First Arriving Network
Powered by the First Arriving Network,Reaching 1M+ First Responders Worldwide

What Comes First, the Nitro or the IV?

In comments to my last EMS Newbie post, reader 40Lizard commented on the discussion Ron Davis and I had on this episode of Confessions of an EMS Newbie:

Funny you should mention starting an IV before giving NTG- we’ve been having that discussion in class this week- and the general consensus is that unless we are SuperMedic and can have divine intuition on how the pt is going to react to the NTG- we’d better have a line in place before giving it! :)

Um, no offense to you, 40Lizard, but… horse shit.

Allow me to tell you a little tale about a patient I had some years back. We were called to the local nursing home for a patient with respiratory distress. We get there, and find a lady who weighs about three hundred pounds, parked on a chair in front of the air conditioner, oxygen mask strapped to her face at – unusual for a nursing home – an appropriate flow rate of 8 liters per minute.

Now, the lady has really exaggerated air hunger, and from across the room she sounded like a washing machine with the top left open. She’s diaphoretic as hell, and I don’t know who had the more desperate look on her face; the patient, or the LPN attending her.

Now, for you experienced medics out there, this presentation is probably just screaming “CHF! CHF!” in big red, flashing letters, and you’d be right. That’s exactly what was wrong.

She had decided to celebrate her recent discharge from the hospital (for CHF exacerbation, oddly enough), by treating herself to a pound of salted pistachios.

Obviously, this did not prove to be a good idea.

Her heart rate was 140, blood pressure 240/120, and respirations of 40, all with an oxygen saturation of 78% on 8 LPM oxygen. She was obviously tiring, and had that, “I’m about to pass out and you’re going to be picking my large butt off the floor” look about her, so the first thing I did was get her on our cot.

My partner, being the quick-thinking type, was already setting me up an albuterol nebulizer. Unfortunately, she was quickly thing the wrong things, but she can’t really be faulted for doing what she was taught. Lots of EMTs (and nurses and ER docs, I might add) think that albuterol cures all respiratory ailments.

I shook my head and ordered, “Nitro.”

She gave me a quizzical look, but gave me the spray bottle of Nitro anyway. The nurse gave me a nervous look and said, “Um, she hasn’t complained of chest pain…”

I ignored them both, lifted the lady’s face mask and told her to lift her tongue… and promptly delivered a triple squirt of sublingual nitroglycerin spray.

Both the LPN and my partner nearly fainted dead away. But they recovered, and managed to help me load the patient in the rig. I repeated that triple dose of Nitro three more times on the way to the ED. After the last dose, I noticed was getting close to our destination, and decided an IV might be in order, you know, to keep the nurses happy. So I managed to get a 22 gauge in her hand (and it pains me to admit I stuck something that small), and I was still taping it down when my partner opened the rear doors of the rig.

Inside, the receiving ER doc turned out to be none other than our service medical director, a man with whom I’ve taught many an ACLS class. We’ve got that whole absolute trust thing going on, but it really wouldn’t have mattered if it had been another doctor.

So I give him the basic rundown, “CHFer, just got out of the hospital today, celebrated by eating a big salty bag of pistachios. Looks like flash pulmonary edema. Initial BP was 240/120 and sat was 78% on 8 liters, but I’ve been hitting her with the Nitro all the way in, and her BP is down to 160/90, and her sats are 100% now. Breathing a lot easier, too.”

“Any Lasix?” he wanted to know.

“Nope,” I shook my head, “didn’t figure it was a priority, and I just got my line as we pulled up anyway.”

“I agree,” he nodded. “How much Nitro did you give her?”

And that’s when I hesitated.

“Um,” I hedged, “how much Nitro did I give her, or how many times did I give her Nitro?”

He cocked an eyebrow at me quizzically, put on his Medical Director Face, and said, “How about you tell me both.”

So I swallowed hard, and admitted, “I gave her four rounds of Nitro… 1.2 mg at a time.”

He kept that same quizzical expression on his face and said, “You know that’s not in the protocol. And you felt comfortable triple-dosing her with Nitro, without an IV?”

Oh well, if I go down, might as well go down swinging.

“Very comfortable,” I affirmed. “She didn’t need Lasix or fluids, she needed vasodilation. And if a certain medical director I know would push the company to adopt a CPAP protocol, she’d have had that, too.”

He laughed and said, “Well, she’ll have BiPAP as soon as respiratory gets down here, and if that medical director had any pull with the corporate bean counters, a certain ‘I’d rather beg for forgiveness than ask for permission’ medic I know would have had it to play with. Now get your ass back to work.”


The previous anecdote was merely intended to demonstrate that, indeed, lots of Nitro can be safely administered without an IV, and you need not be Supermedic to know when it can be done. All you need do is assess your patient.

I know of medics who devoutly believe that an EMT-B should never assist a patient in taking prescribed nitroglycerin tablets. I don’t know if it’s just protecting medic turf or some baseless superstition about precipitously dropping BP with one or two doses of Nitro, but it’s probably a little of both. And it’s just as wrong as the notion that EMS personnel should never administer more than three doses of Nitro before consulting with medical control.

First of all, the three dose limit on Nitro is something that cardiologists instruct their patients. It doesn’t apply to us. It is simply a trigger for calling 911, in the event that the patient’s chest pain turns out to be more than stable angina.

The end point of Nitro dosing for EMS personnel should be relief of symptoms, or a systolic BP approaching 90 systolic. Period. That applies whether you’re an EMT-B assisting a patient with their Nitro, or a medic administering it yourself. And honestly, if you’re a medic, you probably still need to be giving it to your MI patients, even if you’ve achieved adequate pain relief with opiates. I know the Mayo Clinic studies suggest that Nitro mainly makes us feel better, not the patient, but they are not yet the standard of care.

Secondly, cardiologists apparently believe it is safe to prescribe to their patients who presumably will not have an IV when they take it. Heck, it’s rare enough that they even know their blood pressure before that pop that little white pill under their tongue.

The only time you need be concerned with obtaining an IV before you give Nitro is when the BP is low or borderline, or the patient is suffering from a right ventricular infarction.

A 12-lead EKG takes about 30 seconds to obtain. If it indicates an inferior wall infarction, do a 15-lead EKG (or a second 12-lead with lead V4R). That’s another 30 seconds to determine if your patient is having an RVI or not. If that happens to be the case, you might need to start an IV before you administer Nitro.

I emphasize the word might, because RVI is not an absolute guarantee of preload dependency. If the patient is truly preload dependent, and thus prone to a precipitous drop in BP from relatively small doses of vasodilators like Nitro, there will generally be other clinical signs that point to that fact.

