
Appendicitis
Brain tumor
Bulimia
Cancer
Chemotherapy
Chronic fatigue syndrome
Concussion
Crohn's disease
Depression
Diabetes
Dizziness
Exercise
Flu
Food poisoning
Gastroenteritis
Gastroesophageal reflux disease
Gastroparesis
Heart attack
Hydrocephalus
Irritable bowel syndrome
Kidney failure
Kidney stones
Medications
Ménière's disease
Migraine
Morning sickness
Narcotics
Nervousness
Norovirus
Pancreatitis
Peptic ulcer
Sleep deprivation
Stress
Superior mesenteric artery syndrome
Sugar high diet
Tobacco smoking and second-hand smoke
Tullio phenomenon
Withdrawal Syndrome
Vertigo
Vestibular balance disorder
Viral hepatitis
Acute HIV infection

 

[Sasha]

Nausea Differential:

Adverse drug reaction
Addison disease
Alcoholism
Anxiety
Appendicitis
Brain tumor
Bulimia
Cancer
Chemotherapy
Chronic fatigue syndrome
Concussion
Crohn's disease
Depression
Diabetes
Dizziness
Exercise
Flu
Food poisoning
Gastroenteritis
Gastroesophageal reflux disease
Gastroparesis
Heart attack
Hydrocephalus
Irritable bowel syndrome
Kidney failure
Kidney stones
Medications
Ménière's disease
Migraine
Morning sickness
Narcotics
Nervousness
Norovirus
Pancreatitis
Peptic ulcer
Sleep deprivation
Stress
Superior mesenteric artery syndrome
Sugar high diet
Tobacco smoking and second-hand smoke
Tullio phenomenon
Withdrawal Syndrome
Vertigo
Vestibular balance disorder
Viral hepatitis
Acute HIV infection

Oooh. Someone can use wiki.

 

[daedalus]

Oooh. Someone can use wiki.

Quite a useful little website

 

[VentMedic]

How many are not relevant at all to this patient? Maybe he didn't disclose he was HIV postive.

Again, going with the known:

70 y/o
IDDM
3 stents that are at least 5 years old

Actually, the majority of problems on that list can cause severe complications to a patient with the above history and should be taken seriously.

 

[chute43]

Maybe it wasn't that you didn't treat the pt as ALS, downgrading his level of care could appear as not being in the pts best interest.

How many MIs have typical signs?

Was BLS therapy in the pts best interest?

Did the pt have the potential to be having a silent MI?

The pt has all the prior Hx for a silent MI.

Dont most LAD coronary blockages present without CP?

I believe the Nurse felt you as the higher qualified provider should have provided a higher level of care even if that higher level of care was just monitoring the pt with the skill of a paramedic.

I don't believe the pt deserved a 12 lead? I would have treated the pt was ALS, with O2, EKG, and IV access. I am ofcourse in a different region with different protocals.

Ask yourself did you treat the pt with the highest level of care? Did you treat the pt in regard to treating worst case? In court could you truely justify your actions of sending the patient in BLS especially after ALS had been established?

I am not really trying to monday morning quarterback your actions but you asked the question "what I missed", and respectfully that is my thought on the subject.

kary

 

[Ridryder911]

Bottom line.

Yes, your honor I was taught nausea and even associated vomiting can be an associated sign of an AMI. Yes, as well your honor I was also taught that those with DM and in particular those with a know positive cardiac hx. can present to be mildly symptomatic.

As well, yes a simple little thing such as ECG could had help rule out an underlying issue.

Does one not also perform an twelve lead ECG on any person that also has a hx of event of diaphoresis, unknown etiology of vertigo, confusion, falls not associated w/tripping, heaviness in arms, jaw, associated pleuritic pain, severe abdominal pain, history of direct chest wall trauma and basically any associated symptom that can be linked to a potential AMI? Anyone that has a known history of coronary occlusion or positive history of an AMI with any associated or link symptom should be at least assessed for a AMI.

or

Look at this way. Did you hook them up to the monitor? Then why? You then obviously thought of potential cardiac and if you thought of that, a diagnostic ECG should had been performed.

