A couple of days ago, I was reviewing a PCR from one of my client services. The rough details are that the patient was an older man with a significant medical history. His chief complaint was pain consistent with Acute Coronary Syndrome. At issue were a few things that had been picked up as sub optimal in his treatment.
First, despite some evidence that this might be a STEMI patient, the receiving hospital was not so notified. This is bad medicine since even during the middle of the day, it takes some time to prepare the cath lab for an emergency patient. At night, it’s far worse since very often doctors and other staff have to be called in from home.
That was a pretty clear cut failure on the crews part and one that I would have to discuss with them.
The other issue was that they had given only one Nitroglycerin spray and despite some time to they got to the hospital and the patients continuing pain. The protocol that they work (and many systems) work under is that they can give up to three sprays before having to contact medical control. Of course the three includes any that the patient might have taken. Provided that the patient has his own Nitroglycerin and that it’s not expired. That last is much more of an issue if the bottle is open.
Of course the protocol calls for an IV to be in place before Nitroglycerine is administered.
Which started me to thinking, always a dangerous thing.
Here are the issues with this protocol as I see them.
First, if there are signs, symptoms, and EKG data consistent with a STEMI, why waste time giving any Nitroglycerin? Is there any evidence that doing so is of benefit to the patient? If the problem is ischemia, then it’s a reasonable approach. However, if the problem is injury or infarct, is there a benefit or are we wasting time?
Fentanyl, or if you are in a regressive system, Morphine is the medication that should be given. Yet, based on the same advice that my fathers cardiologist gave him almost 40 years ago, we have a protocol for ALS providers to follow.
That’s the first question.
Here is the second question. Why do we need to start the IV before hand? The patient can take his own Nitroglycerine without starting and IV on himself. Even worse, BLS personnel can “assist” the patient with taking his own medication and they don’t have to start an IV either. (They aren’t allowed to in this state anyway).
Yet, when a paramedic shows up, before he can give more Nitroglycerine, he must start an IV on the patient. Or at the least call medical control which might nor might not say “Go ahead with the NTG, but get the IV as soon as you can.” When I was working we had a medical director who was a bit more progressive than most. He told us to do exactly that without having to get our permission slip signed by on line medical control. If the patient really needed an IV and we couldn’t find access, we could always place an IO.
I think part of the fault here is with the education of paramedics. There are some times when it’s fine to give Nitroglycerine without first starting and IV and there are other times when it’s not fine. The key is to know the difference.
The other fault is with the protocol itself. Why give Nitroglycerine by rote when we have much better diagnostic equipment than we did back when said protocol was first written? As I said, take three Nitro and then call the ambulance is advice that doctors have been giving to their patients since forever. It’s fine for lay people, but it seems pretty silly to restrict paramedics to doing that.
Maybe it’s just me, but I think that’s another medical myth that needs to be revisited.