Look for things like orthostatic weakness, syncope or hypotension, and look for Kussmaul’s Sign.

Normally, when you see significant jugular venous distension in a heart patient, you’d expect to hear wet lungs to some degree. Also, JVD usually decreases with the negative intrathoracic pressure of inspiration.

The jugular venous distension in Kussmaul’s Sign does just the opposite: it worsens (or stays the same) with inspiration, and it’s usually present with dry lungs. This is a hallmark sign of impaired reight ventricular filling, and a big clue that vasodilation with Nitro may result in you having your patient flat on his back with his legs in the air, cursing the fact that you didn’t get an IV while they still had a blood pressure.

But it doesn’t take Supermedic to figure that out, it just takes assessing your patient. And it ain’t really all that common anyway.

Comments - Add Yours

  • Nurse K

    Acute CHF exacerbation is one of my favorite presentations and I have a serious love of BiPAPs and nitro in combination…

    If the BP is really 240, sure, why not hit ‘em with some nitro w/ or w/o an IV? Breathing comes before circulation. The chance that you’ll drop them to passy-outty range is pretty slim. However, probably not the best idea to be triple-dosing x 3, Hero of the Century, even if you’re King of Assessments.

    As we all know, medics can’t be winging nitro doses far outside of protocols. Probably shoulda called medic control there, my friend.

    How many medics can localize an MI based on a 12-lead? You and like two other guys?

    • Manda

      Nurse K, I hear where you are coming from and can understand your reasoning. However it may be a little off. You see, my company doesn’t have medical control. We have our protocols, an MD who expects us to know them and be proficient in working with as well as around them. We do have supervisors we call for assistance with RSI and sometimes surgical airways if needed. Sometimes. We also have a STEMI protocol where we treat and transport directly to the cath lab. We must be able to determine where the infarct is, including doing a right sided ECG if indicated, whether they qualify for us to be able to call the cath alert in the field, or if we need to notify and provide rapid transport because they are just below the bar but still urgent.

      The truth is depending on your MD and your competency level, you can wing all kinds of things outside of all kinds of places. That’s why we are ‘the eyes and ears of the physician’. Diagnose, treat, transport to the hospital and tell the doctor and sometimes Nurse J what we have done. Not Hero of the Century, not King of Assessments, just doing the job. And if I may say, he’s darn proficient at it.

    • Christopher

      At least in our area it is expected that a medic can localize an MI based on a 12-Lead. Part of being a Code-STEMI system.

    • Anonymous

      1. There are plenty of progressive EMS systems in the U.S. that allow more liberal dosing of Nitro in CHF/APE. In fact, so was the system I was in at the time of that call, at their next protocol revision. Do medics in your area really lag that far behind the times?

      2. Winging it? Yeah, but I wasn’t just pulling those ideas out of my ass. And as far as consulting medical control, the medical director agreed with my approach. And as referenced in #1, soon gave it official blessing for our other medics.

      3. STEMI localization and recognizing infarct impostors is really child’s play. Why, it’s so easy, even an ER nurse like yourself can do it. I’m sorry that the medics you deal with are a bunch of booger eating morons (or maybe that’s just your misinformed impression of them) but STEMI localization doesn’t require a Hero of the Century, King of Assessments to do. Even an average medic can do it, and I certainly don’t consider myself the equal of, say, Tom Bouthillet, at 12-lead EKGs.

      if it’s too difficult for your medics to learn, perhaps you should give them one of those idiot acetate overlays that map out STEMI locations. You know, the ones they make for ER nurses to use. ;)

      • Nurse K

        I’ve heard a lot of cardiac-related EMS reports ‘n read a lot of ‘em too, but never have I ever heard a medic refer to the location of a supposed STEMI. At best, they’ll rattle off the leads where the elevation is, which is something my kid can do just fine as well. Maybe they’re supposed to know that stuff or secretly do know it but don’t feel like saying it to others, but can’t say that they’ve ever volunteered that info to me nor a physician.

        I can’t say that I CARE where the STEMI is M-F from 8 am until 5pm when the cath lab is open, but otherwise, might be handy to be given the heads up since we’ll have to be playing with them for 10 minutes while the cath people brush their teeth and come in.

        • Anonymous

          Well, if you haven’t ever heard it, experienced it or seen it, it must not happen, huh?

          • Nurse K

            Whatever. Never seen it and I work in a receiving hospital with a cath lab that takes patients from all over the place (ie. many medics in many companies) in addition to other scattered hospitals with agency, some of which send ‘em out, but most of which keep ‘em there. When I hear a medic share the secret of where the MI is, I’ll email you or something. Don’t be holding your breath, though.

          • Joebsimcox10

            Dang you guys sure are carrying the hatchet. I work in a rural area and can tell you where the MI is coming from but to my local facilities it doesn’t matter because they do their own and the ER Docs and some of the nurses have your opinion of street medics. And wouldn’t listen if we told them anyway. That being said Driver calm down I know where you’re coming from but feuds like this are why we don’t paid like we ought to, I have taught and been taught respect for both sides of this argument and have RN friends who started as EMT’s and Medics and even knew an ER Doc or two that started on the streets. So we all need to learn from each other and agree to disagree if we can’t agree.
            Driver I love your posts they remind why started in this field and why I can’t seem to get away from it and they also point out realities to outsiders who dare to read.

          • divemedic

            Not only can medics here localize MI locations, it is taught in this area during medic school by at least 3 of the 4 local paramedic factories.

          • 9-ECHO-1

            Hey, AD…following this little exchange has been…well…amusing. Me? I’m no Tom B. either, but me and my cohorts here in the Wake County (NC) EMS System regularly relay to the catch-capable receiving hospitals not only the leads with changes, but the artery we think is involved as well.

            If Nurse wants to hear a medic relay the MI location, I’ll try and get him some tapes of our medics doing it.

        • CBEMT

          At best, they’ll rattle off the leads where the elevation is, which is something my kid can do just fine as well.

          Probably because they realize who their audience is.

    • Dan

      I could localize an MI based on a 12-lead seven months before we got to the cardiology section in Paramedic School, and I’ve been running right-sided 12-leads and 15-leads since about two months after that. Really not that difficult.

      As far as the stacked doses of Nitroglycerin, studies have shown that CPAP in conjunction with liberal doses of nitrates leads to improved outcomes in CHF, whereas the old practice of diuretic administration has been shown to cause poorer short-term outcomes. In fact, the Pennsylvania State ALS protocols call for “stacked” Nitro based on blood pressure. Between 140 and 160 systolic gets one squirt, between 160 and 180 gets two, and above 180 gets three. Considering that Pennsylvania is generally behind the times in comparison to other EMS systems in the United States, if even they have stacked nitro for CHF as a standing order, do you REALLY think medical command contact is necessary?