Remember a twelve lead is just one more vital sign. Three leads does not mean poop. Monitoring leads does present nothing more than an occurrence (lethal) has to occur before your eyes.

Yes, nausea can be associated with tons of other illnesses, so can chest pain but have we not been taught to assume the worse? A simplistic and non invasive test that can save ones career better yet potentially someones life for an additional thirty five seconds... is worth it.

I have highlighted those with nausea should as well be considered to have a twelve lead performed.

Nausea Differential:

Adverse drug reaction
Addison disease
Alcoholism
Anxiety
Appendicitis
Brain tumor
Bulimia
Cancer
Chemotherapy
Chronic fatigue syndrome
Concussion
Crohn's disease
Depression
Diabetes
Dizziness
Exercise
Flu
Food poisoning
Gastroenteritis
Gastroesophageal reflux disease
Gastroparesis
Heart attack
Hydrocephalus
Irritable bowel syndrome
Kidney failure
Kidney stones
Medications
Ménière's disease
Migraine
Morning sickness
Narcotics
Nervousness
Norovirus
Pancreatitis
Peptic ulcer
Sleep deprivation
Stress
Superior mesenteric artery syndrome
Sugar high diet
Tobacco smoking and second-hand smoke[/B]
Tullio phenomenon
Withdrawal Syndrome
VertigoVestibular balance disorder
Viral hepatitis
Acute HIV infection

Many of those can be associated with dangerous electrolyte, hormonal imbalances, or associated symptoms that can be linked with associated coronary syndromes or before making diagnoses to rule out CAD a ECG should had been performed.

Alike taking a set of vital signs, an ECG is just another assessment tool. Simple monitoring lead does not cut it, especially if you have a twelve lead on hand.

R/r911

 

[VentMedic]

I believe the Nurse felt you as the higher qualified provider should have provided a higher level of care even if that higher level of care was just monitoring the pt with the skill of a paramedic.

Excellent point...

Who did the Patient Care Report? Is there a record of an "ALS" assessment?

If an EMT-P performed and "ALS" assessment to determine it was a "BLS" patient, that assessment should be documented with the Paramedic's signature. As well, if an EMT-B cared for the patient during transport there should be documentation of their observations during transport. If our FD Paramedics assess a patient in the field and then hands off to a BLS truck, their report accompanies the patient. The BLS truck will then have their report for what happens from that point on.

In the hospital, there is not a "BLS" or "ALS" mentality. The RN is responsible for giving any reports about the patient, not the CNA. The RN would not do an assessment and determine that it is okay for the CNA to pass on the report to the next RN or doctor. In this situation, the RN probably had specific questions about how the patient was assumed to be BLS and what assessment was done to make that determination.

I would also include from the list posted for N/V:

Exercise - Some people are out of shape and don't know what their health status is. Many people have dropped dead while excercising, including children.

Bulimia - The constant purging definitely takes a toll on the electrolytes and CV system.

Norovirus, flu - Monitoring may be necessary for at risk populations especially the elderly. Usually the ED will do an EKG and use a cardiac monitor to determine if the patient needs further monitoring on tele especially if the correction of the electrolytes is still being done.

Tobacco smoking/second hand smoke - Many patients presenting with N/V will get a 12-lead which even if it doesn't show an AMI, it may show cor pulmonale. This will then get the patient a work up for COPD or some other disease. Often the first steps toward diagnosing COPD and other pulmonary diseases are through EKG changes. This is especially true for the spouses of smokers.

Chronic Fatigue Syndrome - Closer attention is now being paid to the cardiac status of those with this disorder, especially women as the many recent new articles have stated from the research. Cardiomyopathy has been missed by doctors who blew off the symptoms. There are numerous articles from Cardiac and Exercise labs that indicate an inability for the patient reach their max or low cardiac output levels have been noted. There are those that do have evidence of poor wall motion and old infarctions found on their EKG but the etiologies is still being investigated.

