Washington DC medics in trouble again

[WolfmanHarris]

I couldn't imagine even considering a rule out of ischemic chest pain without a 12 lead. Then again, I also can't imagine not transporting this guy without a lot more information and even then...

[speedygodzilla]

I couldn't imagine even considering a rule out of ischemic chest pain without a 12 lead. Then again, I also can't imagine not transporting this guy without a lot more information and even then...

Not quite sure as I am an EMT-B just starting medic school. It is my under standing that we can't rule out ischemic chest pain in the field, only rule in. So until the hospital runs their test than it is still possibly ischemic cx pain. Right?

[Dustdevil]

That is a safe conclusion. You can rule out other causes. And you can rule in other causes too. But even if you rule in something as benign as GERD, you still cannot rule out a non-STEMI without in-patient evaluation. There is no law against having more than one cause going concurrently, and people will definitely do this. You can significantly lower your index of suspicion enough to skip the cath lab, but not enough to no-ride the patient.

[WolfmanHarris]

We always maintain a high index of suspicion for cardiac ischemic chest pain, but there are times in my mind when a rule out is possible. Best guess, wishful thinking and shitty assessment aren't one of them. Note that I haven't said not transport, but I'm not giving ASA and Nitro to every single chest discomfort, nor will I not give it just b/c the pt has abdo pain and SOB instead of CP, if those are symptoms consistent with their normal angina pain.

Good example of this, I was in clinical at the ER on Friday and my instructor had me run the assessment and then looked at me and said "you're on scene with this guy, how are you treating." His c/c was suddent onset 8/10 sharp pain radiating across the chest and into the back. Recent surgical history. No cardiac history and in fact is part of a clinical trial that saw him have a clear cardiac stress test and angiogram recently. I looked at her and said I would transport and oxygenate but would not be giving ASA and NTG at this time as I didn't believe that his condition met my ischemic CP protocol. Got to listen in with the Doc and the med student after and the Doctor confirmed that he was also thinking pulmonary embolism.

We don't make a routine habit of ruling out ischemia, but we also don't assume that everyone with CP is having an MI regardless of the history or presentation.

[Dustdevil]

...I would transport and oxygenate but would not be giving ASA and NTG at this time as I didn't believe that his condition met my ischemic CP protocol. Got to listen in with the Doc and the med student after and the Doctor confirmed that he was also thinking pulmonary embolism.

PE or AA. Either way, it is a true emergency, and ASA and NTG would both be seriously contraindicated. Nice job.

[WolfmanHarris]

I thought AA but no significant difference in BP from one arm to the other. Oh on top of the recent surgical Hx (umbilical hernia repair 2 wks prior; bowel obstruction repair 6 wks prior) he had a Hx of gout so I considered the possibility of crystals forming a thrombus. Now after the fact I'm wondering, could that even happen with gout? I know most of the crystal form in the joints and connective tissues.