      You may deal with protocol monkeys (or think you do), but the modern Paramedic is a clinician. You may think that clinical decision making is nursing territory, but that opinion is at least 15 years behind. We’re much more than a ride to the hospital.

      • Nurse K

        Maybe rural medics are just better at judgement calls and related artforms…Our people have things like “call to cath lab/hospital” parameters of 20 minutes total, including ride to the person’s house, interventions, and ride to the hospital from the person’s house. They might just not need to get very detailed with their “assessments” because they’re already in the garage. If you’re in “city limits”, it’s not unusual to have a 911 call to balloon time of something like 15-20 minutes during regular business hours.

        • Manda

          Ma’am, I have the exact same parameters and live in one of the largest cities in the country. We *better* be able to tell them the location, it’s required. To call and say ‘I have a STEMI! *click*’ is what you have to deal with? Seriously? I’ll give you a couple other parameters as well

          – 12 lead, ASA, O2 within 5 minutes of patient contact. aka ACS protocol
          – On scene time 10 minutes or less from calling a cath alert.
          – 2 IVs, naked and prepped as much as possible, multiple 12 leads enroute
          – Metoprolol when/if indicated
          – Transport directly from the stretcher to cath lab, and assist with transferring and further prepping the patient.

          And I can do all that while chewing gum at the same time!

          Maybe you aren’t being told the location because you personally don’t need to know? When I call I talk to the charge nurse. What happens after that is the responsibility of that person as far as who else they choose to tell. And honestly, I don’t know that I would stop my transferring care and giving info to the folks who need it (ER doc, cath lab) to answer your question. Your not knowing is sounding more and more like a personal problem, rather than a systemwide one. Unless your people really are the city bred, balls-to-the-wall running, 20 minutes from when the call goes out to the patient is in recovery magic working, cookbook, truck monkey medics that you make them out to be.

          That being said, there are a few medics out here in need of recurrent training, and hospitals in other areas where it’s basically a cluster from the second ST elevation is seen. Maybe you are a victim of this experience?

          Maybe you should sit in on the next cardiology lecture at the college with the medic students? Find an ACLS class” that way the squiggley lines on the graph paper make more sense..

        • Tom Bouthillet

          “If you’re in “city limits”, it’s not unusual to have a 911 call to balloon time of something like 15-20 minutes during regular business hours.”

          Not a snowball’s chance in hell.

          • Too Old To Work

            The fastest door to balloon time I ever had was 14 minutes for a patient that I called in as a “possible STEMI”, but my gut feeling was that it was definitely a STEMI even though it didn’t quite meet the criteria. The attending physician had exactly the same instinct and sent the patient right to the cath lab. And it was a STEMI. One other hospital generally has sub 20 minute door to balloon times, but the others are 20 or more even during business hours and much worse at night.

            That’s not because they don’t trust our interpretations, it’s because of where the cath labs are located and the ennui of some of their staff.

          • Nurse K

            The fastest door to balloon time we had was 8 minutes, not including patients who went directly to the cath lab c/o STEMI being called in the field. In other news, my penis is the biggest one in the room.

          • Tom Bouthillet

            Talk is cheap. I have heard of 15 minute door-to-balloon times (and I question the methodology) but your claim was 15-20 minutes 911-call-to-balloon. There’s just no way and it has nothing to do with your penis.

            Call processing: 1-2 minutes
            Reaction time: 1 minute
            Wheels up-to-wheels down: 4 minutes (generous)
            Wheels down-to-patient’s side: 1 minute (generous)
            Patient’s side-to-12-lead ECG: 5 minutes (generous)

            We’re 13 minutes into the call (best case scenario).

            You would have us believe that the patient can be loaded for transport, taken to the hospital, delivered to the cardiac cath lab, prepped (including consent), cannulated, cathed, cuprit artery identified, wire across the lesion and balloon inflated in the remaining 7 minutes?

            As Judge Judy would say, “Liar, liar, pants on fire!” You’re doing wonderfully in Minnesota but you’re not deities.

          • Too Old To Work

            Tom, what are you calling “door to balloon” time? Maybe I have the wrong definition, but I think of it as from the second we hit the ER door until the balloon goes up in the cath lab.

          • Rogue Medic

            Too Old To Work,

            I don’t think that Tom misunderstands Door to Balloon time.

            Nurse K had stated –

            If you’re in “city limits”, it’s not unusual to have a 911 call to balloon time of something like 15-20 minutes during regular business hours.

            Tom is just making it clear that from 911 call to balloon is going to take significantly longer than 15 – 20 minutes.

            Perhaps if the patient is right around the corner from the hospital and everything works perfectly, this time will work, but that would be something that I describe as unusual. Nurse K stated that this is not unusual.

          • Anonymous

            I transport patients regularly to a couple of major hospitals with 24 hour cath labs, one of which is an accredited chest pain center.

            Even for them, a door-to-balloon time of 15 minutes or less is smokin’, even with the patient in their ER when the MI happens. It just takes longer than that.

          • Bobball

            I see 2 different measurements being bandied aobut (beside’s Nurse K’s pencil). Door to Balloon and call to balloon.

            I’ve seen door to balloons in the 10 minute range occasionally (when everything is perfect). Call to balloon of 20 minutes? As Tom points out, even with a generous response time, you’re talking 25 minutes (and that’s considering only 4 minutes to package/move/treat the patient, 5 minutes to drive to the hospital, and 3 minutes to unload, get to the cath lab, and have the patient prepped, and ballooned. 911 call to balloon of <30 minutes is considered exemplary.

          • Too Old To Work

            Maybe, but your brain is definitely the smallest in the room.

          • Rogue Medic

            Nurse K,

            The fastest door to balloon time we had was 8 minutes, not including patients who went directly to the cath lab c/o STEMI being called in the field.

            You are suggesting that a walk-in patient can get from the ED doors to the cath lab and have the balloon inflated in 8 minutes?

            From the way you worded this, you appear to be suggesting that prehospital STEMI alerts, who appropriately by-pass the ED, have even faster Door to Balloon times.

            I do know what the word means, but I think the relevant word is inconceivable.

    • Bobball

      FWIW our pulmonary edema protocols specifically recommend triple-dosing NTG (we don’t carry IV NTG, very frew agencies in our system do). Really haven’t seen problems with this over the 7-8 years we’ve been doing it.

      As for locaing an MI based on 12-lead? AD, 2 other guys, and, oh, at least 116 or so at my agency (not counting the students riding with).

