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Just So We’re Clear On The Concept…

… nitroglycerin isn't for chest pain. Nitroglycerin is for vasodilation.

It just so happens that coronary artery vasodilation often happens to relieve chest pain in patients with stable angina. In the genuine acute coronary syndromes, not so much.

In his JEMS article on the subject, Chris Kaiser questions the "3 nitro rule" common in many EMS protocols.

I have to agree with Kaiser, and it's just this sort of unmitigated horse shit that gives me the pink leg* whenever I read it. "Administer 3 nitroglycerin and contact medical control" is one of the sillier rules that persist in modern EMS protocols, implemented by those absentee medical directors Rogue Medic likes to rail about so much. Folks, the 3 nitro rule doesn't apply to us.

It has never applied to us.

Three nitros was simply the trigger for the patient to call 911. It was something the cardiologists told their patients: "Here, put one of these little white pills under your tongue when your chest hurts. Take one every five minutes, and if you take three of them and your chest is still hurting, call 911."

That's all it was – a threshold for summoning the medical professionals to render further care. Yet in many EMS systems, it's also the set of protocol handcuffs that force those same medical professionals to limit their treatment to no more than what the patient can do himself.

The only legitimate endpoints for nitroglycerin administration are relief of symptoms, and hypotension.

And heck, even that's a matter of some debate. Some sources consider a BP of 100 systolic to be the endpoint, while others say it's 90 systolic. For my purposes, I'm not real concerned with a BP hovering between 90 and 100 systolic, unless they start out that way.

The folks that screech about an EMT-B assisting a patient with their prescribed nitroglycerin love to use the Right Ventricular Infarction Bogeyman to support their argument that no one but a paramedic with a 12 lead EKG machine should be fooling around with nitroglycerin, despite the fact that many of those same medics don't even bother to do the right-sided chest leads to diagnose that right ventricular infarction.

They also ignore the fact that an RVI patient who is preload dependent, usually looks that way. They have, like, clinical signs and stuff like orthostatic syncope or dizziness, Kussmaul's Sign, or the really big clue: they're borderline hypotensive to begin with. You're not gonna run into many of them that have a BP of 150/90 and then go into the toilet with one dose of nitro. More likely, they're gonna be hovering in the "Hmmm, I wonder if I oughta be giving nitro with a BP in that range," territory. If your paramedic spider sense is tingling that way, it doesn't necessarily mean don't give the nitro; it just means you should have a means of dealing with potential hypotension before it occurs. Get your line first.

For the most part, the problem with nitroglycerin isn't that we're giving too much of it, it's that we're not giving enough. Rather than futz around with Lasix on our acute pulmonary edema patients, filling their bladder when we ought to be emptying their lungs (because contrary to popular belief, most of these patients are not volume overloaded), we ought to be fogging the nitro to them like there's no tomorrow.

To hell with the 3 nitro rule, let's figure out a way to give nitro via in-line nebulizer attached to our CPAP masks.

And just in case I didn't make my point earlier, I'll repeat it: Nitro isn't for pain relief, it's for vasodilation.

If it relieves their pain, fine, there's no need for narcotics. But if it doesn't relieve their pain, you ought to be dispensing the opiate candy toute suite, with a goal of zero pain, while still maintaining an adequate respiratory rate and blood pressure. Less pain equals less catecholamines equals less myocardial workload equals smaller infarct size equals better outcomes.

But still keep giving the nitro anyway, because like I said before, nitro isn't for pain relief.

Nitro is for vasodilation.

* Pink leg is when the red ass has gotten so extensive that it has spread into the surrounding tissues.

Comments - Add Yours

  • http://sixlettervariable.blogspot.com Christopher

    Amen brother. Some of the newer CPAP-masks at least allow you to administer NTG through the front port without having to break the seal. Maybe a setup with a straw poking thru the mask?

    Although, nothing makes people crowd around the radio faster than, “patient has received 20 sprays of nitro, 2-0 sprays.”

    • Medic768

      How long are your transport times that you are giving 20 sprays of ntg?

      • Anonymous

        If you’re giving three squirts at a time, three minutes apart, they don’t have to be long transports at all, especially when you figure in scene time.

        Ambulance Driver

        ________________________________

      • http://roguemedic.com/ Rogue Medic

        5 NTG soon after patient contact/assessment. 

        3 minutes later, BP, then 5 more NTG.

        3 minutes later, BP, then 5 more NTG.

