Redemption

[Asysin2leads]

This is a follow up post to "Call from hell...", the two fit together nicely.

Today, dispatched for a cardiac, arrived to find 56 year old male sitting in wheelchair at work (works as a security guard) AOx3 reporting "trouble with his heart" that he knew was occuring because he had gotten sweaty. Had a cardiac history, was previously treated for a rapid heartbeat, but could not elaborate. Pt. in no obvious distress, more annoyed that he was being embarassed at work.

Was coming rushing into work today when he felt dizzy, lightheaded, and started sweating. Sitting down made him feel better, however, he still felt "not right". Reported mild discomfort in chest and left arm, 2/10, did not take anything for relief. Negative nausea, vomiting, negative headache, still dizzy

Skin is cool, pulse is rapid, weak, blood pressure 160/120, HR 150, lungs clear bilaterally, SP02 98% on room air 100% on NRB. EKG shows borderline SVT/Sinus Tachycardia, around 150, 12l lead showed borderline ST elevations V2, V3, V4.

History of NIDDM, HTN, takes antihypertensives, glucophage, compliant. No allergies.

PE: pupils equal, reactive, negative cyanosis, negative JVD, trachea midline, negative accessory muscle use, equal chest expansion, lungs clear bilaterally, abdomen soft, non-tender, negative incontinence, PMS present x 4 in extremities, negative edema.

I had the weirdest sense of deja vu, another diabetic presenting with a borderline SVT but in no obvious distress. I was on my guard like Macauly Culkin at a Michael Jackson sleepover. Administered 02, 10 lpm via NRB, established IV 20 gauge on a knuckle vein, the only site available, trust me, I searched high and low for a better one, but he was a diabetic, obese, and had nothing for periphery. I elected to treat for an MI, giving 162 of ASA and 400 mcg S/L of NTG, no relief. Heartrate had then increased to 176. I really felt deja vu. Administered 6, 12, and 12 of adenosine, patient reported he could feel it working, but there was no change in the rate. Heartrate had now increased to 180. Pressure was stable, 140/120. Pt. reported increased discomfort in the chest, now at 5/10, then 7/10. Elected to treat for possible continued ischemia and repeated NTG administration x 2. Had my partner contact telemetry for diltiazem and repeats of the nitroglycerin, and morphine. I closely monitored the blood pressure to make sure he did not go hypotensive due to the NTG, he maintained at 140/120. Granted orders for diltiazem, 25 mgs, denied morphine or repeats of NTG. Administered the diltiazem, and within seconds his rate was down to 76. He reported immediate relief, so much so that he didn't even really want to go to the hospital. We convinced him it was really advisable. As I listened to him talk to his wife on his cell and complain he had to go to the hospital, I knew I had done the right thing, and in a way, felt redeemed.

Of course, no good deed goes unpunished, and I had a later telephone Q&A session with the telemetry physician about "exactly what protocol I was working in". NTG, ASA, and morphine fall under our chest pain protocol, while adenosine and diltiazem fall under our SVT protocol. I got a nice lecture about not "jumping back and forth." The attending physician at the hospital did not have a problem with the NTG administration or treating for an MI, so my question is this, do you think I was out of line to think outside of the box and try and treat both the SVT and ischemia with the evidence presented? Is there an absolute contraindication for morphine and diltiazem? I know ACLS suggests treating with a beta blocker after Morphine, Oxygen, Nitroglycerin, and aspirin, if needed, what about a calcium channel blocker? Was there a medical reason for raking me over the coals for actually thinking about my treatment and not just cookbooking, or was the doc just mad that I was not being a good little soldier?

[EMS49393]

For what it's worth, I think you did the right thing. You didn't have just SVT. You didn't have just an MI. You had a patient that had a 12 lead indicative of an MI that happened to also have a rapid heart rate. You had a patient that was a diabetic, and obese. You had a PATIENT, not a protocol. My protocols are very liberal, and we rarely have to call for any orders. Based on what you explained I would have probably treated this patient the same way. I might have used Amiodarone instead of Cardizem. (Cardizem is a calcium channel blocker, btw.) That's only because I'm paranoid about the ejection fraction, and you stated your patient had a cardiac history. I wouldn't have given anymore NTG, only because it didn't seem to be effecting the patient in a positive way, therefore I couldn't justify further pollution of the membranes. If three doses doesn't get it, then I'm moving on. I'd have been a little ticked about being denied morphine. Your patient probably could have benefited from it. Beware the diabetic and the silent MI. As we have read they often do not present as a chest pain complaint but instead seem to have a lot of issues that point in many directions.