  • Chance

    I agree with your post. I’d like to state that this is my feeling on the matter:

    If it’s just chest pain without the trappings of Pulm. Edema or CHF, then IV first – expecially with symptoms of R involvement. I’m utterly terrified of giving that nitro and causing them to go instantly into shock.

    • sincitymedic

      as a paramedic and not an er nurses who only follow protocols and drs direct orders we have to make decisions and stick to them. speaking about protocols you can go above them and do national standard of care stuff and get away with it. as an intermediate you may not have the clinical knowledge to skip starting the line but as a medic you have to decide if you can or cant do it or if your pt can or cant wait for the line. if you follow the protocols blindly you will kill pts. as a medic you must decide whats better for “this” pt not whats better for most pts each one is different and you have to decide.

  • Twoxrifles

    No good medic would withhold NTG with that kind of presentation. But to tell a new medic to throw protocols out the window, not smart. You don’t have to call your medical control. Call the destination Doc. Doubt they would have any problem with your plan. But once you step out of your protocol, you better CYA. No super medic can prevent litigation if they stepped outside their box. Good, bad or indiferent.

    • Anonymous

      Point of clarification: I do not suggest that medics abandon their protocols and ad lib treatment. I merely shared an anecdote in which I got away with doing so. Personally, if there are EMTs out there who abandon their protocols on so weak a basis as “AD does it all the time!”, they really don’t deserve to be EMTs, do they?

      And a minor quibble with your litigation point. Even stellar, within-the-protocols care can’t prevent litigation. But to prove negligence, one of the required elements is proof of harm. If it didn’t harm the patient, there is no case.

      • Yoda The Medic

        Well, I’m not sure why your medical director didn’t bust you for practicing medicine, which is what you did. Standing Medical Orders are just that, and giving 1.2 mg when your protocols call for 400 mcg would seem to be something a physician can do and a paramedic can’t.

        So, kids, as AD admits, he “got away with” ad libbing medical care. and doing so is really pretty reckless.

        • Yoda The Medic

          To quote Jerry Caesar: “Reverend, you’ve got balls as big as church bells”.

          • Anonymous

            That’s a fair criticism, Yoda.

            You may have the impression that I routinely flout protocols and make my own treatment decisions. I can certainly see why, based on this post and others I’ve made, but that is not really the case.

            On the other hand, I have demonstrated, throughout my 17-year career, a willingness to ignore protocols if the situation demanded it. Normally, one would make a phone call and consult with OLMC in that situation, and I encourage other EMTs to do just that.

            I have had the luxury of working in systems where I know all of the ER physicians, and we have a certain level of trust between us. Whether it be the small rural system where the ER docs and I hunt and fish together, or the mid-sized urban system where I may see an even dozen docs on a regular basis… we have a comfort zone. It’s with these docs that I feel comfortable omitting that step of consulting with OLMC.

            When I’m working an area where I don’t know the doctors personally, I am much less likely to do that – not because I’m any less sure of what is needed, but I’m less sure if the doc will bristle at me free-lancing. Few of the physicians I have regularly worked with ahve had an issue with any deviation from protocol I’ve made, provided I’ve been able to offer sound reasoning behind my decision. That has been the case even when their treatment approach has been different from my own. It’s also why I rarely have problems getting the orders I need via OLMC – I know what orders I want, and why.

            Still, there have been situations where I’ve nearly done something that I knew the patient needed, and I knew the OLMC physician wouldn’t have been able to protect me, even if he wanted. July 4, 1997 comes to mind. I remember thinking, as I was about to make the incision in a surgical cricothyrotomy, “It sure was nice being a paramedic. I wonder what I’ll do next?”

            At the time, surgical crics were a big no-no in Louisiana, but I truly felt the patient would die without it, and I was out of options. Luckily, I thought of another waaaaaaayyy outside the protocol option, and wound up securing the patient’s airway without the surgical cric.

            But I’d have made the cut if I had to, and been willing to accept the consequences.

          • Yoda The Medic

            I appreciate the civil response. And although I’ve lost you for a while, I have read you over the years and I know you’re not a regular freelancer.

            I have a different perspective, working in a resource hospital where protocols are developed and medical oversight is provided. So protocols are not suggestions, they are standing orders.

            But Rogue is right, it depends on how the state law is written, or in my state, how our protocol policies (and cover page, which describes how they are to be used) read.

          • Anonymous

            I once wrote an EMS1 column on this subject, entitled “The Two Most Important Words in an EMS Protocol,” that adequately sum up my feelings on the subject. Rather than re-state them here, read that one if you haven’t already.

            Louisiana’s a bit different in that we don’t have resource hospitals. The system’s medical director sets the treatment protocols. The accepting physician at the receiving hospital is your de facto OLMC. If necessary, you may contact OLMC for further steps in your protocols that require direct orders, or permission to deviate from protocols or initiate treatment not specifically outlined within the protocol. As long as it’s within the statewide scope of practice, it’s kosher.

            I’d had occasions where OLMC docs ordered me to do something contrary to protocols. Most times, they’re just differences in approach to treatment, and as long as they were willing to sign off on the orders, I had no problem carrying them out. There have been rare occasions, however, when my OLMC orders not only contradicted my written protocols, but also defied common sense. In those situations, I respectfully (and on a couple of regrettable occasions, rather disrespectfully, but i was only echoing the doctor’s attitude) declined to carry out those orders.

            You’re right, though. There are plenty of medics out there who think they know better than the doctors. I’m not one of them, although I’ve been accused of it by people who don’t know me well. Those medics make us all look bad.

        • Rogue Medic

          Whether it is practicing medicine depends on the way the state laws are written and the way the protocols are written.If the state laws are written in a way that prohibit deviation from protocol, then the state legislators are giving the medical orders (practicing medicine). If the protocols are written in a way that prohibit deviation from protocol, then maybe AD was practicing medicine. It is probably better to intubate these patients, than to provide appropriate care. After all, EMS exists to take care of the protocol and F*(# the patient.As AD pointed out, sometimes the medical director will learn from a demonstration of what is documented as the most appropriate medicine.Maybe the medical director did not consider this to be practicing medicine (without a medical license).In what way is providing the best treatment he has available reckless?We need to get medical directors to pay attention to what is good patient care. We should not behave like protocol monkeys.Great job, AD!

          • Yoda The Medic

            I guess I’m lucky. Our medical directors are all experienced emergency department physicians who are doing this because they love it. They stay on the cutting edge of medicine, and we develop protocols that are consistent with the standards of care in both EMS and the emergency department. I’m not sure I can envision a medical director in our EMS region learning from a paramedic, even someone with 17 (or more) 30 years of prehospital experience.

