Atypical Cardiac Chest Pain

We taught you what cardiac chest pain looked like, right? You remember.

We painted the perfect picture for you in your cardiac emergencies lecture in your EMT class. The pain felt like a pressure. It was brought on by exertion. It radiated to the left arm and through to the back. Sometimes, in your EMT skills stations, we would get fancy and have it begin at rest and radiate to the jaw. Just trying to keep you on your toes after all.

All this stuff is good to know. But we may have done you a disservice. You may be walking around with the idea that you can do a quick OPQRST and a SAMPLE and walk away with a fairly good feel for whether or not your patient is having a heart attack. You may be dead wrong.

What we may not have told you was that a large percentage of your patients suffering acute myocardial infarction won’t look anything like this. Atypical cardiac chest pain, those folks who have heart attacks but don’t quite feel like they’re supposed to feel, are actually very common. Common enough that we may need to think of a new name for them. Research says that the atypical folks may be a whole lot more typical than we think.

Did you know that the patient who is having a true myocardial infarction is 10% more likely to have pain radiate to his right arm than his left? Wrap your brain around that one.

It gets worse:

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What Is A Pandemic Anyway?

This pandemic word has been getting tossed around a bunch in the media lately. Ever since the World Health Organiztion started raising the pandemic alert level back in April of 2009 the media started tossing the P word out there like it was a bad cliche or a Geiko commercial. But what is a pandemic anyway? What makes one disease a pandemic and another one a run of the mill epidemic?

To answer that question lets start with that other, over-used media phrase “epidemic“.

Epidemics are all about predictability. (Not rate of spread or numbers of individuals effected.) So lets say you’re a run of the mill influenza virus and you’re off doing your seasonal influenza thing. The Centers for Disease Control may predict that you’ll infect 8.2-12.9% of the population this year.

To become an epidemic you need to beat your numbers. You need to outperform your statistical curve. Step up big time and infect 14% of the population and you too may be granted the status of “flu epidemic”.

Pandemics are a bit different. Pandemics need to meet a few more criteria before they get dubbed pandemic.

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What Is Muscular Dystrophy Anyway?

Since we’ve been talking about the fill the boot campaign the annual MDA telethon, why not use our “what is” series to take a closer look at the group of diseases we commonly refer to as muscular dystrophy.

While most EMS caregivers have a general idea of what to expect in a muscular dystrophy presentation, few of us are as knowledgeable as we should be about what muscular dystrophy is and what it does to the body. Let’s take a closer look.

While we tead to refer to muscular dystrophy as a single defined disease process, it is actually a group of disease that share some common characteristics. Add to that the fact that all of these diseases are degenerative in nature and you can imagine how remarkably different these patients can be.

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Wrong Medicine

Some of the stacks of trip reports were nearing four feet high and they filled the musty closet. Dividing them up, we started sorting through them in earnest. The dates indicated that the calls had been run between 1972 and 1978. Most of the narratives were as brief as the treatment lists.

Hall Ambulance’s station one was an older house in an early residential area of Bakersfield, California. It had been, at one time, the residence of the company’s owner, Harvey Hall. In the early days of the ambulance service, Harvey had both lived in the home and run his fledgling ambulance service out of it. 

One of the crews stationed at the home had gone digging in the dusty storage closets and struck EMS history gold. Stacks and stacks of old trip reports from the Mother, Jugs and Speed days of EMS. That’s where we found it. A call run by our medical director back in his days as a paramedic for the service. A cardiac arrest, no less. The total list of treatments given; CPR, BVM, Epinephrine 1mg, Sodium Bicarbonate 2 amps.

The year was 1991. We found this hilarious. We were still in our ACLS infancy. There was no CPR first or AEDs or Amiodarone. Nobody had heard of capnography and there was nothing therapeutic about hypothermia. Yet we felt very advanced looking at our medical directors run report. The massive Sodium Bicarbonate doses of the seventies had long since gone away. 

More than happy to reminisce about the call, our doc read the report with a bemused sort of faraway look and announced, “I remember this guy.” He told us the story of the overweight, mid-sixties male who had collapsed in the parking lot across from the hospital. And then he made an observation that has stuck with me my whole career.

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Beyond The 1-10 Pain Scale

How bad does it hurt? I’m willing to go out on a limb and say that this is, quite possibly, the most common question we ask in EMS. And it can be a difficult question to answer. How bad compared to what? How do we reconcile the patient with significant pain who winces and says it only hurts a little. Or what about the patient who is relaxed and seemingly comfortable while reporting the worst pain they have ever felt?

Not everyone feels pain the same way. Some patients feel pain more than others. And, perhaps even more significant, some patients fear pain more than others. What’s a clinician to do?

You and I aren’t the first ones to wrestle with this question. Medicine has devised a multitude of way to ask patients how much pain they are experiencing. We’ve even gone lengths to try to assess which ones are comparatively more accurate. From numeric rating scales to verbal rating scales to visual analogue scales. (No, I didn’t make that up.)

If you prefer to know who’s scale you’re using you can try the Wong-Baker faces scale, the McGill scale or even the Walid-Robinson pain index. (The patient needs to be taking opiates to use that last one.)

The truth is, we may just be wasting or time trying to develop more sophisticated and accurate ways of asking this question. With rare exceptions, prehospital folk tend to use the standard numeric rating scale, A.K.A. the 1-10 scale. It’s simple, it’s relatively fast and it doesn’t require us to carry around cards with faces on them or lists of questions.