        3 minutes later, BP, then 5 more NTG.

        That’s 20 NTG in 10 minutes. Never mind transport, what kind of scene time do you average?

        En route, keep repeating the multiple NTGs and consider an IV. If I had the ability to give NTG IV boluses, the IV would be a priority, but this is CHF so the IV is only nice to have..

        • guest

           Fortunately, I work in a system with an ultra-progressive medical director. We use nitro drips once the patient has relief.

          It amazes me how much paramedics simply dont give a f**k about their jobs.

          BTW Rogue medic, I <3 U and everything you do.

          • http://roguemedic.com/ Rogue Medic

            I don’t have a problem with using a drip to maintain a therapeutic level. That is the purpose of the drip. 

            With the huge variation in the NTG doses used to treat CHF, a pump needs a bolus setting to give a large dose and return to the drip rate previously set.This is the kind of thing that will get the “What if . . . ?” people panicky. 

            We need to come up with an Ativan spray for those who cannot understand the appropriate way to balance risk and benefit. If we kill the patient by not giving enough medicine, the patient is still dead and it is still something we can be sued for – and it is a malpractice case we should lose. 

            .

      • http://sixlettervariable.blogspot.com Christopher

        Just long enough.

  • http://hybridmedic.com HybridMedic

    One every 5 minutes? I give my first 3 or 4 in the first 5 seconds.

  • http://twitter.com/xxDerekNxx Derek Noll

    Awesome, awesome! Definitely agree 100% with all the points you make. 

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  • P_G_S

    Silly question but one I have thought about at times (at least due to my state’s protocols): We’re only permitted to use nitro as a medication for chest pain and CHF.  However, what about that patient that is presenting with alarmingly high blood pressure, a “screaming headache all day no matter what I take”, presents risk factors for CVA/stroke (overweight, smoker, age), etc.  Would it really be a bad idea to administer a tab or two or three to this patient to attempt to bring down that BP?  Just wondering how y’all see this.

    • Medic768

      The reason nitro isn’t used fir treatment of hypertensive crisis is that when the bp is that high, a rapid drop (like what you get from nitro) can cause renal damage as well as cardiac and cerebral ischemia. Patients need oral or iv meds that drop their pressure gradually. Your thought process is right, I have had many students ask me about this, but there is a reason why it isn’t in the protocols.

    • Anonymous

      Some systems do allow use of nitro for hypertensive crisis. My opinion is, there are better drugs for it, like labetolol or oral clonidine.
      You have to be careful lowering BP in stroke patients. They *need* a certain amount of hypertesnion to maintain cerebral perfusion, and if you lower their BP to a level you feel vomfortable with, you’re making that infarction much bigger.
      The key to treating hypertension in stroke patients is in getting it *just* low enough to treat, usually less than 180 systolic and 110 diastolic.

      Ambulance Driver

      ________________________________

    • P_G_S

      People! People, do you see why I spend so much time on these sites?! Because I LEARN STUFF!  :-)  We don’t have a very progressive state (yet) so I always benefit from your experiences and your knowledge.
      Thank you all!

    • Vince D

      AD and Medic768 pretty well summed it up, but I might also add that hypertensive crisis is frequently a misnomer and even in the ED elevated blood pressures rarely need to be treated. The docs still might treat them anyway for a whole host of reasons, but an isolated finding of 260/138 doesn’t mean the person is going to stroke out right in front of you (assuming they’re not already elevated from a stroke), and just like Medic768 said, if you drop that 260/138 to even 170/100, you’re going to cause a whole lot more trouble.

      The other reason we may not want to treat someone’s HTN is that the main strong indications (I can think of right now) for dropping it are either end organ damage (usually kidneys), which you won’t be able to prove, or aortic dissection, which even if you diagnose, you probably don’t carry any drugs that are easy to titrate up and then turn off quickly if the patient crumps. It’s a similar story for stroke, except that the “correct” BP is very much debated (along with the need to even drop the pressure), although AD’s levels meet what most neuro surgeons tend to ask for these days (I usually hear 160-180 systolic).

      As a result, in the field, unless I was running a mini ICU in a plane or something, I could think of almost no instances outside of acute pulmonary edema where I would be requesting orders to drop someone’s BP. Of course that’s just the opinion of some guy on the internet, so you may very well be instructed otherwise.

    • Too Old To Work

      Yes it would be a bad idea. Two words. Rebound. Hypertension.