There are also many other diseases of the heart and chest that can cause N/V and can be extremely serious. Some may not be readily apparent on an EKG but may have abnormal heart sounds. These patients may still benefit from the inital and continued assessment of an ALS provider. Any observations made by someone who is well trained/educated in assessment may be valuable to making a diagnosis or giving the doctor a good starting point when passed on to the ED staff. This shouldn't be just a ride to the hospital. EMS providers should realize their role and responsibilty they have to patient care in the healthcare system.

Some of the situations played out in the TV show HOUSE are not that far fetched. It many take several days to make a true diagnosis and one may not be made as to the cause of some symptoms. However, it may take just one observation made by some healthcare provider that solves the mystery.

 

[vquintessence]

Sorry to jump into the tail end of the conversation... but what exactly is wrong with performing diagnostic testing? Hospitals do this all the time to gain an almost 95% understand with a good certainty of what exactly is happening to their pt.

<<<warning: paragraph long, relevant, personal story>>>
When I was a pre-teen, I had an anaphylaxis reaction to several wasp stings to my chest while mowing the lawn. The allergy was known, and hell I'm allergic to all bee's except honey bees, but ground wasps give me the worst reaction. Instantaneous urticaria and started to develop SOB/chest tightness in a couple min. No personal stranger to experiencing allergic reactions, and my mum, an RN, was home and gave me my epi-jr shot and rushed me herself to the hospital (8min drive). She didn't call EMS because of a horrible experience involving my grampa, an AMI, and the medic completely trivializing AND missing the STEMI. Thank god the receiving hospital had an accredited cath lab... my family could have easily settled the 200K municipal lawsuit should they have sought it.

Anyways, get to the hospital, and end up with more epi, benadryl, zantac, neb, O2, NS (no idea how much, probably KVO?). After the slew of crap they threw at me, a pre-teen with obvious anaphylaxis c known culprit (wasp and pmhx bee allergy), I still got these "weird stickers across my chest put on by some old lady"...

Now, pre-teen still experiencing chest tightness obviously secondary to anaphylaxis reaction... and they still gave the 12 lead. Were they wrong in doing so? Or were they just ensuring I received full care?

It is obvious the situation between this and the OP's are drastically different; sick vs not sick, let alone interventional medicine, but the similarity lies in this: What is wrong with performing diagnostic testing? A 12 lead takes 2 minutes MAX during the winter with a jacket and layers. I am not Dr Ambulance, and even if I were, I'm sure Dr Ambulance would run a slew of tests before deciding on a definitive diagnosis.

 

[BLSBoy]

Anyways, get to the hospital, and end up with more epi, benadryl, zantac, neb, O2, NS (no idea how much, probably KVO?). After the slew of crap they threw at me, a pre-teen with obvious anaphylaxis c known culprit (wasp and pmhx bee allergy), I still got these "weird stickers across my chest put on by some old lady"...

Now, pre-teen still experiencing chest tightness obviously secondary to anaphylaxis reaction... and they still gave the 12 lead. Were they wrong in doing so? Or were they just ensuring I received full care?

Its not so much the "Chest tightness" that caused them to do a XII lead on you, it was the fact that you recieved several doses of Epi, which puts strain and increased workload on the heart.

 

[frogtat2]

Epi

I am an EMT-I on a small rural service. After reading your initial question, here are my thoughts.

I don't think that you necessarily missed anything. However, if this had been my patient I would have put him on a cardiac monitor. I would have wanted to assess his cardiac status and that would require an EKG.

Don't beat yourself up over this. You did what you thought was appropriate at the time. Use this experience as a stepping stool and learning tool. We have all been there before, and will most likely be there again. Just do the best you can for each patient and continue to study and learn. Thats all any of us can do.

 

[daedalus]

Now, pre-teen still experiencing chest tightness obviously secondary to anaphylaxis reaction... and they still gave the 12 lead. Were they wrong in doing so? Or were they just ensuring I received full care?

Not to trivialize your horrible ordeal you went through as a child, but how is this relevant to preforming a 12 lead in a N&V patient? You were given epinephrine and nebulized medications, and those are potent on the heart.

I will pose my question a different way;
Show me a study where preforming field 12 leads in patients with vomiting lead to something good instead of increased costs and unnecessary testing.

