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Re: Re: Puzzler

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You're onto something. However, you need to need more to make the NTG/no

NTG decision, and the saline lock/NS decision. What can you do with the

equipment you have to get a better impression of what may be happening with this

patient's heart?

G

>

>

> I'm going with an inferior MI affecting the right coronary artery , as

> indicated by the ST elevations in leads II and III. The reciprocal change in

> lead

> I is also indicative of this form of MI.

>

> I'm going to go with the saline lock, due to his current blood pressure

> already being elevated. Holding off on the NTG for now.

>

> I'd encourage my patient to go to the teaching hospital because he needs a

> cath lab which the community hospital does not have.

>

> -Wes (eager EMT)

>

> In a message dated 7/25/2006 10:36:07 PM Central Daylight Time,

> wegandy1938@wegandy writes:

>

> Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for

> a free trip to Opdyke West, TX to enjoy the July weather.

>

> While this is for paramedics, knowledgeable, precocious, and eager EMTs are

> welcome to chime in.

>

> Your 58 year old male patient complains of chest pain which began

> approximately one hour prior to your arrival at his side. He relates that

> the pain is

> now 10 on a 10 scale, has not diminished since it started, and he is in

> great

> distress, with breathing difficulty, a look of panic in his eyes, ashen,

> moist

> skin, and he also complains of nausea. He begs you to help him.

>

> Your partner places the pulse oxymeter on him and begins to set up oxygen.

> The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now placed

> the electrodes for your monitor on his chest. Unfortunately, your service

> has not yet purchased 12-lead monitors, so your monitor is designed to read

> leads I, II, and III. As your partner administers an aspirin to the patient,

> you

> watch the monitor in Lead II and see sinus rhythm with a high ST elevation.

> Switching to lead I, you note sinus rhythm with ST depression, and in Lead

> III you see marked ST segment elevation.

>

> Your partner now has an IV established in the left arm, and he asks you

> whether you want to hang NS or place a saline lock. All the while your

> patient is

> begging you to do something about his pain.

>

> Should you go with a saline lock or hang NS? Should you administer

> nitroglycerine? Morphine?

>

> Are there any other interventions you can do to help you decide those

> issues?

> If so, what?

>

> You are 12 minutes from a community hospital with a small ER and no cath lab

> and this is where your patient wants you to take him. You are 25 minutes

> from a large teaching hospital with a cath lab. What should your destination

> be

> and if you determine to go to the larger hospital, what do you tell your

> patient to get him to agree?

>

> Gene G.

>

>

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Susie,

You're on the right track, but I'm not following your description of what

MCL3 is. And is that what you really need to see? What's under the center of

the chest? Isn't there a better look that you can get by doing something

similar? Heck. I'm probably giving it away.

GG

>

> Move the positive electrode (red) to the center of the chest between the

> nipples and switch the monitor to Lead III. This (MCL3) lead will allow you

> to look at the anterior-septal part of the heart. You may see reciprocal

> changes in this lead much as you would in V1-V4 if this is truly an inferior

> MI.

>

> Susie Jechow

>

> Re: Re: Puzzler

>

> > You're onto something. However, you need to need more to make the

> > NTG/no

> > NTG decision, and the saline lock/NS decision. What can you do with

> > the

> > equipment you have to get a better impression of what may be happening

> > with this

> > patient's heart?

> >

> > G

> >

> >

> >

> >>

> >>

> >> I'm going with an inferior MI affecting the right coronary artery , as

> >> indicated by the ST elevations in leads II and III. The reciprocal change

> >> in

> >> lead

> >> I is also indicative of this form of MI.

> >>

> >> I'm going to go with the saline lock, due to his current blood pressure

> >> already being elevated. Holding off on the NTG for now.

> >>

> >> I'd encourage my patient to go to the teaching hospital because he needs

> >> a

> >> cath lab which the community hospital does not have.

> >>

> >> -Wes (eager EMT)

> >>

> >> In a message dated 7/25/2006 10:36:07 PM Central Daylight Time,

> >> wegandy1938@ wegandy1938@<w

> >>

> >> Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is

> >> for

> >> a free trip to Opdyke West, TX to enjoy the July weather.

> >>

> >> While this is for paramedics, knowledgeable, precocious, and eager EMTs

> >> are

> >> welcome to chime in.

> >>

> >> Your 58 year old male patient complains of chest pain which began

> >> approximately one hour prior to your arrival at his side. He relates that

> >> the pain is

> >> now 10 on a 10 scale, has not diminished since it started, and he is in

> >> great

> >> distress, with breathing difficulty, a look of panic in his eyes, ashen,

> >> moist

> >> skin, and he also complains of nausea. He begs you to help him.

> >>

> >> Your partner places the pulse oxymeter on him and begins to set up

> >> oxygen.

> >> The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now

> >> placed

> >> the electrodes for your monitor on his chest. Unfortunately, your service

> >> has not yet purchased 12-lead monitors, so your monitor is designed to

> >> read

> >> leads I, II, and III. As your partner administers an aspirin to the

> >> patient,

> >> you

> >> watch the monitor in Lead II and see sinus rhythm with a high ST

> >> elevation.