  • Vince D

    Love the article AD, and completely agree with the need for ongoing dosing of nitro for patients in hypertensive CHF (or someday perhaps normo and hypotensive) or those with CP in whom we have a high suspicion of ACS, but have to disagree with your final point on opiate analgesics. I’ve been running around the internet harping on this recently, but I think it is very significant that data from the CRUSADE registry showed an, in my opinion, very believable association with increased mortality in patients with NSTEMI who were admitted to the hospital. This view is even supported by the AHA recommending caution when administering morphine to US/STEMI patients.

    Like all medications, there’s a time and place, and I do very much believe that narcotic pain relievers have a role in patients with STEMI or in very significant distress, but simple ongoing pain prehospitally may not be the right indication. In a lot of places, much of the care in ACS is dictated by patient symptoms since there is no ED test for ongoing ischemia. Sure, a troponin will bump if there is an infarction, but ischemia doesn’t necessarily mean infarction, plus a pain-free patient with an elevated troponin is much more likely to receive less than maximal therapy for their ACS (opinion and experience, not fact).

    Like you, I agree that we can do a lot more to improve out patients’ comfort prehospitally, and strongly support EMS use of opiate analgesics, it’s just that in this instance my first goal is to do no harm, and if the patient has UA/NSTEMI, I believe we will be doing harm. While it may be similar to old-school surgeons saying morphine was contraindicated in abdominal pain because they wanted to be able to savor the pain and gauge the patient’s clinical course, there are two main differences here. First, with the advent of CT scanning, which most abdominal pain patients will receive (rightly or wrongly), you don’t need the patient in discomfort to tell you there is something wrong in their belly. In that instance, you can usually be guided by the test results, but as I said before, there is no ED test to rule out ACS. Secondly, there was no outcome data to actually back up the practice of letting abdominal pain linger, but for chest pain I think there is a pretty decent link between morphine and worse outcomes.

    All that being said, that one study is not enough to overturn protocols or create a huge change in practice, but I’ve gotta head to work and I’m sure there will be a few questions about my views, so I should just clarify that even though I tend to lean against morphine in NSTEMI/UA, there’s a reason that we may be told to give it by protocols or med control and it’s certainly not a topic worth getting into arguments over.

    • Anonymous

      I’m gonna have to read up on the CRUSADE trial, but let me pose this question: Is it possible that the patients who received morphine had worse outcomes because they had conditions that *needed* morphine? You’re not going to give narcotic pain relief to a stable angina patient if nitro relieves their symptoms, and it stands to reason that NSTEMI patients would have poorer outcomes  – they’re in worse condition in the first place.
      In other words, correlation does not equal causation.

      This sounds like a job for – ta da! Rogue Medic! Maybe he could dissect CRUSADE and give us his impression.

      Ambulance Driver

      ________________________________

      • Vince D

        Hmm I left a reply a couple of days ago but I think it got lost in the internet since it contained a link and went for moderation.

        Anyway, to rehash my comment, you do in fact bring up the biggest of several flaws in the study. It’s one reason why I don’t really think it’s wrong to give morphine, although I still think it may not be right. In most cases I would have just brushed off a retrospective registry analysis like this as data dredging, but in this instance I still kind of like the study for two reasons. First, I must admit, is my own personal opinion that the results make sense. It’s not at all evidence based medicine, however it is a bias carved from following scores of chest painers through their ED stay and some of their post-ED course, so hopefully it’s got at least some foundation in reality. The second reason is more objective, and it is that the authors attempted to control for risk differences between the groups (not foolproof, I know), and still, in every single subgroup they looked at, the worse outcomes associated with morphine persisted. Maybe the morphine patients really were just that much sicker, but I think it’s a strong enough case to make us at least question our use of morphine in UA/NSTEMI, then hopefully someday down the line we’ll actually get a randomized trial to see if this correlation actually involves causation. Slim chance, I know.

        Until then, it’s my opinion that morphine should be a last-line medical therapy for chest pain. Only after attempting all other medical options to get the patient’s ischemia under control should morphine be administered, and when doing so, with full knowledge that the patient’s symptoms have just been thrown out the window as a clinical marker and that a cath should probably be upgraded from “after the weekend,” to a bit sooner. So it’s not that I necessarily dislike morphine, I just think that in EMS we have neither the ability to maximize medical therapy in 99% of services, nor the capability to affect the patient’s post-ED (or even intra-ED) management, and as a result probably we shouldn’t be mucking around with their ability to tell us their heart isn’t getting perfused.