            Of course, our region had dozens of paramedics who think they are smarter than their medical directors. They are wrong, and universally full of both themselves and of crap.

          • JPINFV

            I surely hope that this isn’t the case for two reasons. First off, if the person, regardless of education or health care level, is wrong, blatantly disregarding them loses a valuable teachable moment. Second, different experiences, educations, and perspectives can very easily lead to someone learning something new or an alternative way of proceeding. Most likely anything learned won’t be ground breaking information, but even the little tips and tricks can go a long way.

        • JPINFV


          I personally view the practice of prehospital care to be just about as close to practicing medicine as one can get outside of physicians and midlevels (NPs and PAs). It’s a field that, albeit much more rarely than advertised, decisions have to be made quickly. EMS protocols (where the underlying philosophy can vary from being a bible to a general guideline, even in a small geographic area. Links available on request) work for 95% of the population. However, I’d hope that paramedics are educated enough to understand when their patient’s individual situation falls outside of those guidelines and take action as appropriate. Sometimes that individual situation may dictate faster action than waiting a few minutes to get someone on the radio. Sometimes not. As such, understanding the underlying pathophysiology and the hows and whys of individual interventions are much more important than the actual number or steps on a protocol.

          My personal opinion (as someone who in a few short years will no longer bound by a legal scope of practice or protocols) is that any intervention taken by any provider should be done because that intervention is appropriate for that individual patient. 95% of the time the protocol should match the interventions provided not because the interventions were picked because of the protocol, but because the interventions were right for that patients and because the protocols represent the optimal plan for the majority of patients with that disease or disorder. EMS protocols can’t cover every situation, and this should be realized by everyone involved.

    • JPINFV

      Personally, I think that the concept of protocols needs to be rethought completely. Protocols shouldn’t be an end all, be all of treatment. They should be recognized as what they are, the ideal treatment plan for 95% of the population. The paramedic should be educated to know when s/he is treating that 95% and when s/he is treating the 5% and the plan needs to be tweaked. Ideally, the paramedic should be drawing up a treatment plan based off of his/her assessment of the patient. Yes, 95% of the time that treatment should match the protocol, but it should match the protocol because interventions 1, 2, and 3 are indicated based on the patient’s condition, not because the protocol said so.

      • JPINFV


        I’d also like to make a preemptive comment. The concept of medical control as a way to limit liability or litigation is the way of the technician, not the professional. Act like a technician, be treated like a technician. Act like a professional, be treated like a professional. This isn’t to say that “online medical control” (“consult” is a better word than “control”) isn’t a valuable tool, but it should be an appropriately used tool, not just because someone is afraid of making a decision they know is correct.

        • Yoda The Medic

          I realize it’s semantics I’m going to argue, but do you mean “technician” or “clinician”? Because when I think of (and teach) students, I see technician as “monkey-see, monkey-do” vs a chinician who looks at the patient and the situation and makes a treatment plan that is appropriate to this patient, his/her disease process here and now.

          Otherwise you get the stroke patients with a SBP of 190/110 getting atropine and paced because they have a heart rate in the 40’s with sinus bradycardia.

          Emergency Medical Clinician – Paramedic, anyone?

          • JPINFV

            Sometimes semantics are important, sometimes semantics are just that, semantics. I think the argument over license vs certificate is semantics (mostly because the terms are used interchangeably in California’s code covering physicians. Reference on request). However, the difference between a technician and a professional or the difference between a professional and a clinician are different because it’s also a mindset. Personally, I’d argue that the term “professional” would include the term “clinician” but not the term “technician.”

            Similarly, I 100% agree with your analysis of the difference between a technician and a professional/clinician. The problem I see with this, though, in terms of EMS is that there are plenty of providers (both at the EMT and paramedic level) who are perfectly happy being technicians and following their protocol cook book without thought or question. See A, do 1. See B, do 2. Never looking at the whole picture. Alternatively, there are plenty at both level who want to act as clinicians (acting within their scope of practice, of course. Hopefully realizing the limitations of their individual education). The problem is that you can’t design a system to cater to both sides of the coin. A technician paramedic in a clinician designed system is dangerous while a clinician paramedic in a technician designed system is going to become disgruntled, and most likely leave to another health care field (EMS brain drain, if you will). I’ll personally admit that if I was in a more clinician orientated area (I grew up and initially worked as an EMT during undergrad in Southern California. Major parts of So. Cal. are still living the glory days of Emergency! style of calling the base hospital for almost everything), it would have been a harder decision to not become a paramedic instead of pursuing medicine.

  • Medicpike1

    Finally, a common sense approach! In my world, there are only 2 end points for NTG that is helping the patient: arrival at the ED, and an empty bottle. Also, if the patient is hypertensive, the line can wait.

  • Sandro Rettinger

    I’m certain you are right (because you are a medic with N years of experience and I am still in I school) but nevertheless, the reason for me to start an IV before giving nitro is: It’s in the state level protocol and I don’t want to lose my license after working so hard to get it.

    • Anonymous

      And that’s a damned good reason to do it, Sandro! You may be technically in the right, but you won’t be able to help many patients from the unemployment line! ;)

      You’ll find in your career that there are a whole lot of protocols out there that don’t make sense, and that most state-mandated protocols, while intended to provide a floor for competent care, actually represent a ceiling that prevents excellent care.

      throw in the bureaucracy inherent in such things, and it’s no wonder that many state protocols lag years behind current research and treatment guidelines.

      • Sandro Rettinger

        You will be pleased to note that we’re being taught “work the code on scene”, though. :)

        Our protocols for nitroglycerin are actually fairly bizarre. Basics can administer nitro to a patient who has a prescription for nitro (whether we use their nitro or not) after getting a BP and HR and making a call to medical control. Intermediates can deliver nitro without the call to MCEP, but we have to have an IV in place. And Paramedics not only have to have an IV in place, but a 12 lead as well. It’s one of few drugs in the scope that gets more restrictive the further you advance.

    • CBEMT

      To be fair, the number of things that would have to go wrong for you to lose your license over an order of treatment issue is fairly large and almost impossible to prove that it made the life or death difference. I hate slaving to the protocol when I know that bending it a little will benefit the patient more than regurgitating said protocol onto the patient.

      Remember, your patient hasn’t read your protocol- s/he is very rarely going to fit into it’s neat little box!

  • I_drivecode3

    Great article

  • usalsfyre

    She would have gotten an IV early here. Not because of any fear of NTG, simply as a route for an NTG infusion. These work much better in conjuction with CPAP, as you don’t have to work around the mask.

