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I'm thinking Jesus would have a problem with it. A HUGE problem. I seem to recall a few (10 to be exact) little rules he thought were important. One of them said something about STEALING. When an illegal comes to this country, he/she takes goods and services that are bought and paid for by, as well as designated for- US citizens. Liberals decided to not only ignore the ILLEGAL part, but push for those services for those who broke that rule. While we are at it, I also seem to recall something about coveting thy neighbor's goods, so I'm thinking that could apply to our south of the border neighbors as well. So, my answer is no different than Jesus'. I think that puts me in pretty good company. Why don't you follow what Jesus would do?

Don't be lulled into a false sense of security. This could very well be an MI. There was a study in Annals of Emergency Medicine in 2002 that showed that only 53% of people presenting to the ER had chest pain. Studies have also shown that cardiac pain can be relieved by a GI cocktail (I beleive it was something like 10% of people with MIs had relief with a GI cocktail, can't find the study right now). As for using nitro to decide of something is cardiac or not, another study (Henrickson CA et al. "Chest pain relieved by nitroglycerin does not predict active coronary artery disease." Ann Intern Me;d, 2003 Dec 16: 139: 979-86) showed that nitro has a sensitivity of 35% and specificity of 59%. Cardiac disease is the great imitator.

As some of you are aware, I am just starting my first practicum of the paramedic program I am in. The purpose of this practicum is to start thinking like a medic, not an EMT, and become proficient in assessment, history-taking, and differential diagnosis, learning to integrate paramedic skills and scope of practice. I had a call the other night, and I would like some opinions on it. I hope I can explain it well enough. We were called to an 85yo male, complaining of abdominal pain causing shortness of breath. We arrive on scene, and he is in his recliner, alert and oriented, no obvious distress, good skin color. Note he has a urinaery catheter bag at his feet, and tube coming from under his bathrobe. (also note a good collection of Playboy and Penthouse magazines under the end table next to him - good on ya, old guy!). Guy is deaf as a stone, so I have to yell (even though both his hearing aids are in) to get any information. He is complaining of abdoninal pain he describes as pressure, like gas "if I could just fart, I would feel better" kind of discomfort. He says that it feels like it is pushing upwards, and that makes him short of breath, especially when he lays down. He says this started 2 days ago, and was bad the night before, and he considered calling 911, but hoped it would just go away. On assessment: HEENT: skin pink, warm, dry, pupils ERL, patient does not appear dehydrated Neck: no JVD noted Chest: note bruising common to elderly, especially those on warfarin, no sternal scar, no medication patches. Denies chest pain or discomfort. Lung sounds have fine crackles in all lobes, and patient says he had pneumonia 2 months earlier, and still gets a bit of a cough Abdomen: distended, quite rigid, no bowel sounds noted (am thinking possible bowel obstruction at this point). Patient says discomfort is across entire abdomen, but at one point, when asked to point to the pain, he points to just above umbilicus. No pulsating masses.. Pelvis: urinary catheter, urine in collection bag is dark, like tea, about 200mL. Patient stated he had had a BM earlier in the day, but smaller than usual, no diarrhea or pain during BM. Legs: significant pedal edema, pitting, bruises, difficult to find pedal pulses, good motor function and sensation Arms: strong radial pulses, movement, and sensation, same type of bruises as on legs and chest Back: unremarkable Initial Vitals: HR 60, strong, irregular (patient states irregular HR is normal for him) BP 170/100 resps 22 SpO2 95% on room air Temp: 36.5C BGL: 5.8mmol Hx: No known allergies Meds: metoprolol, nitro patch (only wears for 8 hrs/day), lasix, flomax, diazepam, warfarin, prednisone MI 3 years ago, had 3 stents put in prostate cancer - hence the urinary cath denies CVA, diabetes, HTN, any other medical issues eating normally, no decreased level of consciousness, can recall all events Because of the SOB, and at one point when I was trying to get information, he pointed above his umbilicus, I ran a 3 lead.... Rate was irregular, between 60 - 130, with several PVC`s (4 -5 per minute). I did a 12 lead, which showed elevation in V2, V3, V4 and depression in V5 and V6. So, I showed it to my preceptor, and say my gut tells me this is an old cardiac issue, not acute, and that we are still dealing with a GI issue, not a cardiac issue, but I want her opinion on it. She looks at it, shows it to the other medic, and we discuss back and forth for a minute.... my argument is that he is pink, warm, dry, good SpO2, no cardiac complaints except the SOB, and is it possible that the 12 lead could be showing prior injury, not acute onset? But, I question my preceptor - should we be treating the cardiac findings as well, with ASA and nitro? I don't want to treat based on monitor findings only, when his symptoms appear non-cardiac.... They agree, and we transmit the 12 lead to the hospital (gotta love bluetooth technology) and call the ER doc. He says give ASA and nitro, and treat as cardiac until we get to hospital. So, we draw blood tubes, give the ASA and nitro, continue O2 via nasal cannula, continue monitor, and transport.... There was no change in patient condition, so I still think it was GI, but we never got back to the hospital so I could follow up.... It was good to see that my preceptors were as stumped as I was..... I was completely convinced it was a total GI issue, until I got the 12 lead.... but then when I saw the ST elevation, then I thought "Whoa, do we have more going on here?" And yet the only cardiac symptoms were the shortness of breath, and irregular heartbeat, neither of which were acute onset. The one ER nurse said she remembered him from a prior visit, where he had the same symptoms, and he was admitted, given doses of Lasix, and returned home within a couple days. So….. my questions are: - is it possible for a 12 lead to have ST elevation or depression that is from prior damage, not acute onset? - Would you have treated as a cardiac patient, or a GI patient, and why? I am hoping to be able to follow up on this guy my next tour – the ER docs where I work are pretty good about discussing cases so you can learn from them.

