Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Star of Death

Vince writes about a shocking unexpected rare not exactly every day occurrence in EMS. Star of Death is a criticism of the approach to patient care in a large EMS agency.

Vince’s post raises several questions.

First, here is his summary of the events that were described in the article.[1]

A 39 year old man who was having chest pain and shortness of breath had complete resolution of his symptoms after about 6 hours. The bad news is that the symptoms went away right along with that nagging heartbeat he had.

Does it seem as if he left out some detail? Something that might show the paramedics in a more favorable light?

It sure does seem that way. Vince can be a rather harsh critic Vince can be a rather harsh observer. Reading the entire article does not make things look any better. The point of view is mainly from the family, but most of what I copy is attributed to people speaking for EMS. This incident has not been fully investigated. There has not yet been an article that I have read, about an incident I was involved in, that did not have inaccuracies.

Paramedics are required by department protocol to transport by ambulance a patient who asks to go to a hospital, said Alan Etter, a spokesman for D.C. Fire and Emergency Medical Services.[1]

This may surprise some people, but that is the job. That and providing patient care.

checked his vital signs and performed an electrocardiogram, the results of which they said were normal.[1]

If they actually said that, who trained these clowns? Who is providing oversight to allow such idiocy to persist.

The term Normal Sinus Rhythm is one I do not believe should be used in the patient care setting. The word normal is inappropriate in describing anything about a patient with a medical complaint. To say that it may be normal is entirely different.

People get upset with EMS using the word diagnose. Even though we diagnose and treat all of the time. We use a bit of medical terminology sleight of hand to change it to working diagnosis, or some other demonstration of placing appearances before substance.

If diagnosis is outside of the scope of practice of EMS, why is it that so many in EMS are comfortable pronouncing a diagnosis of normal? Pronouncing does appear to be the wrong word in this case.

The EMTs asked Givens whether he had eaten or had anything to drink that evening, and he said he had eaten a burger, Givens said. They told him and his mother that he probably was suffering from acid reflux and suggested he take antacid.[1]

As long as he isn’t on a starvation diet, we’re out of here and back to bed in 5 minutes!

Why is it that doctors, medics, and nurses are so quick to ignore the serious condition and focus on something that means less work? The job is to prepare for the worst and hope for the best. To approach patient care in any other way, is just plain wrong. This does not mean that you follow the defensive medicine approach of a CAT scan for every head ache, but that you fully assess the patient in the way that a competent professional would. Jumping to the conclusion, that a patient does not have a legitimate cardiac complaint, without a full assessment is wrong. Too bad it isn’t rare.

“As per protocol, we are conducting a thorough quality assurance case review, and we will determine whether proper care was provided and if the two medical events are related,” Rubin said in a written statement.[1]

Rubin is Fire Chief Dennis L. Rubin. How would the two be unrelated? If they had transported him to the hospital, he might have died in the hospital. He may have had a heart attack or it may have been something not cardiac. If he had been transported, there would have been some documentation to help them come to a conclusion. They cannot prove that the 911 call and his death are unrelated. Will they try?

Is 39 too young to have a heart attack?

Should 39 be considered young? Since I am older than 39, I say yes. The question should be, is any age too young to have a heart attack? Since I have treated teenagers who have had heart attacks, I say no.

Conversely, there is no age at which a heart attack becomes mandatory. We are dealing with likelihoods. Knowing just the age, I would say a heart attack is unlikely. When you add chest pain and difficulty breathing, I would have to be a fool to say a heart attack is unlikely.

Jack Benny claimed to be 39 years old for most of his life, so it isn’t a bad age, but it does not rule out heart attack. And heart attack vs indigestion is not the extent of the differential diagnosis. Did EMS get a thorough history? I do not know, but I do not suggest to a patient that chest pain is probably just indigestion.

Is there any research to suggest that 39 year olds, with chest pain and difficulty breathing, should be considered to have agita, rather than angina?

I’d ask them how comfortable they are with saying, Would you like fries with that? I would, but they would probably try to discourage the customer from purchasing the fries, since fries might cause indigestion.

On L & D calls, does the medic suggest, You probably just need to sit on the toilet and have a good bowel movement?

On CHF calls, You’re hyperventilating. Just breathe into this paper bag.

On amputations, Pull yourself together?

Footnotes:

^ 1 Man Dies at Home After Paramedics Diagnose Acid Reflux
By Elissa Silverman
Washington Post Staff Writer
Thursday, December 4, 2008; Page B04
Article

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