Chest pains

[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!

 

[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!

SINCE you asked....I did. I guessed Gall Bladder. Yep, me. 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. <_<

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