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Re: [E-Chir] Scenario 4

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  • Kathleen Gormanshaw
    Well, there s a text book heart attack set-up, at least for a man. Women don t usually get the arm pain: Surprisingly, fewer than 30% reported having chest
    Message 1 of 6 , Dec 21, 2009
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      Well, there's a text book heart attack set-up, at least for a man.  Women don't usually get the arm pain:  "Surprisingly, fewer than 30% reported having chest pain or discomfort prior to their heart attacks, and 43% reported have no chest pain during any phase of the attack." From:  http://usgovinfo.about.com/cs/healthmedical/a/womensami.htm  It doesn't mention whether women are as likely to deny an attack as men or not.
       
      So I have a patient who alarms me but doesn't want me to fuss over her.  The next steps will depend a lot on how well I know her, and what I know about her.  Unless I think I can change her mind very quickly, I'm going to quietly whisper in the autocrat's ear to go call an ambulance, discretely.  I hope the ambulance guys have better expertise on convincing her to go to the hospital.  (I should probably just whisper to the autocrat anyways.)
       
      How to change her mind?  I might talk about how active she was last time I saw her, and that this is reallly NOT like her, something must be wrong.  Or maybe how her breathlessness reminds me of my asthma attacks, and those are scary, but medications really help fast.  Or maybe appeal to her sense of family, and how much they'd worry if something happened to her, she should get checked out to make sure they don't worry.
       
      Eyrny

      On Mon, Dec 21, 2009 at 1:40 PM, Ninka <dyscordant_rose@...> wrote:


      (Just in case you find some time between all those dinners and have a couple of brain cells that you wish to rub together during this holiday season...here's another scenario for you) :D
       
      You arrive at your local event shortly before the gate opens and are just trying to get you and your gear through the door when you are met by the autocrat of the event who asks if you'd be willing to take a look at Mary. The atutocrat tells you that Mary was part of the set-up group who arrived about an hour and a half ago. They'd all been working pretty hard getting chair and tables moved, hauling boxes in for the bar, hauling stuff in for the kitchen and whatever else has needed to be done before the gate opens. The autocrat tells you that she's been a bit worried about Mary, who didn't seem all that well when she got to the site earlier and now seems to be slowing down; needing to sit more often.
       
      You find your kit in amongst your gear and follow the autocrat to where Mary is currently sitting in a chair in the hallway outside the kitchen. You recognize Mary as one of your older members..you seem to recall that she had had her 50th birthday a couple of months back. Mary appears to be having some mild breathing distress. She appears pale and sweaty. When she sees you coming she shakes her head and tells you that she doesn't know what all the bother is; she is just winded from all the work due to the fact that she thinks she's been coming down with a cold or something which started last night. You notice that she can't seem to speak more than 5-6 words without having to take a breath.
       
      When you attempt to question her further you do discover that she is a bit nauseated (though she hasn't thrown up yet) which she attributes to coming down with something. You notice that every so often she reaches over to rub her left shoulder. When you question her about that she tells you that it doesn't hurt though it does ache but she states that its just from carrying boxes that she probably should've let younger good looking men carry rather than an old lady like herself. Other than a bit of dizziness now and then today Mary won't admit to feeling anything else and continues to claim that she is just feeling under the weather.
       
      Discuss.


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    • Bethoc (Lesley)
      Eryny allued to the difference between men and women with heart attack symptoms and provided a link to substantiate her point. Very nice.   However, from
      Message 2 of 6 , Dec 21, 2009
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        Eryny allued to the difference between men and women with heart attack symptoms and provided a link to substantiate her point. Very nice.
         
        However, from personal experience, I'd like to point out that
        1) it is also less common for men to have the crushing left sided "classic" arm and left sided chest pain caused by a heart attack (the left sided grab the chest collapse is "old school" thinking)
        2) pre-existing conditions like a breathing disorder (COPD) or metabolic disorder (diabetes) can modify the symptoms of a heart problem so that they aren't recognizable as a "classic" heart attack
         
        and I hate to say it but...
        3) in the field we are not medical doctors and it is not our job to diagnose someone... so try not to get caught up in "diagnose" the person, because you can miss something...
         
        In this example, the woman could have one of a number of physical problems related to the organs of the upper body including but not limited to aortic or thoracic anyeursm (weakening of the artery in the main trunks), plumonary disease (breathing disorder), pulmonary edema (water in the lung), exercise induced asthma, pneumonia, pulmonary embolism (clot in the lung), coronary spasm (muscular narrowing of the arteries supplying blood to the heart), congestive heart failure (weakened heart which causes water to back up into the lungs), heart block (where the top and the bottom of the heart don't communicate/function properly), coronary artery disease (umbrella term to include anything that affects the function of the heart because of clotting of blood vessels), severe allergic reaction to an unknown allergen, some kind of cancerous tumor (particularly lung is found late in the game) and to a lesser extent some kind of abdominal pathology.
         
        Rather, I recommened that we focus on the very drilled in first aid skills...and recognize early that this woman needs early medical attention.
         
        Get permission to assist, get 911 enroute, and do the ABCs - maintain her airway, coach her breathing and be prepared with universal precautions barriers if needed to perform AR, and watch/treat her circulation: rest, recumbent posture or shock position, treat her for shock, nothing by mouth and be prepared for CPR if required. Do your secondary assessment when you know your ABCs are covered, just to make sure you haven't missed anything.
         
