“Local Hosspital, this is Medic 7, local hospital, come in please.”
“Medic seven, go ahead.”
“Local Hospital, I have an ETA of approximately 10 minutes. This is a 56 year old female STEMI alert. He chief complaint is general malaise for several days. We have 4 millimeters of elevation in V1, 5 millimeters in V2, and 3 millimeters in V3. The rhythm is a sinus, at a rate of 65, without ectopy. Her blood pressure is normotensive, she has had her aspirin, and is receiving nitro every 4 minutes. I am transmitting her 12-lead now. We will see you in 10.”
“Medic seven, we’ll see you in 10. Local Hospital clear.”
This whole activating the cath lab from the field sounds great and all, but it doesn’t work when you have a doctor who thinks your job is to deliver his paycheck.
Neither myself, or my paramedic partner-of-the-day expected to find a STEMI on this lady, but we did. An anteroseptal one at that. So we did what paramedics do: we treated the patient.
We gave her aspirin, and we administered nitroglycerin. We performed serial 12-leads. Every 4 minutes, about 2 minutes after each nitro, I pressed the ’12-Lead’ button on our Lifepak 15. And I set up the automatic transmit option, so that Local Hospital received each 12-lead about 30 seconds after I did.
And what do you know. Her ST-segment returned to baseline. And what else do you know? Hotshot new doctor wouldn’t activate the cath lab. Because the last 12-lead showed no elevation.
Well, duh. I put a chemical band-aid on her, but now she might need some PCI.
“She doesn’t have any ST elevation now, so let’s put her in room 9.”
“She did have elevation, but you are right, she doesn’t have any now.”
“It’s not a STEMI.”
“It was a STEMI.”
“I’m the doctor, I know what I’m doing.”
“Then you should know what I was doing in the ambulance.”
“You were giving nitroglycerin to a patient without chest pain.”
“Nitroglycerin causes vasodilation, and reduces myocardial oxygen demand, which can help return an ST segment to the baseline, just like it did on her ECG. Y’all do PCI in the ER now?”
“She doesn’t need a cath.”
“She needs a cardiologist.”
“I will make that call.”
I never did find out what happened with that patient. I hope the hotshot doctor called cardiology. I won’t pretend to be a doctor, but I can prove the lady was having a STEMI.
She’s hotshot’s patient now.
All the tools in the Verse yet some GP on ER rotation ends up stopping every minute of benefit we give. Like when we hit the doors with CPR in progress and they want to stop compressions to check a pulse.
We now see them as they used to see us.
Several thoughts and a memory:
I doubt in this particular case that it was a GP on ER rotation but, good grief! It might as well have been.
It would be interesting to possess all the records and present them to a cardiologist and see what he or she thinks.
I wonder if this doctor was not willing to admit that you were right in front of God and everyone but when you left, he ended up calling in the cardiologist so only God knew that he was admitting you were right.
So why is it that they try to assert that we (EMS) are part of a team when we’re obviously not considered that way by the people who receive our patients. I don’t know what it is about some doctors (and nurses and paramedics) that they can’t say, “Wow, you’re right, I should have thought about that.” I do that not infrequently with my EMT’s who suggest things to me that I might not have remembered. The endpoint is not being right all the time but good patient care.
If this happened to me, absent the patient demanding it, my next similarly afflicted heart patient would go to a different hospital the next time where they could get more competent care.
The story: There was an ER doc “back in the day,” when we had to get orders for everything who constantly denied my orders requests, never believing that my assessment was correct. He was a very good ER doc, but he just didn’t trust medics. When I would get the patient in, he’d say, after his exam, “You were right.” But this went on and on.
One afternoon I had a call to a residence where a man in his mid-fifties had been out cutting grass, had started feelin poorly and came into the house, laid down on his bed, and died. Well, that’s what it appeared to be anyways when I got there. He was lying on the bed and looked dead. No detectable breathing, no pulse. But when I dug around in the neck to be certain I couldn’t find a pulse, he moaned. Aha! So +cardiac monitor = idioventricular rhythm, rate = 30, more or less -> very low BP = no palpable pulses. No 12-leads in those days in the field (this is almost exactly 30 years ago).
I told my partner to go to the ambulance and get orders for an IV D5W and up to 1 mg of atropine, as we did in those days. Meanwhile, I got the patient on oxygen (no pulse oximetry at that time) and moved him to the stretcher and set up the IV. Partner came back and said that the doctor had said to start the IV but denied the atropine order. I said, “If I can’t put anything in it, I don’t need a damned IV.”
We moved him to the ambulance and I opened the windows (we could do that in those days) and said, “Blow all the sirens you’ve got as loud as you can all the way to the hospital,” thinking I might be able to generate a sympathetic response. Dadgum if it didn’t work. Patient started stirring and heart rate started to come up.
I thought, “Well, by God, if he wants me to put in an IV, I’ll put one in,” and started a 14-guage line in the antecubital. That big sewer pipe did it. The guy began to really wake up.