Edit: I posted this in the wrong forum somehow, I apologize, I have no idea how to put it in the correct forum. I'm an occasional lurker on the forums, but haven't really contributed much. A little bit about me first - I began in volunteer EMS since 2003, been an EMT since 2004, began working professionally in 2007, and finished my Paramedic degree this Spring. In addition to my A.A.S. in Paramedicine I also have a B.S. in software engineering (don't ask) and an M.P.A. My goal is ultimately to become an EMS manager. I generally agree with the "consensus" among the most active posters - that the Fire Service may not be the best way to run EMS. That being said, I had an interesting discussion with an individual at my part-time job the other day. His full time job is in the Fire Service, with an agency that does BLS first response only. Now, I don't want this to turn into a fire service bashing thread, regardless of how any of us might feel about that method of delivery. The way the system works is that this fire department "first responds" to all medical "emergencies" within their district - regardless of severity or origin - they respond to the doctor's offices, to low-priority psychiatric complaints, etc - everything except for scheduled interfacility transports. A private service (my full-time job) responds for the ALS and transport components. I personally believe that they don't need to respond to everything in their district, I would advocate for no more than NAEMD-coded "Delta" and "Echo" level responses, as well as special assists (known severely morbidly obese patients, MVA's, etc.). However, their position is that as they are tax-supported, they have a responsibility to respond for every fire, medical, or rescue request within their district. Let us assume, for the purposes of this discussion, that this is the way the system is set up. Let us also assume that for the foreseeable future this arrangement cannot be changed - we will have a minimum of 2 firefighters trained to the EMT-B level or higher (but only capable of practicing with this agency at the EMT-B level) responding on an engine, truck, or light rescue, with an ALS or BLS transporting ambulance, depending on the EMD coding of the response. Recently, the "posting scheme" (the private service uses system status management) was changed within the service area at the request of the fire department. The ultimate purpose of this, it seems, was actually to DELAY responses within the district. The assumption among many employees of the private service was that the department wanted to "look good" by "showing up first." I must confess, from our perspective, this is exactly what it looks like. Now, response times for the ambulances are still well within contracted targets, and well within NFPA standards (contracted targets are 7:59 for NAEMD Echo, Delta, Charlie, and Bravo responses; 11;59 for Alpha and Omega responses). The reason for the change, it was explained to me, was not to "look good." Rather, this department was experiencing a problem. Their EMT's were becoming too reliant on the ambulance crews and the Paramedics. Due to the ambulance being less than thirty seconds behind the fire apparatus in many cases, and often even being first on scene, the BLS assessment and treatment skills of the firefighters were being degraded. The concern of the department that should the ambulance service be experiencing higher-than-normal call volumes, or a delayed response for whatever reason, the EMT's on board the fire apparatus would simply not know what to do if they had, say, 10 minutes with a patient rather than between 30 seconds and a minute as is often the case. The solution, of course, was to shift the starting locations of the ambulances so that the firefighters would have on average 2-3 minutes with the patient, allowing them to complete their initial assessments including vital signs and begin "routine" BLS interventions - ASA, O2, etc. - prior to the ambulance crew's arrival and beginning of ALS assessments and interventions. I personally don't agree with the solution that was presented and in effect. However, I came to fully understand the fire department's point of view - assuming the firefighters will in fact respond, how do we ensure that they have adequate "patient contact" time to maintain their skill levels? Should it be required that they complete mandatory monthly ride-alongs with the ambulance crews? Should it be required that they maintain part-time employment with an ambulance service? Your comments and suggestions would be appreciated. I'm not really in a position to change anything, but as someday I hope to be in a position where I would have an impact and a decision-making role in an EMS system, it is, I think, a useful discussion. Again, I would appreciate if this doesn't devolve into yet another fire-service EMS bashing thread - rather a genuine thoughtful discussion of our identified problem. Thank you all for your input.

