Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 Okay, I have a question for you all. Please feel free to reply in any way you wish.... 43 y/o male presents with sudden onset of chest pain, s.o.b, with some nausea. This persons o2sat is 96% on room air, twelve lead shows Sinus rthym. Onset time is less than 15min ago. Pain is a " 9 " on a 10 scale. Pt has no significant hx, is obeise and a heavy smoker, with possible cocaine use. Question is this, is there a time frame from when you experiance chest pain till when you see any c changes in the EKG? A. Dempsey EMT-I/FF University Health System Department of Correctional Healthcare Services Bexar County Detention Center ----------------------------------------- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 > 43 y/o male presents with sudden onset of chest pain, s.o.b, with some > nausea. This persons o2sat is > 96% on room air, twelve lead shows Sinus rthym. Onset time is less > than 15min ago. Pain is a " 9 " on a > 10 scale. Pt has no significant hx, is obeise and a heavy smoker, with > possible cocaine use. > > Question is this, is there a time frame from when you experiance chest > pain till when you see any c > changes in the EKG? > Did the patient present with any other signs/symptoms? Fever, body aches, vomiting, diarrhea, etc? Does the pain increase or decrease on inspiration? Obviously, ruling out the worst possible case scenario is admirable, however there are that cause chest pain (pleurisy, for example). On a side note, was the patient treated as a potential cardiac patient? By that I mean, was there any relief with SL nitroglycerin (assuming his vital signs were within normal limits). -Alfonso R. Ochoa Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 You may not see any changes until it is way too late. If you are asking if you can rule out an MI by a clean 12 lead, followed by a repeated 12 lead that show no ACS changes, the answer is a resounding no, ECG changes may come too late to stop the damage before it starts. No hard and fast rule to apply here. CP with a social history such as his needs a cardiac work up to include 12 leads, labs and films. Hatfield FF/EMT-P www.canyonlakefire-ems.org ---------- Original Message ---------------------------------- Reply-To: texasems-l Date: Wed, 7 Feb 2007 00:12:13 -0600 >Okay, I have a question for you all. Please feel free to reply in any >way you wish.... > >43 y/o male presents with sudden onset of chest pain, s.o.b, with some >nausea. This persons o2sat is >96% on room air, twelve lead shows Sinus rthym. Onset time is less >than 15min ago. Pain is a " 9 " on a >10 scale. Pt has no significant hx, is obeise and a heavy smoker, with >possible cocaine use. > >Question is this, is there a time frame from when you experiance chest >pain till when you see any c >changes in the EKG? > > A. Dempsey EMT-I/FF >University Health System >Department of Correctional Healthcare Services >Bexar County Detention Center > > > > >----------------------------------------- > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 in answer, vital signs were 158/102, pulse of 70, respiratory rate of 22, only complaint was sudden onset of chest pain with s.o.b.. SL NTG was given with some relief, (a debate rages here... One nurse states that since the EKG shows no issues, the person cannot be having cardiac issues and wanted to send him on his merry little way saying he was just having some anxiety issues.) My arguement to the nurse was " stop treating the darn machine and treat the pt. This is where the arguement has ensued. A. Dempsey EMT-I/FF University Health System Department of Correctional Healthcare Services Bexar County Detention Center Re: EKG question > 43 y/o male presents with sudden onset of chest pain, s.o.b, with some > nausea. This persons o2sat is > 96% on room air, twelve lead shows Sinus rthym. Onset time is less > than 15min ago. Pain is a " 9 " on a > 10 scale. Pt has no significant hx, is obeise and a heavy smoker, with > possible cocaine use. > > Question is this, is there a time frame from when you experiance chest > pain till when you see any c > changes in the EKG? > Did the patient present with any other signs/symptoms? Fever, body aches, vomiting, diarrhea, etc? Does the pain increase or decrease on inspiration? Obviously, ruling out the worst possible case scenario is admirable, however there are that cause chest pain (pleurisy, for example). On a side note, was the patient treated as a potential cardiac patient? By that I mean, was there any relief with SL nitroglycerin (assuming his vital signs were within normal limits). -Alfonso R. Ochoa ----------------------------------------- Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 >>a debate rages here... One nurse states that since the EKG shows no issues, the person cannot be having cardiac issues and wanted to send him on his merry little way saying he was just having some anxiety issues.)