Nitro with a right sided MI

[EMTgirl84]

I am an EMT and I have a partner that does a lot of questionable things. I just wanted to ask for some advice and input. We get called to a patient having chest pressure. We get on scene, pt. is ambulatory. Pt. walks to the cot and we load pt. up and start treatment on scene. Pt. was shoveling the driveway when the pressure starts. Pt. describes it as being in the middle of the chest and a little bit of back pain and it is more of a pressure type feeling than pain. Pts. medical history is high cholesterol and a smoker. Pt. is in late 50's and does have a family history of MI. Pt. is also vomiting. My partner can't hit an IV after 3 attempts. I set up the 12-lead and what I see is not "normal" to me. I am just getting ready to start a medic class so I haven't learned how to read a 12-lead yet, but when I printed off the strip it say acute mi at the top. We are 45 minutes out from the nearest hospital and we do have access to a chopper 1 mile down the road. Pts. vitals are 98/P pulse is running 50-55, O2 sat is 94, pt. has some shortness of breath, as well as vomiting, color looks like crap...grayish, and pt. is clammy. My partner gives her a spray of nitro with no IV line established and then we take off. We go non-emergent. We had sent the EKG to the hospital en route....next thing I know, dispatch is telling me to tell my partner to contact the hospital immediately. The hospital precedes to explain to my partner that this pt. is critical, having a right side MI and needs to go straight to the cath lab. It's almost like my partner didn't even know what was going on or how to read the strip. I then get upgraded to emergent. We get to the hospital and the doctor's are pissed! Pt. goes staright to the cath lab and my partner gets to have a little talk with the supervisor. My partner says that he is "sick" and that is part of the reason he made poor decisions. What are your thoughts?

[brock8024]

Did you do a V4R on this pt. IF not then it is my understanding that you cannot tell that they are having a right side MI. I was taught never to trust they writing at the top of the paper. With that BP and heart rate I would not have giving the nitro but I was not there.

Did he ever get the IV started?

[EMTgirl84]

Yes, we do have V4R and no he never got a line started.

[JakeEMTP]

There really is no excuse for misreading a EKG. I can understand your partner not wanting to give nitro since they couldn't establish a IV line. With a systolic pressure of 98 ( why by palpation?) I might be hesitant to administer it also. Do you not have IO access?

Your patients c/c and presentation would immediately alert me to the possibility of an MI. Sounds like your partner had a massive brain fart. Their action/non-action with this patient would have resulted in our Medical Director suspending their privileges to function until this case was reviewed by the EMS oversight committee. He does not take these sort of things lightly. Immediate remediation is required.

[EMTgirl84]

I completely agree and I guess this is why I am so frustrated. This is not this first incident and I really don't think that it will be the last. I continue to get called in the office everytime a call goes wrong because I am technically the only witness. I don't want to be in the middle of it. My supervisors need to take care of it with my partner. I could write a book on all of the things that he has done wrong. I have worked with some fabulous paramedics and I am just sad that some people who call 911 for help may actually end off worse than when they call.

[brock8024]

So you done two ekg's on this man and sent both of them to the ER? So what level are you? Just wondering.

So he did or did not give the nitro? I am lost now. Did he give any other meds or treatments for his pt.

At your level if you know how to check for a right sided MI but not know how to read a EKG then you should take a class. It would help in the future. It also show that u have motivation to learn.

[Eydawn]

Her original post says that the partner gave the pt a spray of nitro and off they went, with no IV access established.

I wouldn't give nitro with a BP that low and a patient looking utterly like crap... perhaps I need some more education as to nitro use however.

Would you give nitro in an unstable MI with a systolic BP above 100 for pain relief? Or would you give something else, like morphine? Why?

Wendy

CO EMT-B

[EMTgirl84]

He did give one spray of nitro, but never established a line, which really made the docs happy as you can imagine. Other than the nitro, he gave some 02, 2 liters nasal. I am an EMT-B and I pretty much do everything on a call as long as it's not out of my scope of practice. I can do 12-leads, but I don't know how to read them yet. Like I said, I definately want to learn, I start a medic class next month. Basically if I don't do things, then they won't get done. I offered to do a 12-lead on a pt. with chest pain that had a heart history last week and my partner said no, I'll get it en route...45 minutes later, he never did it, just wrote his report.

[brock8024]

It all depends on the pt. Is the BP 102 or 110? If I have a iv then I can fix a pressure problem if needed. Both MS and Nitro are going to lower pressure.

I treat all patients separate. It is a critical thinking skill. You have to be able to look at the whole picture not just, Ok his bp is 100 or greater going to give the nitro.LOL

[EMTgirl84]

I've been in the field for three years now in a rural setting and city setting and same with my partner as well. I have never seen anyone have as many problems with patient care as my partner. We took a pt. who was hypoglycemic the other day, again 45 minute transport time, sugar of 37, attempted a line...never got one so no D50 was given nor glucagen and when he gave report at the hospital, the pts. sugar was 18. I'm just frustrated because I can't fix the problem myself! I know what needs to be done, but I'm not a medic yet so my hands are tied!