Well the question was answered. To touch up on the intubation stuff. The reason that Paramedics can do somethings a RN can't, is because the field we are in: Pre-Hospital Care. We don't have (for the most part) other higher Medical Authority onscene, providing care. We learn all the ACLS & PALS stuff without taking these classes; its our Scope of Practice. The way Paramedic Training is; we have rotations in many areas like the ICU, ER, AMB, OR, etc. Many RN Prigrams only require Med-Surg clinicals. If a RN wants to work in the ER, CCU, PICU, or any specalty floor; they must take an internal Critical Care Course and many will require the RN to become a CCRN. Its the nature of the game. A RN fresh out of school can not work a code but a Paramedic can. Its just not the fundamental skillset of the RN. That being said, the RN has so much more movement than any EMS Provider can imagine (unless I get my way from NREMT, NAEMSE, NHTSA, etc for higher learning). The RN from the Crimean War days, has advanced so far. The Degrees like ASN, BSN, MSN, & PhDN. The Advance Licensed Titles like Clinical Nurse Specialist, Case Manager, Nurse Practitioner, Nurse Anesthetist, & Doctor of Nursing Practice. Its on a WOW factor. So much more movement for the RN, clinically and administratively. RN can work in so many settings. They can pursue further in the Nursing field. EMS must mirror what Nursing has achieved through the years but we won't due to Politics: skills w/o edu. Go and push yourself to the limit. Keep up the success. I respect the Nursing field. I'm in my last quarter of classes to get my ASN; hope that NCLEX is easier than preached about. So I can appreciate the difficulties. My theory is that EMS will remain stagnant because what it has evolved into: a hobby for most. A Volunteer Ambulance Service as the only means of EMS in areas is ridiculous. Nothing against the concept of Volunteering but in the most powerful country (Next to China), most suburban residents depend on Volunteer EMS for care & transport to the ER. At least Paramedics will always be a paid service. I've worked in a flycar ALS service and the longest I've waited for the Ambulance was for 45minutes because the VAC and the neighboring VACs didn't have members available. My company had to send one of our Ambulances (which was for Private Transport) to come to the scene. But Volunteering is great but it shouldn't be this way & in some areas the only way. I love being a Paramedic, the adrenalin rush was great when I was younger. Now I want something more stable and progressive. Bring on the replies; I know many will thrash me. Its my opinion based on fact. All the best...

First let me complement you on your thorough and diligent assessment. A lot of people never realize that the "paramedic assessment" is *much* more about diligence than it is about diagnosis. As far as your questions: No. ST elevation means the condition is acute. With rare exception (like in the days following a CABG), there is no such thing as "old ST elevation." Keep your STEMI mimickers in mind (LBBB, BER, LVH, pacers, etc etc etc), but real ST elevation is something to be considered as cardiac injury. Depression can be a number of things, but "cardiac depression" is caused by ischemia or is a reflective change from injury. Consider it an acute problem. Whats the difference? What does a "cardiac" patient get that a GI patient does not? If you are worried about a AAA or some sort of GI bleed I would imagine you might be concerned about ASA (and I would too), but it seems you did the right thing by passing that decision on to on-line medical control. NTG as well. Other than that, both GI and cardiac patients get IV/Monitor/O2 and continued reassessment. Don't forget that this patient may have both a GI problem and a cardiac problem. It is not necessarily one or the other. You can't rule out cardiac because he has problems in his belly. Take heart, though. Our job is largely the same. Prepare for something worse to happen, consult on any meds you might want to give (if any), and reassess, reassess, reassess.