<< The 12 lead is only a part of the picture. The nurse was premature in her judgment. This is one reason people are admitted for serial EKGs and enzymes when they have chest pain indicative of ischemia. -- Grayson, CCEMT-P, etc. MEDIC Training Solutions http://www.medictrainingsolutions.com/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 In a message dated 2/7/2007 12:18:25 AM Central Standard Time, kenneth.dempsey@... writes: Okay, I have a question for you all. Please feel free to reply in any way you wish.... 43 y/o male presents with sudden onset of chest pain, s.o.b, with some nausea. This persons o2sat is 96% on room air, twelve lead shows Sinus rthym. Onset time is less than 15min ago. Pain is a " 9 " on a 10 scale. Pt has no significant hx, is obeise and a heavy smoker, with possible cocaine use. Question is this, is there a time frame from when you experiance chest pain till when you see any c changes in the EKG? What is his pain description? His blood pressure on presentation? Any diaphoresis? Is there any family history? Any relief with NTG and O2? With the history given, the chap is an MI waiting to happen (risk factors: Male, over 40, obese, smoker, possible drug use as a minimum). He gets admitted to Cardiology, and possibly an urgent cath without waiting for EKG (or possibly any enzyme bumps). ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 6, 2007 Report Share Posted February 6, 2007 In a message dated 2/7/2007 12:47:55 AM Central Standard Time, kenneth.dempsey@... writes: in answer, vital signs were 158/102, pulse of 70, respiratory rate of 22, only complaint was sudden onset of chest pain with s.o.b.. SL NTG was given with some relief, (a debate rages here... One nurse states that since the EKG shows no issues, the person cannot be having cardiac issues and wanted to send him on his merry little way saying he was just having some anxiety issues.) My arguement to the nurse was " stop treating the darn machine and treat the pt. This is where the arguement has ensued. make that SIX risk factors and insist that the nurse take ACLS again....she obviously slept through the part about 'Risk Factors " and 'silent MIs'..... ck S Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 In a message dated 2/7/2007 8:29:47 AM Central Standard Time, kenneth.dempsey@... writes: In the end, the pt started complaining of pressure. The only other complaint was lower back back. This pt was held up from advanced care for approx 4hrs. I was informed by this nurse that she was far more educated and trained than I was, even considering me with my 20+yrs as an emt and that the EKG was normal the entire time meaning that he was not in any cardiac distress, and was placed in an non-emergent priority, and no notification to the on call md for follow up orders. My main goal here was to see if anyone could state for certain or have any good leads located in literature on when one would see visible changes to the EKG once the onset of cp begins. I have yet to find any referances. Then that case needs to be referred for QI through what ever means available. There's no way she met JCAHO standards, much less what should be taught in ACLS. SEVEN risk factors (now we have typical chest pain as well as elevated blood pressure, Male, over 40, smoker, obese and suspected drug usage, not including any occult family history or high lipids) would have me chatting with the nurse manager for the unit! This is just the sort of patient that ends up in the 15% 'unsuspected' mortality statistics. Any doctor who discharged that patient without at least two sets of enzymes AND an urgent cardiac stress test of some sort or a heart cath would be sucking wind if any problems developed, therefore the nurse definitely needs retraining. ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 In a message dated 2/7/2007 10:10:20 AM Central Standard Time, jkaymdc@... writes: Obese, smoker, etc..probably diabetes of a sort...how many of us have seen EKGs without changes or even good looking EKGs that were accurate? What are his cardiac enzymes? I'd trust that more than the EKG, however, I'd be trusting how the patient looks, what he describes and my gut feeling more than anything...but that's not scientific, I know. Jules: obviously, in the field, even the fancy Triage Rapid Assay kits are in short supply. In addition, even the first markers often won't rise for several (up to 6) hours after onset of significant pain. You are exactly correct in saying that the way the patient looks, plus significant risk factors, are the most important factors in field and ED triage of this kind of patient. I know some programs who will observe and stress test ALL patients with chest pain with three risk or more factors, despite initially normal resting EKGs and normal enzyme levels, and some authorities are recommending it for patients with only two risk factors. ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 In the end, the pt started complaining of pressure. The only other complaint was lower back back. This pt was held up from advanced care for approx 4hrs. I was informed by this nurse that she was far more educated and trained than I was, even considering me with my 20+yrs as an emt and that the EKG was normal the entire time meaning that he was not in any cardiac distress, and was placed in an non-emergent priority, and no notification to the on call md for follow up orders. My main goal here was to see if anyone could state for certain or have any good leads located in literature on when one would see visible changes to the EKG once the onset of cp begins. I have yet to find any referances. A. Dempsey EMT-I/FF University Health System Department of Correctional Healthcare Services Bexar County Detention Center Re: EKG question In a message dated 2/7/2007 12:18:25 AM Central Standard Time, kenneth.dempsey@... <mailto:kenneth.dempsey%40uhs-sa.com> writes: Okay, I have a question for you all. Please feel free to reply in any way you wish.... 43 y/o male presents with sudden onset of chest pain, s.o.b, with some nausea. This persons o2sat is 96% on room air, twelve lead shows Sinus rthym. Onset time is less than 15min ago. Pain is a " 9 " on a 10 scale. Pt has no significant hx, is obeise and a heavy smoker, with possible cocaine use. Question is this, is there a time frame from when you experiance chest pain till when you see any c changes in the EKG? What is his pain description? His blood pressure on presentation? Any diaphoresis? Is there any family history? Any relief with NTG and O2? With the history given, the chap is an MI waiting to happen (risk factors: Male, over 40, obese, smoker, possible drug use as a minimum). He gets admitted to Cardiology, and possibly an urgent cath without waiting for EKG (or possibly any enzyme bumps). ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 >> (a debate rages here... One nurse states that since the EKG shows no >>issues, the person cannot be having cardiac issues and wanted to send >>him on his merry little way saying he was just having some anxiety >>issues.) My arguement to the nurse was " stop treating the darn machine >>and treat the pt. This is where the arguement has ensued. Obese, smoker, etc..probably diabetes of a sort...how many of us have seen EKGs without changes or even good looking EKGs that were accurate? What are his cardiac enzymes? I'd trust that more than the EKG, however, I'd be trusting how the patient looks, what he describes and my gut feeling more than anything...but that's not scientific, I know. Jules ________________________________________________________________________ Check Out the new free AIM® Mail -- 2 GB of storage and industry-leading spam and email virus protection. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 In a message dated 2/7/2007 10:10:20 AM Central Standard Time, _jkaymdc@..._ (mailto:jkaymdc@...) writes: I'd be trusting how the patient looks, what he describes and my gut feeling more than anything...but that's not scientific, I know. Maybe more so than we give credit too? Read Blink and some of the stuff Deepak Chopra has done on things like intuition and gut feelings. Epithelia cells are amazing things. He's sick period. I'd be working him us as BLS guy holding my Medic to meet me en-route (if need be) and as I like to say I'd be " swiftly " transporting him to the closest cardiac cath capable ED in the area (if the distance was right of course). Louis N. Molino, Sr., CET FF/NREMT-B/FSI/EMSI Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant Buddhist philosopher at-large LNMolino@... (Cell Phone) (Home Phone) (IFW/TFW/FSS Office) (IFW/TFW/FSS Fax) " A Texan with a Jersey Attitude " " Great minds discuss ideas; Average minds discuss events; Small minds discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) The comments contained in this E-mail are the opinions of the author and the author alone. I in no way ever intend to speak for any person or organization that I am in any way whatsoever involved or associated with unless I specifically state that I am doing so. Further this E-mail is intended only for its stated recipient and may contain private and or confidential materials retransmission is strictly prohibited unless placed in the public domain by the original author. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 the no ekg changes means no ami is the same as " if they didnt pee themselves or poop their pants they couldn't have had a seizure " they teach nurses that, also. please don't flame me.... it's in several nursing texts i own. jim paramedic RN student jkaymdc@... wrote: >> (a debate rages here... One nurse states that since the EKG shows no >>issues, the person cannot be having cardiac issues and wanted to send >>him on his merry little way saying he was just having some anxiety >>issues.) My arguement to the nurse was " stop treating the darn machine >>and treat the pt. This is where the arguement has ensued. Obese, smoker, etc..probably diabetes of a sort...how many of us have seen EKGs without changes or even good looking EKGs that were accurate? What are his cardiac enzymes? I'd trust that more than the EKG, however, I'd be trusting how the patient looks, what he describes and my gut feeling more than anything...but that's not scientific, I know. Jules __________________________________________________________ Check Out the new free AIM® Mail -- 2 GB of storage and industry-leading spam and email virus protection. --------------------------------- No need to miss a message. Get email on-the-go with Yahoo! Mail for Mobile. Get started. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 In a message dated 2/7/2007 10:38:28 PM Central Standard Time, kenneth.dempsey@... writes: well I dont know what his markers were. The pt didnt live long enough to find that out. But I am still going round and round on this subject. ok...was there an autopsy performed? the slides of the heart tissue would be the 'final' diagnosis in this case. ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 well I dont know what his markers were. The pt didnt live long enough to find that out. But I am still going round and round on this subject. A. Dempsey EMT-I/FF University Health System Department of Correctional Healthcare Services Bexar County Detention Center Re: Re: EKG question In a message dated 2/7/2007 10:10:20 AM Central Standard Time, jkaymdc@... <mailto:jkaymdc%40aim.com> writes: Obese, smoker, etc..probably diabetes of a sort...how many of us have seen EKGs without changes or even good looking EKGs that were accurate? What are his cardiac enzymes? I'd trust that more than the EKG, however, I'd be trusting how the patient looks, what he describes and my gut feeling more than anything...but that's not scientific, I know. Jules: obviously, in the field, even the fancy Triage Rapid Assay kits are in short supply. In addition, even the first markers often won't rise for several (up to 6) hours after onset of significant pain. You are exactly correct in saying that the way the patient looks, plus significant risk factors, are the most important factors in field and ED triage of this kind of patient. I know some programs who will observe and stress test ALL patients with chest pain with three risk or more factors, despite initially normal resting EKGs and normal enzyme levels, and some authorities are recommending it for patients with only two risk factors. ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 7, 2007 Report Share Posted February 7, 2007 well Doc, I wish I could give you all that, but I am just the poor low man on the totem pole. I just know that there was bad judgement on part of a nurse in a system that refuses to recognize the input of a medic because as I was told, my job is not of a profesional standing and I.... and I quote here... " need to remember my place " . I did file a complaint with our medical system and the BNE. As of date, nothing has happened. A. Dempsey EMT-I/FF University Health System Department of Correctional Healthcare Services Bexar County Detention Center Re: Re: EKG question In a message dated 2/7/2007 10:38:28 PM Central Standard Time, kenneth.dempsey@... <mailto:kenneth.dempsey%40uhs-sa.com> writes: well I dont know what his markers were. The pt didnt live long enough to find that out. But I am still going round and round on this subject. ok...was there an autopsy performed? the slides of the heart tissue would be the 'final' diagnosis in this case. ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 8, 2007 Report Share Posted February 8, 2007 In a message dated 2/8/2007 12:52:58 AM Central Standard Time, kenneth.dempsey@... writes: well Doc, I wish I could give you all that, but I am just the poor low man on the totem pole. I just know that there was bad judgement on part of a nurse in a system that refuses to recognize the input of a medic because as I was told, my job is not of a profesional standing and I.... and I quote here... " need to remember my place " . I did file a complaint with our medical system and the BNE. As of date, nothing has happened. and the nurses complain about bad docs! ck S. Krin, DO FAAFP Quote Link to comment Share on other sites More sharing options...
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