    Most of the medics I work with can easily localize infarct locations and the vessles associated with them. It is expected to be in the report. Most of the time we simply call in lead elevations because “Lead II,III and AVF” is easier and clearer to communicate over the radio than “12 lead findings are consistent with an inferior MI”

    Protocols should be just guidelines. Unforunately too many medics are scared of their own shadow, and think it limits liability if they follow them to the letter. I know of a medic that refuses to cease a resus without calling an online control first, even though it’s an offline deal for most of us. The reason? He wants the docs name on the chart. Until we get rid of this kinda thinking, medics will continue to be our own worst enemy.

    • Too Old To Work

      Your system does IV NTG? That is cool. Can you share some of the details, especially of storage and what kind of pump you use. I’ve been trying to get out system to do this for a while, but without luck.

      • Anonymous

        We carry it in our CCT rigs at The Borg, and our protocols allow us (critical care medics) to use our CCT meds on 911 calls. We have to mix the Tridyl and we have low absorption tubing to administer it through.

        • Rogue Medic

          Why not carry NTG in a bottle and draw it up for slow bolus injection by syringe?

          No pumps, but it does require training the medics in the appropriate bolus dosing of NTG.

          Aren’t we already using bolus dosing? The sublingual absorption is a little slower, but giving the IV NTG as a slow IVP produces the same result.

          Should competent medics have any trouble doing this with appropriate education?

    • usalsfyre

      Sorry for the delay in reply, strangely enough it’s actually been ADHF central around here lately, in the last 2 shifts I’ve hung NTG infusions on three occasions for this reason.

      We store our NTG wedged as tightly as possible in a cabinent. A can koozie actually helps with the breakage isseu, and the NTG fits nearly perfectly. Pumps are simply the dumb plumb pumps used by the ED of our base hospital. I’ve used minimeds at a previous job, however they are no longer a viable option due to Alaris discontinuing support. The Gemstars look interesting if you can afford to buy multiple pumps per truck, they’re small and I’ve head good reports of durability, as well as being a smart pump. In addition to NTG infusions we also carry enaliprat as an afterload reducing agent. This combo has worked very well for us so far, however is expensive.

      Rogue Medic, not a bad idea, but competent medics at times proves to be a problem nationwide.

      • Rogue Medic


        There are many ways to treat patients using NTG. We just need to find the way(s) that work best in the prehospital setting. Carrying a bottle of Tridil and using 5 ml syringes to draw up 1 mg at a time (assuming a concentration of 200 mcg/ml) is just one way of delivering a slow IV push of NTG.

        Slow IV push vs. infusion? There is no reason to believe that this is a very important distinction.

        Is this more complicated to teach than intubation, which includes the essential when not to intubate? Or interpreting 12 lead ECGs?

        If the problem is a lack of competent medics, then I agree that NTG can be dangerous, but that applies to the NTG spray and tablets, too. Incompetent medics can be dangerous in so many ways that I could go on all day about the drugs we carry that an incompetent medic can use to injure, or kill, patients.

        • usalsfyre

          I can’t say I disagree with you at all. Unfortunately the reality of the situation is there’s a large block of incompetent medics that no one wants to do anything about because of money, loyalty, absentee medical directors ect.

          I’m fortunate enough to work for an involved medical director that demands real continuing education, not rehashing paramedic school material over and over again. However I’m also aware that I’m one OMD change away from going back to kidergarten card class CE, like most of the nation does. Until we can ensure (paramedics, not states, the federal government, ect) that paramedics get a real education, both inital and continuing, a lot of new things (hell a lot of things we do NOW) will continue to make me nervous.

        • usalsfyre

          I can’t say I disagree with you at all. Unfortunately the reality of the situation is there’s a large block of incompetent medics that no one wants to do anything about because of money, loyalty, absentee medical directors ect.

          I’m fortunate enough to work for an involved medical director that demands real continuing education, not rehashing paramedic school material over and over again. However I’m also aware that I’m one OMD change away from going back to kidergarten card class CE, like most of the nation does. Until we can ensure (paramedics, not states, the federal government, ect) that paramedics get a real education, both inital and continuing, a lot of new things (hell a lot of things we do NOW) will continue to make me nervous.

      • Rogue Medic


        There are many ways to treat patients using NTG. We just need to find the way(s) that work best in the prehospital setting. Carrying a bottle of Tridil and using 5 ml syringes to draw up 1 mg at a time (assuming a concentration of 200 mcg/ml) is just one way of delivering a slow IV push of NTG.

        Slow IV push vs. infusion? There is no reason to believe that this is a very important distinction.

        Is this more complicated to teach than intubation, which includes the essential when not to intubate? Or interpreting 12 lead ECGs?

        If the problem is a lack of competent medics, then I agree that NTG can be dangerous, but that applies to the NTG spray and tablets, too. Incompetent medics can be dangerous in so many ways that I could go on all day about the drugs we carry that an incompetent medic can use to injure, or kill, patients.

  • LadyLizzie

    Interesting post and some very interesting comments coming up. I agree with you that there is a point when assessment can show you that you don’t need an IV before giving nitro. However, I would venture a guess that most new EMT’s or even some new Paramedics just don’t have those assessment skills yet. It takes time to be able to recognize things like that by sight instead of by equipment.
    Although I agree with the main points of this post, I would caution you that a lot of people reading this are new EMTs/new Paramedics/students and may now be thinking that they don’t have to give an IV because they’ll know by looking if the blood pressure will drop or because you made it sound like nothing bad ever happens when you give nitro.
    Remember, people are taught the ground rules for a reason. It takes a couple years of experience and a few rounds trying to figure out how not to get your shiny new cape wrinkled when you sit on it ;) before you can make those judgement calls.

  • Joebsimcox10

    Sounds about right brother Kelley. And to nurse K down there, there are a lot of us out who are very highly trained and knowledgeable (even if we act different sometimes) who can tell you where an AMI is coming from with pretty good certainty. But I also agree with not going to far outside protocol without putting the monkey on someone else so to speak. I only say this because I have been hung out to dry by a Doc who ordered the stuff then refused to sign for it.

    • Rogue Medic


      You encourage calling command, but your justification is a medical command doctor who burned you even though you called command?

      How did calling command (putting the monkey on someone else) help the doctor, help you or help the patient?

  • Too Old To Work

    I’d love to know where NurseK works, so I can stay out of there. All of the approximately 50 paramedics I work with can localize STEMI location based on which leads are elevated. So can most of the EMTs who I work with, but not all.