        Is it helpful to count a pulse? Absolutely... you can tell whether it's too fast or too slow, regular or irregular as you wait for 911.
        Is it helpful to take a BP? Not necessarily... if she has a radial pulse then her pressure is satisfactory for the time being. If not, she's sick and needs to be supine and see medical attention sooner rather than later.
        Is it helpful to count her breathing rate? Sure... but there isn't too much you can do about it at the moment. What's more important is the coaching and monitoring whilst waiting for 911.
        Do you sense a theme in my long winded answer here? This woman needs medical attention is the bottom line. Early access to emergency medical care is the first link the Chain of Survival for cardiac care.
         
        Don't wait and try to fix her yourself because there really isn't too much a first aid responder can do in this situation other than monitor, coach/calm, treat for shock and wait for either the arrival of the ambulance or the person to become ill to the point of unconsciousness.
         
        Also, I say let the paramedics argue with the patient about whether or not to go to hospital. They have the legal document that absolves them of responsibility should the person refuse. As first responders, we don't. This person is not well and you have no idea of telling what is wrong with her.. Neither does she. Quite simply if she refuses to have any help until they arrive (or even afterwards), then any good first responder or paramedic will hang around and visually monitor her until she either gets worse to the point of unconsciousness (and then they can help with her implied consent) or until she improves through rest alone.
        That having been said, I'd still have 911 enroute if she improves even if she declines to go. And I'd still tell her that she needs to seek advanced medical assessment even if she improves when sitting at rest.
         
        well there is my short answer with a lot of words.
         
        who gave me a keyboard when I'm tired and tend to rant?
         
        Happy Holidays everyone!
        and be well
        Bethóc
         
        Per saltire purpure and gules, a sea-unicorn argent within a bordure per saltire Or and argent
         
        Golden Otter Pursuivant, Kingdom of Ealdormere
        Pursuivant, Canton of Vest Yorvik, the High Seat of Septentria
         
        Ut sit magna, tamen certe lenta ira deorum est
        The wrath of the gods may be great, but it certainly is slow
        what does {o'} mean? See Da'ud notation: http://www.sca.org.au/herald/commentary/Da'ud%20Notation.htm 
         
        solis sacerdotibus. Ave atque vale.


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      • Wolf
        Since Mary is now 50, she can not be classified as a spring Chicken any more. All of us non spring chickens now know that the activities of the day can
        Message 3 of 6 , Dec 22, 2009
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          Since Mary is now 50, she can not be classified as a "spring Chicken" any
          more. All of us "non spring chickens" now know that the activities of the
          day can leave us with all kinds of misc aches and pains, However Alarm bells
          go off as soon as she mentions the fatigue, shoulder pain, shortness of
          breath and nausea along with her story of exertion ( which could explain the
          sweating, but somehow I doubt it ). I would also be enquiring about her
          state of balance, has she experienced any headache or dizziness in the last
          24 hours.

          Although a heart attack is classically associated with severe pain across
          the chest, many people feel only a tightness or squeezing sensation in the
          chest. The discomfort of a heart attack may be confined to the arm, upper
          back, neck, or jaw. Some people only experience a feeling of indigestion,
          nausea, shortness of breath, or sweating. The discomfort associated with a
          heart attack usually lasts several hours. Other ailments such as Angina can
          cause identical symptons but are usually shortlived. I would be politely
          asking Mary about any history of cardiac issues, and would want to check her
          heart rate. If elevated then there is another clue.

          In any case I would be stongly suggest higher level medical intervention as
          soon as practical if not an immediate call to EMS

          Farquhar
        • b1laxson
          While reading it definitely starting have the heart attack flag go up. Its been pointed out though it could be many other things. From experience as a First
          Message 4 of 6 , Dec 23, 2009
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            While reading it definitely starting have the "heart attack" flag go up.

            Its been pointed out though it could be many other things.

            From experience as a First Aider/Chirurgeon it is particularily awkward when the 1st Aider feels there is a potentially fatal situation developing.

            Arranging for transport by paramedics is the way to go. It was particularily frightening having a possible fatality in a POV (personally owned vehicle). Its been a mental shift to be thinking "get them medical care" instead of "to the hospital". Alot can happen on the road which the paramedics can deal with.

            It is though very frustrating when the person goes "no no, don't call". Guidance has been to favor calling 911 to have them encourage the patient. Also, as someone else has already reminded us when they pass out "implied consent" comes into affect.

            Brian the Green
            1st aider
          • Kathleen Gormanshaw
            ... The nice thing about all those possibilities are ALL of them need me to call an ambulance. Well, nice might not be the best word, maybe simple . So my
            Message 5 of 6 , Dec 23, 2009
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              On Mon, Dec 21, 2009 at 10:34 PM, Bethoc (Lesley) <bethoc12thc@...> wrote:


              In this example, the woman could have one of a number of physical problems related to the organs of the upper body including but not limited to aortic or thoracic anyeursm (weakening of the artery in the main trunks), plumonary disease (breathing disorder), pulmonary edema (water in the lung), exercise induced asthma, pneumonia, pulmonary embolism (clot in the lung), coronary spasm (muscular narrowing of the arteries supplying blood to the heart), congestive heart failure (weakened heart which causes water to back up into the lungs), heart block (where the top and the bottom of the heart don't communicate/function properly), coronary artery disease (umbrella term to include anything that affects the function of the heart because of clotting of blood vessels), severe allergic reaction to an unknown allergen, some kind of cancerous tumor (particularly lung is found late in the game) and to a lesser extent some kind of abdominal pathology.
               
               
              The nice thing about all those possibilities are ALL of them need me to call an ambulance.  Well, "nice" might not be the best word, maybe "simple".  So my course of action is the same, no matter what I imagine the problem to be.
               
              Eyrny
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