        With all that being said, I’m not crazy enough to think this is something worth getting into arguments with other providers or docs over. I’d still very willingly give morphine as a med control order or if I really thought the patient would benefit, but still, anytime I see someone getting morphine for their chest pain, I like to wonder just what effect that will have on their clinical course.

        Cheers AD, and I hope you’re feeling better soon.

  • BH

    When I started we never had a limit except for BP and pain, like it should be.  Now we do.  BLS is limited to a max of three of the patient’s own, including whatever the patient has already taken, ALS to three on top of whatever the patient has taken. 

    BLS can also take them all the way down to 90, but I can’t take it past 150 unless I have an IV.  Somebody please explain it, because the state can’t….

  • guest

    AMEN! Oh, how I wish more people would use thier brain and come to realize these facts. As a fellow borg drone I have had this argument many times with fellow drones and superior drones.

  • http://roguemedic.com/ Rogue Medic

    IV bolus NTG.

    No need to remove the mask.

    No need for pumps (although wearing pumps can get you a lot of attention in a kilt).

    Easy to titrate – if you have a clue. If you don’t have a clue, stay away from patients.

    .

    • Too Old To Work

      No one is going to approve giving IV NTG without a pump in place. Which just means that we have to get the pump manufacturers to develop a pump that is suitable for EMS.

      • http://roguemedic.com/ Rogue Medic

        I was told that no one is going to approve standing orders for morphine – too dangerous.

        Silly me. I kept pushing for it.

        I was told that no one would approve fentanyl for EMS – too dangerous.

        Silly me. I kept pushing for it.

        You tell me that no one is going to approve IV NTG without a pump – too dangerous.

        Silly me. I will kept pushing for it.

        IV nitrates have been used for decades.

        There is no good evidence that IV bolus NTG by syringe is dangerous, or do you know of any?

        I will continue to write about studies using IV bolus NTG and I expect that the doctors will keep studying IV bolus NTG.

        .

  • Franmacieiski63

    To make is clear since I did an AHA presentation on this topic because I am an advocate for a separate protocol for R-MI, they present with 3 distinct features that do no require a monitor:
    1. Hypotension
    2. Clear breath sounds
    3. JVD
    A Paramedic as well as a Basic are capable of recognizing these clinical signs. Now yes if you do have a monitor handy, use it and do a right sides EKG and look for the elevation in V4. The most common MI in the field is an inferior, and 50% of these specific MI’s are accompanied by a R-MI. I think medics fall victim to the “cookbook medic” stereotype, and forget what exactly NTG’s mechanism of action is. If the patient exhibits CHF exacerbation or acute MI beyond treating R-MI then NTG is exactly what they require. O2 to cardiac muscle = good; relieving pulmonary edema through vasodilation = good. Simple as that.

  • Pingback: The 3 Nitro BS – Part I | Rogue Medic

  • stephen

    Lets see….is there something to be said about even doing little squirts of 100 mcg’s of IV nitro also when you start the drip???  If you think of a single NTG tablet as delivering 400 micrograms in around 5 minutes…….  well, gotta break from tradition from time to time huh????

    • http://roguemedic.com/ Rogue Medic

      100 mcg is probably too small to make a difference. Multiply it by 10 or 20 times and that should help the patient.

      .

  • Pingback: Is IV Bolus Nitro Dangerous – Part I | Rogue Medic

  • http://twitter.com/MedicHo Heidi Ho

    Preach on!!!

  • Bob Agard

    After being treated for a heart attack four years ago, I was given a little bottle of nitro by my cardiologist, and told to put a pill under my tongue if I had chest pain. I used it once a few weeks later, and have put the little bottle in my pocket every day since, but not using it again. Though I don’t understand most of what is written here, I get the message that it is okay to use those little pills if I ever have severe pain again.

    • http://roguemedic.com/ Rogue Medic

      Bob Agard,

      Those pills have probably lost their potency. 

      One way to find out is to read the fine print. How long are the contents of the bottle considered to be still usable after opening the bottle?

      What is the expiration date on the bottle?

      Does it say to keep it out of a warm, humid environment – such as a person’s pocket?

      If you want a quick and dirty test of how much the pills have deteriorated, roll one through your fingers, if it crumbles at all, there is probably no effective medication left in the pill. 

      That does not mean that if it does not crumble at all it is still effective. It is just a demonstration of how much change can occur.