 

[Juxel]

I was writing a response to support not doing a 12-lead, but then I re-read the OP and saw the stomach pain that went away. That, combined with the n/v and the past medical hx, would warrant a 12-lead in my opinion.

Studies have shown that n/v is the main (or only) presenting symptom in approximately 20% of STEMI's with no associated chest pain. The study found the other non-pain symptoms to be dyspnea (50%), diaphoresis (18%), and syncope (12%).

Are there any others on that list that you would skip a 12-lead? According to this study, n/v should be quite alarming and would certainly warrant a 12-lead.

Epi-do, if you brought me this patient with no 12-lead I wouldn't be upset as a hospital provider. The standard of care for n/v when there is a clear history is not a 12-lead and I frequently see patients in the ER that I discharge without ever doing one. However, given this patient's age and hx, it would probably be better to err on the side of caution.

 

[daedalus]

In the hospital, there is not a "BLS" or "ALS" mentality. The RN is responsible for giving any reports about the patient, not the CNA. The RN would not do an assessment and determine that it is okay for the CNA to pass on the report to the next RN or doctor. In this situation, the RN probably had specific questions about how the patient was assumed to be BLS and what assessment was done to make that determination.

This is a good point. Why do we do this in the field? Should the EMT be restricted to driving and assisting the paramedic on scene? Why is it okay to punt patients who we do not believe deserve paramedic care to EMTs? RNs do not get to punt "BLS" patients to CNAs, they take care of each patient at the same level with the advanced education they have.

 

[daedalus]

Studies have shown that n/v is the main (or only) presenting symptom in approximately 20% of STEMI's with no associated chest pain. The study found the other non-pain symptoms to be dyspnea (50%), diaphoresis (18%), and syncope (12%).

"The most common side effects with OsmoPrep [and others I looked up] are abdominal bloating, abdominal pain, nausea, and vomiting"
-Manufactures website

Pt with anxiety(causes nausea) before colonoscopy ingests bowel prep(common side effects include nausea, vomiting, and pain), and experiences an episode of isolated vomiting.

occums razor

Plus, while this patient may receive EKG in the hospital, we are talking about the field.

 

[VentMedic]

daedalus,

I think we're getting somewhere now.

Think of doing the 12-lead as just another VS as Rid stated. EKG changes might be transient and EMS might be the providers that catches the changes. I can't tell you how many times I have watch a patient in the ICU with my finger poised on the 12-lead machine waiting for them to do what they did again. Ischemia or aberrancies vs VT are examples of something one can see but only momentarily. A Paramedic just might have the opportunity to capture something that will pull the puzzle together.

I'm going to post this link again from another thread.
Electrocardiographic Manifestations and Differential Diagnosis of Acute Pericarditis

http://www.aafp.org/afp/980215ap/marinell.html

Look at the long list of etiologies for pericarditis. Now look at the list of differential diagnoses. Any clue that can be passed off in report might be very beneficial in narrowing down the process to start definitive care. I can not stress enough for good "ALS" assessments with a "medicine" point of view. Don't become just ambulance drivers and give the hospital staff a chance to view you as such because of your reports with the "we are different because we are in the field" mentality. The providers that get the most respect in the ED are those that do put a little extra effort to do a detailed assessment and be thorough with the histories or look for clues at scene. There are things that the ED staff do not have access to but the EMS providers may get first hand knowledge of.

It is all about the medicine for the greater good of patient care regardless of what treatment you can provide from your findings.

Edit:
Okay forget my first remarks. Forget the Colonoscopy prep. That is a distraction for you. Many patients have conditions that can be exacerbated by tests or their prep which is why we may do an EKG before sending them home with the prep and another before they get the procedure as well as being on a cardiac monitor for the procedure which may get stopped because of EKG changes.

 

[Ridryder911]

I will pose my question a different way;
Show me a study where preforming field 12 leads in patients with vomiting lead to something good instead of increased costs and unnecessary testing.

Show me where it costs more and what is and who is determining what is unecessary?

R/ r911