> >> Switching to lead I, you note sinus rhythm with ST depression, and in

> >> Lead

> >> III you see marked ST segment elevation.

> >>

> >> Your partner now has an IV established in the left arm, and he asks you

> >> whether you want to hang NS or place a saline lock. All the while your

> >> patient is

> >> begging you to do something about his pain.

> >>

> >> Should you go with a saline lock or hang NS? Should you administer

> >> nitroglycerine? Morphine?

> >>

> >> Are there any other interventions you can do to help you decide those

> >> issues?

> >> If so, what?

> >>

> >> You are 12 minutes from a community hospital with a small ER and no cath

> >> lab

> >> and this is where your patient wants you to take him. You are 25 minutes

> >> from a large teaching hospital with a cath lab. What should your

> >> destination

> >> be

> >> and if you determine to go to the larger hospital, what do you tell your

> >> patient to get him to agree?

> >>

> >> Gene G.

> >>

> >>

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Guest guest

Gene,

After the O2, IV, NS at TKO, Vitals. I would complete a manual 12 lead, or

MCL using my trusty squirrel driven LP 5. Check R4, Viagra status, quick

transport to the appropriate facility for definitive care.

Ron

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Move the positive electrode (red) to the center of the chest between the

nipples and switch the monitor to Lead III. This (MCL3) lead will allow you

to look at the anterior-septal part of the heart. You may see reciprocal

changes in this lead much as you would in V1-V4 if this is truly an inferior

MI.

Susie Jechow

Re: Re: Puzzler

> You're onto something. However, you need to need more to make the

> NTG/no

> NTG decision, and the saline lock/NS decision. What can you do with

> the

> equipment you have to get a better impression of what may be happening

> with this

> patient's heart?

>

> G

>

>

>

>>

>>

>> I'm going with an inferior MI affecting the right coronary artery , as

>> indicated by the ST elevations in leads II and III. The reciprocal change

>> in

>> lead

>> I is also indicative of this form of MI.

>>

>> I'm going to go with the saline lock, due to his current blood pressure

>> already being elevated. Holding off on the NTG for now.

>>

>> I'd encourage my patient to go to the teaching hospital because he needs

>> a

>> cath lab which the community hospital does not have.

>>

>> -Wes (eager EMT)

>>

>> In a message dated 7/25/2006 10:36:07 PM Central Daylight Time,

>> wegandy1938@wegandy writes:

>>

>> Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is

>> for

>> a free trip to Opdyke West, TX to enjoy the July weather.

>>

>> While this is for paramedics, knowledgeable, precocious, and eager EMTs

>> are

>> welcome to chime in.

>>

>> Your 58 year old male patient complains of chest pain which began

>> approximately one hour prior to your arrival at his side. He relates that

>> the pain is

>> now 10 on a 10 scale, has not diminished since it started, and he is in

>> great

>> distress, with breathing difficulty, a look of panic in his eyes, ashen,

>> moist

>> skin, and he also complains of nausea. He begs you to help him.

>>

>> Your partner places the pulse oxymeter on him and begins to set up

>> oxygen.

>> The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now

>> placed

>> the electrodes for your monitor on his chest. Unfortunately, your service

>> has not yet purchased 12-lead monitors, so your monitor is designed to

>> read

>> leads I, II, and III. As your partner administers an aspirin to the

>> patient,

>> you

>> watch the monitor in Lead II and see sinus rhythm with a high ST

>> elevation.

>> Switching to lead I, you note sinus rhythm with ST depression, and in

>> Lead

>> III you see marked ST segment elevation.

>>

>> Your partner now has an IV established in the left arm, and he asks you

>> whether you want to hang NS or place a saline lock. All the while your

>> patient is

>> begging you to do something about his pain.

>>

>> Should you go with a saline lock or hang NS? Should you administer

>> nitroglycerine? Morphine?

>>

>> Are there any other interventions you can do to help you decide those

>> issues?

>> If so, what?

>>

>> You are 12 minutes from a community hospital with a small ER and no cath

>> lab

>> and this is where your patient wants you to take him. You are 25 minutes

>> from a large teaching hospital with a cath lab. What should your

>> destination

>> be

>> and if you determine to go to the larger hospital, what do you tell your

>> patient to get him to agree?

>>

>> Gene G.

>>

>>

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Guest guest

Wes, why do you withhold the ntg? You're not quite a star- perhaps a

starling?

I will say though that there have been several good answers- most are on

the right side of the answer...

;-)

R

___

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www.snappermail.com

....... Original Message .......

>

>I'm going with an inferior MI affecting the right coronary artery , as

>indicated by the ST elevations in leads II and III. The reciprocal change

in lead

>I is also indicative of this form of MI.

>

>I'm going to go with the saline lock, due to his current blood pressure

>already being elevated. Holding off on the NTG for now.

>

>I'd encourage my patient to go to the teaching hospital because he needs a

>cath lab which the community hospital does not have.