      Talk with a pharmacist to learn the best way to store nitro and to keep it available for when you may need it.

      .

  • systemet

    Regarding the nitro:

    * Given that there’s no decrease in mortality  / improvement in outcome with AMI, why not just get the 12-lead first?  Then we can look for inferior / posterior wall infarction, and do our 15 if we suspect RVI.

    This is how I’ve always done it.  Why rush to give a vasoactive medication without a line, or without actively looking for the condition we’re trying to avoid worsening?  Worst case: we delay by 5 minutes a drug that has no proven effect on outcomes.

    I agree that if we get partial pain relief with NTG we should continue giving it beyond 3 doses.

    • http://roguemedic.com/ Rogue Medic

      systemet,

      I am much more interested in the use of high doses of NTG for CHF. The doses should be large and frequent until things begin to change, then we just back off a bit. 

      I am not in favor of requiring a 12 lead on huffing and puffing patients prior to NTG, because the work of breathing is interfering with a good 12 lead and the problem is the work of breathing. 

      If there is suspicion of an RVI with CHF, then a 12 lead and/or an IV is indicated. Since I want to give IV boluses of NTG, an IV is not something that should be delayed when it can be used to deliver boluses of NTG. An IV to protect against the possibility of a drop in blood pressure can wait until a few mg of NTG are on board. :-)

      I agree with getting a 12 lead prior to NTG for chest pain. Maybe this will encourage people to get 12 leads faster.

  • Ted

    There’s a certain logical fallacy here.  AD, you seem to be saying that if an intervention* isn’t in the protocol, or is behind a “call medical control” box, then it doesn’t exist.  That’s not the case, or at least it shouldn’t be**.  My apologies if I misunderstood you, but that’s the message I got at the beginning of your post.

    NTG is a great drug for the management of all sorts of vasoconstrictive issues. That said, we’ve all seen NTG have some bad effects (if you haven’t, then you haven’t given enough) related to aggressive BP lowering.  This is why I don’t advocate NTG dosing without an IV if one can be obtained.

    Another issue is the right-sided MI.  As Franmacieiski63 pointed out, this is a syndrome that is classically diagnosable based on physical findings.  Unfortunately, patients don’t always read the textbooks; right-sided MIs can be very sneaky.  ED docs will frequently call their cardiologists for help ruling this syndrome in or out based on clinical findings, lab work, and multiple EKGs; don’t flatter yourself that you can make the decision reliably in the back of an ambulance or in a patient’s living room.

    I’m not saying that high-dose NTG isn’t a good idea in CHF.  I’m a big fan of it, and recommend the writings of Amal Mattu to anyone who has questions.  But I do maintain that it’s a fairly rare patient who needs high-dose NTG in the prehospital arena, and if you’re getting ready to use that sort of therapy it’s a good idea to double-check your thinking.  Calling med control is a great way to do that.

    *such as high-dose oral or IV nitroglycerin

    **and if it is, your system’s problems are much greater than just those reflected in the CHF protocol

    • http://roguemedic.com/ Rogue Medic

      Prehospital high dose NTG is what is most important. 

      Why bring intubated patients to the hospital for what could have prevented the intubation in the first place?

      Are you suggesting that intubation is safer than high dose NTG for CHF?

      .

      • Ted

        I’m sorry, you lost me there.  How do you get from “call med control before giving high-dose NTG” to “intubate everybody with CHF”?

        • http://roguemedic.com/ Rogue Medic

          Avoiding high dose NTG leads to much higher rates intubation and death.

          Even hypotensive patients had their death rate cut by almost half with NTG given by IV before going to the hospital.

          Intravenous nitrates in the prehospital management of acute pulmonary edema.
          Bertini G, Giglioli C, Biggeri A, Margheri M, Simonetti I, Sica ML, Russo L, Gensini G.
          Ann Emerg Med. 1997 Oct;30(4):493-9.
          PMID: 9326864 [PubMed - indexed for MEDLINE]
          http://www.ncbi.nlm.nih.gov/pubmed/9326864

          Where is there any benefit to calling Mother-May-I command?

          Where is this great theoretical danger, when it comes to real patients with CHF?

          Please provide some evidence that there are any bad outcomes due to high dose NTG for CHF.

          Assuming that you find any cases, how does that case outweigh the benefit of cutting the total death rate by about half?

          We are killing patients in order to protect them from the treatment that is best for them. 

          This fear of NTG makes no sense.

          .