Now, as for why you got ripped is really simple. You used critical thinking. You treated a patient instead of a protocol. I feel for you, and I'd be livid if I were in your shoes. The best thing you can do is document everything. I would write up not only what you put here, but I would go into detail as to why you felt you followed the correct line of treatment. I would then state what took place between you and both doctors. If this call comes to Q/I, you'll want to have it.

One last thing, why the NRB at 10 lpm? Why not all 15? With the possibility of an MI, on top of the fact that the heart is not beating with much efficiency anyway, the more Os the better for the tissue. Incidentally, we flow 12-15 with our NRBs, which is the reason the 10 lpm struck me funny.

[Dustdevil]

The litre flow to an NRB is irrelevant. There is no magic number for it. 15 lpm doesn't get you any better fIO[sub:d69b4e1f8b]2[/sub:d69b4e1f8b] than 10 does. Whatever flow is sufficient to keep the bag from fully collapsing on inspiration is fine. Above that is pointless. It has no effect whatsoever on fIO[sub:d69b4e1f8b]2[/sub:d69b4e1f8b]. I don't even chart litre flow when using an NRB. It's like charting your drip rate on a TKO line. Doesn't really add anything of significance to the equation.

I agree. The doc probably just gets nervous anytime somebody uses their own common sense in the field because it is so uncommon. And when it does happen, it probably frequently goes bad. I would hope that he was just using the opportunity to feel you out, let you explain your rationale, and confirm in his own mind that you know what you are doing and thinking soundly. If so, that's a good thing. Now he'll have your name in mind and be comfortable when you function outside the box.

The only other concern I can think of is that if you were thinking possible MI with this patient, he may feel that you should have been on the road with him sooner. The whole "time is muscle" theory and all. If that is the case, then there could be some reasonable question about staying and playing with the arrhythmia. Overall, I think you did fine.

[nsmedic393]

Sounds like a good call and some domn good thinking outside the box. The doctor doesn't make much sense to me though. Sometimes you need to perform a treatment so that you can rule out a specific etiology and move on to annother treatment.

[medic429]

Good job Asys! I would agree that you did the right thing and treated the patient....we jump around in protocols often....sometimes you have to.....

Redemption is such a good feeling!

[Ridryder 911]

Asysin2leads, you treated the patient in whole, the etiology of the problems. I refuse to work for services that will not allow me to be a practitioner, rather than a delegated monkey following protocols. It is nice to see a Paramedic using the cerebral contents and treat the patient appropriate .... many patients fall into categories of protocol, and so many needless procedures and treatments are performed accordingly but yet not appropriately. The gentleman with his outstanding history, and the "routine" tx. did not correct the situation, so you treated the etiology.

Shame the physicians are not as well diverse, and I agree with Dust, thought it was unusual for someone to actually be thinking or as I have begin to see physicians are becoming more "cook-book" in tx modalities.

Continue, the type of care and assessing skills Aysin2leads, EMS needs more that thinks outside the "box" .. who knows maybe you can start a new trend ?...

R/R 911

[nsmedic393]

And who the heck ever decided that we have to pick a protocol at the start of the call and follow that same protcol through to the end of the call regardless of the patients presentation anyways? Like Rid said, do they want a thinking medic or a well trained monkey?

[Dustdevil]

I remember in the late 70's and early 80's, before the so-called "Golden Hour" theory, the theory was that you treated a trauma patient for trauma right up until the time they arrested, and then they suddenly became a cardiac patient, not a trauma patient. That is how rigid the thinking was. Treating symptoms instead of the patient. It was truly retarded, but it reminds me of what you are facing there. We totally outgrew that mentality by the mid 1980's and the more progressive systems were equipping their medics to think and evaluate independently, and make holistic clinical decisions based the patient, not the symptom or disease. Of course, that never happened in a great many of the large urban services. It didn't in Dallas or Houston. And, I doubt it happened in NY, from this scenario. But yeah, you were doing exactly what a professional medical practitioner is supposed to do, and if it bites you in the arse, that's a damn shame. But I also understand that in a system that large, there is just no way to have the kind of quality control needed to have a flexible system that allows for such practise routinely. Anytime you have a large, unwieldy organization, the SOP's must be dumbed down to the lowest common denominator. That's why I really can't understand why any professional would even want to work for a large urban system.

[Mediclease]

Asyson2leads... Sounds like a good call and you did good by the way your were thinking, as for jumping from in protocal to another was good your were looking out for the patient which is what you were suppose to do. Can't understand why the doctor would do that To you. I give you kudos for doing the right thing.

[AZCEP]

If patients would do what they are supposed to, they wouldn't need you in the first place:D

This is like saying, the patient started in VF then went to Sinus rhythm with a pulse, and we kept shocking them.

Maybe ask the doc to explain his reasoning to you, so you can be better prepared next time. Although, it sounds like you were ready this time.

Keep up the good work.