Saturday, August 25, 2012

Prehospital Abdominal Assessment Part 4..MI?

For the upper right quadrant we are not going to concentrate on bleeding ulcers, any stomach disorders, or the spleen.  As I have said before paramedics are experts on what is going to kill you in the next 20 minutes, and the most devastating disorder we can encounter in the upper right, or any quadrant does not even originate from the abdominal cavity, it is a myocardial infarction.

You must scrutinize any and all abdominal pain for the presence of an MI, regardless of what the patient is telling you, regardless of the quadrant, regardless of your gut instinct as to the origin of the pain or discomfort.  Not long ago a woman walked into a hospital complaining of gallstones.  She had a history of gallstones.  She told the triage nurse the pain was more to the upper left quadrant and she was sure it was her gallstones.  The patient stated she should of had her gall bladder removed years ago but did not and now she is paying for it.  The nurse and the patient had a very thorough conversation regarding the patient's history, all signs and symptoms pointed to the gallbladder.  After the patient was escorted to a room the doctor ordered a routine EKG and found the following:

This was no gall stone!  The only reason we perform 12 lead EKGs in prehospital medicine is to quickly identify the presence of an acute MI.  We cannot successfully do this unless we get in the habit of rapidly (within 5 minutes of patient contact) performing a 12 Lead EKG on all patients at risk of having an MI.  That means all chest pain, chest discomfort, dizziness, syncope, shortness of breath, nausea, and yes abdominal pain to name a few.  There are few medical patients that you can absolutely rule out the risk of an MI.  If you are going to perform a 12 lead EKG on a patient it should be done quickly and efficiently.  Train your partner and crew to make this part of their initial physical assessment and acquisition of vital signs.  A well trained paramedic should never say, "do you want to get a 12 lead now or wait till we get to the unit?"  My response to that question is, "exactly how long would you like to wait to determine the patient is having an MI? Would 10 more minutes suffice?"

Don't let an MI slip through your fingers just because the patient describes abdominal pain.  You do not want  to be THAT medic!

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