I’ve always used the numeric scale and I’ve found it to be simple and useful but it has its pitfalls. You need to be careful how you ask the question. You also need to have a few back-up questions ready to help clarify the answer. Here are some of the questions I ask when I’m assessing pain severity.

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What Is GHB Anyway?

Let’s face it, there are a whole bunch of street drugs out there that we as EMS caregivers should understand. While we can’t always be expected to identify the exact drug a patient has ingested. We do need to be able to predict a given drugs effect on the body. We should also be able to take a fair guess at the identity of an ingested drug based on our evaluation of the patient’s physical presentation. GHB is one of those drugs that can be hard to nail down based on the physical signs. But it does leave some clues – if you know what your look for.

What Is It? : A Multi-Receptor Stimulant

GHB is short for gamma-Hydroxybutyric Acid, a naturally occurring substance produced by the central nervous system and found in small quantities in beef, wine and citrus fruits. It was first synthesized in a laboratory in 1874 but it wasn’t used in humans until 1960 when it was used in GABA receptor research and found to have a wide range of effects. In that year, scientists began testing GHB as an anesthetic and in the treatment of insomnia and depression.

The drug acts on both GABA and GHB receptors in the brain. Stimulation of GABA receptors has a sedative and analgesic effect. Stimulation of GHB receptors is primarily stimulatory. GHB also produces a biphasic release of Dopamine which produces euphoria. Understanding this multi-function aspect of GHB is key to recognizing the wide range of physical symptoms that are produced from a single GHB ingestion.

 The Hallmark of GHB Overdose: Wave-like Altered Mentation

A patient experiencing a GHB high will have many symptoms similar to other drugs. But they’ll also have a unique progression of symptoms unlike any other single street drug. This becomes confusing for the emergency caregiver. GHB overdoses don’t follow a linear progression of symptoms They ride waves of symptoms. … Let me explain.

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Treatment of Head Injury

Part three of a three part series

In our last two installments we looked at the way heads get injured and the various ways the brain tends to bleed. In this, our last installment in the head injury series, let’s take a look at basic treatment and management of the head injury patient.

There are a lot of variables that need to be considered when managing a head injury patient in the prehospital environment. Your treatment will be guided by considerations like the mechanism and severity of the head injury, other associated injuries, the patients mental status and their basic stability. 

These are some guidelines when sizing up and prioritizing your care.

Airway Management:

Head trauma management begins with the airway. The brain is sensitive to hypoxia and a poorly managed airway can turn a significant but recoverable head injury into a devastating head injury. Our brain injured patients can present some unique airway challenges. Seizures and posturing can produce trismus and spinal precautions prohibit proper tilting of the head.

In these cases, oral and nasal airway adjuncts are helpful in ensuring proper ventilation while keeping the head midline and neutral. If the Glasgow is less than eight, consider an advanced airway like a king tube, combi-tube or ET tube. All of these should be protected from the possibility of a clenched jaw with some sort of bite block type protection.

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Types of Brain Hemorrhage

Part two of a three part series

In our last post (part one) we introduced the subject of head injuries with an overview of trauma patterns typically found in head injury patients. Today let’s talk about bleeding inside the skull or intracranial hemorrhage. 

Brain hemorrhage occurs when blood vessels inside the skull rupture. There are some non-traumatic causes as well. Ruptured aneurysms and hemorrhagic strokes would be a few examples of non-traumatic intracranial hemorrhages.

We classify bleeding in the skull by location, using the layers of the meninges as a guide. You may recall from EMT class that the meninges are fluid coated membranes that surround and protect the brain and spinal cord. They also encapsulate and limit the ways that blood can move inside the skull. How the brain bleeds is entirely dependant on which meningeal layers capture and contain the blood.

Do you remember those meningeal layers? Lets do a quick review in case you’ve forgotten, courtesy of our friends at ADAM education:

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Responding to Head Injuries

Part one of a three part series.

It seems that after the tragic deaths of both Natasha Richardson and Billy Mays, head injuries have been getting a lot of play time in the media. Richardson died of an epidural bleed after a helmetless fall on skis. Mays was found to have an enlarged heart, but the minor head injury he received the night before his death launched speculation that he had died from intracranial bleeding as well.

Both of these incidents bring to light an important element of head injury response and evaluation. Patients with critical, life threatening brain injuries don’t always present as sick. Often they report feeling just fine. The emergency responder needs to approach head injuries with a high index of suspicion.

Today were going to begin a three part series on head injuries. In part one we’ll take a look at the different ways the skull and brain get injured. In part two we’ll talk about how the brain bleeds and how that can change the patients presentation. In part three we’ll look at treatment considerations for the head injured patient.

Let’s do a quick review of what’s inside your head:

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What Is The Good Samaritan Law?

The term “Good Samaritan” comes from the gospel of Luke. In the parable told by Christ, a Samaritan helped a Jew who had been beaten and robbed. At the time, the Samaritans and Jews were mortal enemies. Through the parable, Jesus attempts to redefine what it means to be a good neighbor.

Reading some recent conversations on the good Samaritan law in a few online forums, I’m reminded not of the biblical parable, but of the parable of the six blind men describing an elephant. Remember that one? One guy feels the side and thinks an elephant is like a wall, the other feels the tail and thinks an elephant is like to a rope? Initiating a discussion on the good Samaritan law in an online forum of EMTs is an invitation for confusion and scorn.

“It only applies to bystanders.”

“No it doesn’t! It only applies to EMS personnel.”

“And only if you’re off duty. Unless you’re a volunteer. And then only … no … wait.” And on and on.

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