    As to the NTG dosing, for CHF we can give 0.8mg doses until the systolic pressure reaches 150 mm/Hg. At that point we will switch to 0,4mg doses. Well, actually, by then we have CPAP on the patient. Which precludes us from going to some of our hospitals because they can’t guarantee that they’ll be able to continue it in the ED. None of which, BTW, have ETCO2 for NON intubated patients. Many of the ED nurses don’t understand ETCO2 readers or the importance of wave form.

    Maybe NurseK should change her name to SnurseK.

  • 40lizard

    Ok, now that I’ve been completely humilated! just remember one thing I am still learning-and remember I don’t have the experience that you do!

    • Anonymous

      Please, please, please don’t take it that way. This wasn’t a condemnation of your approach to things, but rather my issue with the consensus of your peers and classmates.

      And as you can see from comments here and on the JEMS Facebook thread, you have plenty of supporters of your way of doing things.

      Just because I don’t agree with you doesn’t mean I’m belittling your skills or knowledge, okay?

      • landlockedtxn


        listen to AD; I found it to be very intriguing to see both sides. Remember, back many years ago, an old fart of an ambulance driver we both knew and still love, would have been doing things like this while standing up for his decision with a grin on his face and choice words for anyone who disagreed with him.:)

        • 40lizard

          Can’t believe I forgot about that old fart of ambulance driver either-you’re right and I can see him doing that to this day! :)

          • Matt G

            Hee! I get to call AD an “Old Fart” all weekend long while we go hunting, next month.

            40lizard, as a friend of A.D.’s for the last 3+ years, I can tell you that he genuinely LOVES to teach, loves new students who are interested in his field, and is not derisive of someone for opening dialogue. He knows that there are several ways to skin a cat, and is just in search of the one that the safest, most practical, most achievable ways.
            Most importantly, he still likes to learn, still thinks of himself as young, and still has a way of joking in person, in a way that makes you think that you’ve just found an old buddy from college. (Hide yer wimmen!)

            Lotsa love, A.D.!

      • 40lizard

        Sorry I got a little cranky there- it was 230 in the am when I saw that- I didn’t mean to start such a diabtribe- and you have to remember that most of us are still green as can be- so until we get the hang of this- we are going to be more cautious and to be quite honest every medic I’ve ridden with on clinicals is doing this- someone’s giving meds while someone else is getting that line in case they crash- protocols I am sure-

  • divemedic

    People need to remember that the protocols are written for the worst medic in your system. The protocol represents a floor to care, not the absolute. New medics and poor medics tend to blindly follow protocol. As a medic gains experience and confidence, he will find himself departing from protocol more and more frequently.
    As long as there are medically sound reasons for doing so, there is no reason why this shouldn’t happen. A competent, aggressive medic can do much more for a patient than a technician applying a blanket protocol. If this were not the case, medic school would be about 3 weeks long, as it doesn’t take that long to teach the skills needed to follow a protocol.

    I do not like to get orders from ER doctors, because they cycle in and out of our local ERs on what seems like a monthly basis, and do not know all the medics in the area well enough to evaluate whether they are talking to a good medic or an idiot, so they tend to deny all requests for everything. Having an understanding medical director that knows and trusts you, and doesn’t much care if you follows protocol, is a real boon to a street medic.

    • Nurse K

      Protocols not followed that come to mind:
      1. Old dude with chronic pain/narcotic dependence whose family called for resp depression:
      —2 mg narcan IVP all at once leading to: Vomiting (into BiPAP mask), severe agitation/confusion, BP of 250/120 and flash pulmonary edema requiring intubation
      2. Old guy in MVA screaming from neck pain upon arrival. Sitting on the stretcher. “He didn’t want a c-collar or to lie on the backboard, said his neck hurt too much.” No pain meds given. C5-6 fracture requiring a halo. [This type of thing happens all the time…sick of medics “ad libbing” trauma stuff].
      3. 12 year old with history of asthma complains of SOB and chest pain with breathing. NTG SL x 1 given, knocking her unconscious. “She complained of chest pain.”

      • Anonymous

        Yep, shitty examples of care, all of them.

        Problem is, your thinking is so Nurse K-centric that you think it’s that way everywhere else.

        But no matter, you’re not interested in being educating in anything that disagrees with your preconceived notions.

        And yes, I tend to agree with CBEMT. The medics only mention the leads that show ST elevation rather than giving you an infarct locale because they know their audience.

        • Nurse K

          Most nurses could care less, but I like to know if it’s an LAD infarct so I have the stupid defib pads on the patient for when the code on the way to the cath lab and if it’s rt-sided so I don’t d/c their blood pressure with nitro. I’m busy doing other stuff when STEMI person arrives…I’d get written up if I was standing there like a turd looking at a 12-lead measuring ST segment elevations. Just make it easy for the ER nurse and tell her where the blood no pumpy to. If ER nurses get used to hearing “it’s right-sided” or “it’s in the LAD” or whatever, even the dumb, glossy-eyed disinterested ones might figure that bit of info is supposed to make a difference and go seek out additional learning opportunities.

      • CBEMT

        Did you document and report any of those (and the pile of other examples that I just know you’re dying to tell us about)?

        Because if not, you’re just a part of the problem.

        • Nurse K

          Trauma coordinator followed up with neck fracture medics’ boss (I gave him narcs and c-collar on him myself despite being in high heels and business suit), the medics lingered around for like 20 mins after giving us pulm edema guy [what I call the ‘worried linger’] and the doctor told them that they probably caused this with the high-dose narcan and should’ve titrated, and NTG girl medics acknowledged their own mistake. Something to the effect of, “I heard her say chest pain, and I freaked.”

      • divemedic

        and I can tell you similar horror stories about stupid nurses.

        1 Nurse who interpreted an order of 2mg/3cc morphine by neb prn pain, as 3 cc’s of morphine, and then couldn’t figure out why the patient was apneic
        2 The nurse who was attempting to give an updraft to a person in asystole
        3 The nurse who saw that a patient with a Hx of COPD that I put on CPAP that had an SaO2 of 76% and accused me of “knocking out his respiratory drive” when his respiratory rate was 40.

        Does that mean all nurses are incompetent? Or just those nurses?

  • 9-ECHO-1

    Question- How many of you folks are carrying NTG paste? We have it here. I usually drop the first tablet (they took spray away- too expensive they said), then I put the paste on. As to NTG before an IV, depends on the presentation, but then I have onlly had two drop significantly on the BP readings, and one of those was 3 hours after Levitra.

    • Christopher

      We have paste and spray. CHF’ers get sprays then paste once CPAP is applied. C/P folks where NTG Sprays are working get paste once pain free.