By the time we got to the hospital, he was awake, sitting up, and in normal sinus rhythm.
At this point I should say that during the initial assessment, I had forgotten to turn off the printer on the monitor so I had about 30 feet of strip.
When we got into the ER, the doc came in, glanced at the patient, glared at me and said, “So, where’s this big damn emergency that you called in?” I spread my arms wide with about five feet of HR=30 in front of him, and he was stunned. We walked out into the broader ER and he said, holding the strip in this hand, “I don’t believe it.” (not that he really didn’t believe it, he was just surprised) I said, in front of God and everyone, “That’s your problem. You never believe anything that I tell you and never allow me to do the things I need to do to help these patients. And when I bring them in, you always say, ‘You were right.’ When are you going to get it through your head that I know what I’m doing?”
His reply, “There are a lot of people out there who don’t know what they’re doing.”
“And I’m not one of them.”
That was the last time he ever denied me an order.
I had a similar exchange with an ER doc a couple of years back.
Doc: “Why were you giving her Nitro when she didn’t have chest pain?”
Me: “Because she has acute pulmonary edema.”
Doc: “Then you should have given her morphine. Nitro isn’t going to help her.”
Me: “No, morphine isn’t going to help her, but lots of Nitro and CPAP will. And did.”
Doc: “You should have given her morphine and Lasix.”
Me: “I’m not going to argue with you about this, Doc.”
Doc: “As well you shouldn’t, because you’re the dumbassed paramedic and I’m the one who went to medical school.”
[sound of record screeching and all activity in the ED stopping while everyone waited to see how I'd react]
Me: “Funny, all those guys that say morphine isn’t effective and Lasix is harmful, and that we should treat aggressively with Nitro and apply CPAP to our APE patients, they went to med school, too. And they’re out publishing cutting edge research, not practicing half-assed 1980′s medicine in a major hospital right here in 2010.”
Doc: “You’re rude and insolent.”
Me: “Only to doctors who don’t know what they’re doing who treat me like I’m an idiot.”
Funny thing is, but after that, that same doc and I got along great. He’d pretty much let me open the cranial cavity if I thought it was necessary. I think he was one of those types that has to see you stand up to him before he’ll give you any respect.
Charge nurse told me later that the ED attending came over a few minutes later, countermanded every one of his orders, ordered pretty much exactly what I had done in the field, and gave him the stink eye the whole time. The doc then went back to the physician’s lounge, sulking and surfing Medline for the rest of the shift.
Presumably, for articles on acute pulmonary edema.
GREAT story. You are exceedingly fortunate that you have employers who will let you get away with that kind of response.
GREAT story. You are exceedingly fortunate that you have employers who will let you get away with that kind of response.
Apologies. The site was non-responsive so I clicked again. CCC, you can remove the duplicate and this one if you can.
Doc: “As well you shouldn’t, because you’re the dumbassed paramedic and I’m the one who went to medical school.
“And which correspondence course medical school was it you went to doctor? Was it the prestigious “Close Cover Before Striking” school of medicine?
I hate those kinda guys. I am a fan of our STEMI system here (none of this transmitting stuff…literally, we call the Medical Resource Control Center Operator and tell them; “call xyz hospital and activate the cath lab, eta 10minutes” (we call in our regular report on the way in)).
Had a guy not long ago with a heroin OD. Wound up giving him about 0.25 of Narcan. Just enough that he could breathe, protect his airway (though watching was still a good thing) and, if I tapped his shoulder, would answer questions (name, DOB, etc.). Got to the ED and was giving report. When I told of the Narcan dose, the resident looked at me and said, “Don’t you people know how to manage these patients?!” and proceeded to order 2mg of Narcan from the nurse. He pushed it fast as he shook his head and said, “I don’t understand why you didn’t just give him 2 mg right off the bat!”.
The patient proceeded to sit bolt upright, cry out and expel more semidigested foodstuffs than I’d seen in recent history (think Mr. Creosote) coating the resident from face to shoes. I looked at his dripping visage and said, “I thought that was a pretty good reason myself”. The staff doc (who had arrived by then) rolled his eyes at the resident, the nurse laughed at him while beginning to minister to the poor sick patient and the resident looked like I had not only kicked his puppy, but stepped on his nads a little bit too.
Some people…
Some people don’t understand that managing the patient and managing the medical condition are two different things. In a similar instance as yours, I transported a patient into the hospital who was drugged out. Who knows with what?
I arrived on the scene to find a demolished Camaro and was directed to the fire engine where the driver was sitting unsteadily on the tailboard. He was able to respond but was sluggish and confused. I won’t go into the H&P other than to say that I was able to establish to my satisfaction that he was drugged out. Did he have head iinjuries secondary to the crash? My x-ray vision hadn’t come in at the time so I didn’t know for sure. Since the patient was already sitting, we put the stretcher next to the tailboard with a backboard on it and having put a collar on the patient, lifted him over to the stretcher and board. He did lay back but became extremely – and I do mean extremely – combative when I tried to secure him to the board. When not disturbed, he would lie still and drift off into his drugged state.