>

>-Wes (eager EMT)

>

>In a message dated 7/25/2006 10:36:07 PM Central Daylight Time,

>wegandy1938@... writes:

>

>

>

>

>Well, kids, Uncle Gene thinks it's time for a new puzzler. This one is for

>a free trip to Opdyke West, TX to enjoy the July weather.

>

>While this is for paramedics, knowledgeable, precocious, and eager EMTs

are

>welcome to chime in.

>

>Your 58 year old male patient complains of chest pain which began

>approximately one hour prior to your arrival at his side. He relates that

>the pain is

>now 10 on a 10 scale, has not diminished since it started, and he is in

>great

>distress, with breathing difficulty, a look of panic in his eyes, ashen,

>moist

>skin, and he also complains of nausea. He begs you to help him.

>

>Your partner places the pulse oxymeter on him and begins to set up

oxygen.

>The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have now

placed

>the electrodes for your monitor on his chest. Unfortunately, your service

>has not yet purchased 12-lead monitors, so your monitor is designed to

read

>leads I, II, and III. As your partner administers an aspirin to the

patient,

>you

>watch the monitor in Lead II and see sinus rhythm with a high ST

elevation.

>Switching to lead I, you note sinus rhythm with ST depression, and in

Lead

>III you see marked ST segment elevation.

>

>Your partner now has an IV established in the left arm, and he asks you

>whether you want to hang NS or place a saline lock. All the while your

>patient is

>begging you to do something about his pain.

>

>Should you go with a saline lock or hang NS? Should you administer

>nitroglycerine? Morphine?

>

>Are there any other interventions you can do to help you decide those

>issues?

>If so, what?

>

>You are 12 minutes from a community hospital with a small ER and no cath

lab

>and this is where your patient wants you to take him. You are 25 minutes

>from a large teaching hospital with a cath lab. What should your

destination

>be

>and if you determine to go to the larger hospital, what do you tell your

>patient to get him to agree?

>

>Gene G.

>

>[Non-text portions of this message have been removed]

>

>

>

>

>

>

>

>

>

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Guest guest

Very good. Be ready to infuse lots of fluids (1-3 liters) in case of

disastrous BP drop. MS is safer than NTG. If you are lucky enough to carry

Tridil you can titrate a drip, and that's the safest way.

GG

>

> Thought I'd put in my 2 cents just because. Seems like folks are

> leaning in the right direction, just a little off the mark. The Red

> lead should be placed on the right side at app the 5th intercostal

> space, read lead 3, and look for a marked ST elevation. This would

> be an Acute Right Ventricular MI. There could also be an

> accompanying Inferior MI. Treatment: high flow O2, IV NS @ TKO

> unless more needed for hypotention, NTG and Morphine should be used

> with caution because they can cause a BIG BP drop. Keep pacing in

> mind if necessary. By all means, this patient needs to go to the

> teaching hospital. Delay at the smaller facility could be

> disasterous.

> Well, there it is Gene. How did I do? LOL

> Joe T

>

> --- In texasems-l@yahoogrotexasem, wegandy1938@, wegandy1

> >

> > Well, kids, Uncle Gene thinks it's time for a new puzzler. This

> one is for

> > a free trip to Opdyke West, TX to enjoy the July weather.

> >

> > While this is for paramedics, knowledgeable, precocious, and eager

> EMTs are

> > welcome to chime in.

> >

> > Your 58 year old male patient complains of chest pain which began

> > approximately one hour prior to your arrival at his side. He

> relates that the pain is

> > now 10 on a 10 scale, has not diminished since it started, and he

> is in great

> > distress, with breathing difficulty, a look of panic in his eyes,

> ashen, moist

> > skin, and he also complains of nausea. He begs you to help him.

> >

> > Your partner places the pulse oxymeter on him and begins to set up

> oxygen.

> > The pulse ox reads 97%. He is placed on 12 lpm/NRB, and you have

> now placed

> > the electrodes for your monitor on his chest. Unfortunately,

> your service

> > has not yet purchased 12-lead monitors, so your monitor is

> designed to read

> > leads I, II, and III. As your partner administers an aspirin to

> the patient, you

> > watch the monitor in Lead II and see sinus rhythm with a high ST

> elevation.

> > Switching to lead I, you note sinus rhythm with ST depression, and

> in Lead

> > III you see marked ST segment elevation.

> >

> > Your partner now has an IV established in the left arm, and he

> asks you

> > whether you want to hang NS or place a saline lock. All the

> while your patient is

> > begging you to do something about his pain.

> >

> > Should you go with a saline lock or hang NS? Should you

> administer

> > nitroglycerine? Morphine?

> >

> > Are there any other interventions you can do to help you decide

> those issues?

> > If so, what?

> >

> > You are 12 minutes from a community hospital with a small ER and

> no cath lab

> > and this is where your patient wants you to take him. You are 25

> minutes

> > from a large teaching hospital with a cath lab. What should your

> destination be

> > and if you determine to go to the larger hospital, what do you

> tell your

> > patient to get him to agree?

> >

> > Gene G.

> >

> >

> >

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