    • Dan

      Why waste your time with Nitro Paste? Most of the time CHFers who are that critical usually have poor skin perfusion, which would mean the paste isn’t being absorbed at an adequate rate.

  • Jaramillohj


  • Pingback: What Comes First, the Nitro or the IV – A Day in the Life of an Ambulance Driver | Rogue Medic()

  • Yoda The Medic

    Hey, even I know where the location of the STEMI is. It’s in the gallbladder, right?

    • Anonymous

      No, that’s a right shoulder STEMI, because of referred pain.

      No wait, now I’m confused. Maybe it’s a right shoulder STEMI that mimics a gallbladder attack.

      If only I had gone to nursing school instead, all this would make sense to me!

  • Yoda The Medic

    Oh, and back to the IV or not. We changed that protocol about 10 years ago, so they can get one dose and then the IV has to be in place. But I was doing CE today and had a scenario with chest pain, a bradycardic patient with a borderline BP, who was taking two antihypertensives. The idea was not that you should NEVER EVER NEVER give this patient NTG without an IV, but that there were enough things about to make you think twice or even thrice about whether a call to Rampart for a quick consult would be beneficial to all.

    • Anonymous

      Which is the essence of critical thinking and clinical decision-making, when it comes right down to it.

      There are very few hard and fast rules, and varying shades of gray. The astute clinician recognizes that, and isn’t afraid to seek input from others.

  • Crash

    I’m glad that you have such great doctors that have your back if you buck protocol, but not all of us have that. I haven’t been able to ride in a few years but when I did we had some terrible vindictive docs and nurses that would’ve reported us to our corporate AMR masters and we would’ve been fired.

    There was one time I rode with a medic who pulled off a spectacular trauma save by using the experimental fluid replacemant we had on our trucks for research. The patient didn’t quite fit the subject protocols but the medic used it anyway because our guy was in hypovolemic shock and the saline wasn’t cutting it. The patient made it because we bucked the protocol and we still got our asses chewed out by our OMD and given formal written warnings.

    When you get into an environment like that it makes you scared to do anything that goes against protocol, even if you know it’s the best thing for your patient.

  • FireMedic

    If we can get medics to pull their collective heads out of their butts then maybe, just maybe, some MD out there will start expanding our protocols! Treat your patients, not the protocols!

  • Hortoncode3

    Here In Vermont, an action similar to that just got a medic fired. The reason for protocols is (a) you are NOT a DOC, and (b) Liability. Yeah yeah….you’re way smart, we get it..YEARS of experience and all that…got it. I appreciate it. Really. But you do work with a partner, who could have slipped a line post haste, with some re-direction form you, the ParaGod. And tah dah..the woman survives anyway.
    And you and your partner can go home secure in the knowledge that you still own it, instead of your patients family and their lawyers.

    • Anonymous

      Wrong. The reason for protocols is a) to establish a floor for competent medical care for the majority of medical conditions you may encounter. Period.

      But most protocols aren’t written that way. Most protocols establish a ceiling beyond which excellent care cannot rise. They make everybody average – including the medics who are above average.

      And as far as liability goes, when protocols are so restrictive that they fall far behind current medical standards, someone is liable. It may not be you, but it may certainly be your medical director. “I was just following orders” didn’t wash in the Nuremburg trials, although it may work for you in civil court. Still doesn’t abdicate your moral duty to do what is right for the patient.

      And when you’re working with an EMT-B partner, they can’t slip in a line for you. If you ask them to, then you’re involving them in your deviation from protocols, and asking them to exceed their scope of practice, to boot.

      My action in this case deviated from my protocols, but it did not exceed my scope of practice.

      On a final note, if you want to debate me here on my blog, I’m game. Ask any commenter her. But keep it civil. Don’t insult me or my commenters, and lose the snotty attitude, or you’ll be eating the Ban Hammer.

      You just got your one warning to be nice.

  • Pingback: Two Steps Forward, One Step Back | A Day In The Life Of An Ambulance Driver()

  • Eileen

    Sadly that IV thing is fail-safe for docs insurance. People take their nitro alone all the time.

  • Memamedic

    I didn’t like this because it’ll give some medics reason to buck protocol. I knew a medic who lost certification for giving 2 doses of nitro without benefit of IV and the patient bottomed out. We have protocols for a reason and I seriously don’t admire medics who don’t follow them. If you don’t want to follow protocol, go to medical school and become the “God” you think you already are!

    • Anonymous

      It’s a free country. You have every right to be as wrong as you are.

      But by all means, let’s practice like trained monkeys and make patients fit the protocols, and never question when the protocol doesn’t fit the patient.

      Can’t have us medics thinking for themselves, oh no. That would be God-like.

      Stop me when the sarcasm gets high enough to register on you…

    • Rogue Medic


      I didn’t like this because it’ll give some medics reason to buck protocol.

      Then maybe the medical directors need to write protocols better.

      I knew a medic who lost certification for giving 2 doses of nitro without benefit of IV and the patient bottomed out.

      Your anecdote is truly amazing. Occasionally, for non-CHF patients and rarely for dehydrated CHF patients, this will happen. Within 5 minutes, the pressure should return, except when the patient has an RVI. Checking for RVI is more important than having an IV.By the way, what difference would the presence of a patent IV have made?Protocols written by competent medical directors really do have provisions for deviation from protocol written into them. In patient care, anyone who thinks he/she is God is a danger to patients – especially if that person is writing restrictive EMS protocols and authorizing dangerous medics to treat patients.

  • Fred Savage

    26 years as a Paramedic in the field!! Love the stories!! triple squirt of Nitro!! Someone stole that out of my play book!!

  • Ibmules

    I’d like to add: Horse shit to this example of why its not necessary to have an IV while administering nitro. Whereas the OBVIOUS treatment of CHF here is O2, Nitro, (MS if you’ve got it) is correct, the indications for assisting with NTG or administering it for most protocols of chest pain however, definitely warrents an IV initiation concominently or pror to administration….particularly in the event that your MI patient is dehydrated or has right ventricular failure as the result of a right sided MI.

    • Anonymous

      To what example were you referring, the one in the original post, or the myriad examples in the comments?

      Having an IV while you’re administering Nitro is good practice. Requiring an IV before you administer Nitro is not.

      We should have protocols that ensure a minimum standard of care, while still allowing good medics to exercise judgment and critical thinking. Blanket protocols that say things like “You must initiate IV access prior to administering Nitroglycerin” may prevent an inferior medic from making a mistake, but they also ensure something else…

      mediocre care.

      Let’s do what is necessary to educate and field thinking medics, not protocol monkeys