After a couple of attempts, I concluded that he would likely exacerbate any damage to himself more by fighting us than if I just left him alone. So I left him alone and we rode to the hospital with him still and quiet, good movement in the extremeties (for sure), breathing ok, peripheral pulses ok.
We got him to the hospital and the nurses immediately started in on the “he’d not properly secured.” I tried to explain the circumstances to them but they just fussed louder. Then the doctor joined the chorus as we rode him down the hallway. Once in Trauma 1, he ordered the nurses to properly secure him to the board.
The next two or three minutes were instructive. To them. After rendering some soft tissue injuries to a couple of the nurses, breaking a light over the bed and pulling the equipment board (with IV’s, ET tubes and other supplies) off the wall, they desisted in their attempts to “secure him” to the board. The doctor said, “Just let him lie there. He seems quiet if you don’t disturb him.”
I had been observing the circus and at that moment I walked up to the doctor, looked him straight in the face and said, loudly and pointedly, “I told you so. Next time, maybe you people will listen to me.”
For the record, they didn’t. But that’s another story.
So it sounds like you are all about advancing our profession. I am with you there.
Let’s have a discussion then. What evidence is there that NTG would help this patient therapeutically, with no chest discomfort? I understand the logic goes like “Well, it causes coronary vasodilation which helps get more oxygen to the infarcting muscle so I think it should be good” but if we are going to be professional we need (or should need) actual evidence before administering possibly harmful medicine to a possibly sick patient. The ACLS guidelines don’t seem to have any recommendation on giving NTG to pain-free STEMI patients, so where did that idea come from?
Thank you for your concern, Patrick. Regarding the ACLS guidelines, they have consistently shown themselves to be years behind in what they prescribe for medics who wish to use a cookbook. I think we understood 15 years ago that the heart had no vagal tone in asystole, right?
As for the “evidence” you requested; a simple Google search will yield the answers you seek. There are numerous papers published on the ability of nitroglycerin to return the ST segment to baseline. Other are papers that laud the long-term benefits of platelet aggregation inhibition 24 hours after the administration of nitroglycerin.
If I may, from the (apparently) hallowed pages of the AHA publication Circulation, whence from come the coveted ACLS guidelines;
“Conclusions—NTG protects human myocardium against ischemia 24 hours after its administration. To the best of our knowledge, this is the first report that a late PC effect can be recruited pharmacologically in humans. The results suggest that prophylactic administration of nitrates could be a novel approach to the protection of the ischemic myocardium in patients.”
Good day.
“Good day” to you, too. I did Google, and couldn’t find anything in regards to pain-free STEMI as you describe here. The one quote that you did provide is from a study of 66 patients who underwent PCI 24 hours after IV NTG, that’s a bit of a stretch. Whether or not returning an ST segment to baseline truly means the patient is clinically improving or just delays diagnosis of STEMI is up for debate, too.
Listen, I don’t really care too much about what the standing orders or ACLS says either, I’m all about what’s best for the patient. I’m glad you put some thought into your decision and are willing to discuss that reasoning, because I’m genuinely curious. We aren’t opponents here.
Patrick, I dug through the literature on this a while ago, and evidence that peri-MI nitro improves mortality in general is fairly ambiguous. There’s some slim support that it may help and lots of studies that say it may not. Nothing I know of has been done specifically for painless MI.
CCC’s answer was pretty awesome…but in case you’re looking for a different point of view…middle aged female with malaise and STEMI…that is a classic atypical cardiac presentation that certainly warrants treatment (including aspirin and nitroglycerin).
As CCC says…there’s plenty of evidence that treating cardiac symptoms (even if it is not “pain”) is beneficial to the patient.
The more I research women and MI for an upcoming presentation, the less impressed I am with chest pain as a chief complaint. Malaise, dyspnea on exertion, syncope or near syncope, are all red flags. As usual though, the ECG is more confirmatory than diagnostic.
Hope I’m not trespassing, but this is an interesting discussion, as well as very similar to a case I had recently (http://millhillavecommand.blogspot.com/2012/08/importance-of-prehospital-ecg.html).
Of course, your post touches on more than just management of the spontaneously-reperfused STEMI. There are the matters of knowledge of prehospital scope of practice by ED staff, the utility of NTG to effect recanalization, as well as just plain courtesy!
I think I speak for everyone, however, when I admit to a desire to see 1) the first and last ECGs by EMS, and 2) a discharge summary, cath report, ANYTHING, from the hospital as follow-up. I know this is about broader issues, but my curiosity has been piqued!
Thanks! (Walking quietly backwards out of the room.)
I always forget that blog readers like visual stimulation. I will look for those 12-leads, and post them if I can find them.
You can always hang out in this room if you want.
Seems to be a thread right now. Over at Dr. Smith’s ECG Blog, he brings up a case (from 10 years ago)…
http://hqmeded-ecg.blogspot.com/2012/08/spontaneous-reperfusion-and-re.html