          • Ted

            The study you cite has a few problems pertaining to your argument.  One, it is retrospective, which makes it inherently weaker.  Two, it only looks at treatment type, not quantity.  Dosing is not addressed.  Based on the findings of this study, it is possibly that 10 mcg of NTG could do the trick.  Finally, it compares NTG to some unusual treatments (aminophylline, dopamine) without any sort of treatment algorithm.  Without controlling for patient severity it’s hard to draw conclusions here.

            Benefits of calling med control include dosing adjustment, verifying the presence of CHF, and controlling for other factors.  I have seen plenty of other causes of shortness of breath (pneumonia, asthma, emphysema) misdiagnosed as CHF; nitrates do not typically help these patients.

            The danger for high-dose NTG is not theoretical, it is very real.  I’m sure you have read the package insert and are aware of the adverse effects.  If you don’t believe these effects are real, spend some time in an intensive care or cardiac care unit watching the patients on NTG drips.

            NTG is a potentially dangerous drug.  Telling a brand-new medic with 2 years of training and no street experience to administer it in large doses without direct oversight is a great way to cause _more_ bad outcomes, not less.  Like it or not, the brand-new medic is the person that the protocols are written for.

            You are right about one thing: fear of NTG makes no sense.  A healthy respect for it, OTOH, makes perfect sense.

          • http://roguemedic.com/ Rogue Medic

            Ted,

            There are other studies of IV NTG for CHF.

            At EMCrit, Dr. Weingart has a whole page of references linked to his first podcast, which is on the topic of aggressive IV NTG for CHF. I’m sure he needs to hear from you about the evils of NTG.

            On line medical command requirements are just an excuse for medical directors to authorize dangerous medics. 

            Where is there any research of any benefit to patients from medical command permission requirements? The only time I think it is acceptable is for refusals, because EMS is bad at determining who doesn’t need to go to the hospital.

            The FDA label for droperidol states that we are to get a 12 lead on agitated delirium patients before giving droperidol. Just because something appears on an FDA label does not mean that it is reasonable.

            The FDA label also states that fluids should be given to patients who become hypotensive after receiving NTG, even though the patients blood pressure recovers before the fluid could have any effect. 

            Where is there any research that shows that the rare cases of hypotension after NTG resolve faster with IV fluids? Where is there any evidence that these patients are not harmed by receiving IV fluids?

            If a brand new medic is that dangerous, then the medical director should not authorize that medic to work without supervision. On line medical command permission requirements are not supervision, they are only something medical directors point to with a nod and a wink as their pretend supervision. A medic can kill patients with everything in the medic bag – the stuff that requires permission and the stuff given reflexively by the protocol monkeys.

            .

          • Ted

            RM,

            I think we are finally down to the nitty-gritty.  We seem to agree that NTG (and at high doses) is useful in CHF (your comment about the “evils” aside).  We disagree about what constitutes a reasonable amount of supervision for this drug.

            While I will readily admit that individual services vary widely, I’m a big fan of on-line medical control for meds/procedures that aren’t routine and aren’t incredibly time sensitive.  For instance, I don’t think medics should call for orders for synchronized cardioversion.  Either these patients are stable (in which case medical management is more appropriate) or they are unstable (in which case they need to be shocked now, not in 2 minutes after you talk to the doc).  The issue I have with your offline NTG protocol is that it’s a massive dose of a medication with very serious potential side effects that is given OVER TIME (I assume you are not seriously recommending an initial, immediate treatment of 20 sprays of NTG).  I can’t think of a good reason not to talk to a doctor after the initial dosing (say, 3 tabs or so) but before proceeding to the massive doses discussed here.

            On-line medical command is not ” just an excuse for medical directors to authorize dangerous medics. ”  It’s a reasonable and necessary form of oversight for issues that are unusual (such as severe CHF requiring massive doses of NTG in the prehospital arena).  Just because someone is not capable of completely independent practice does not make them a dangerous medic; it frequently just means they’re inexperienced.  Similar oversight occurs for physicians-in-training, physician extenders, and nurses (in fact, paramedics get about the least oversight of any health care worker I can think of).  Oversight is part of how medicine is practiced because it makes sense.  ED nurses get orders from ED docs.  Floor nurses get orders from the admitting doc.  EMTs get orders from med control.  Physicians get recommendations from consultants. Your protocols are the same idea; they are generalized written orders.  It sounds like your medical director isn’t comfortable expanding them to include the interventions you’re discussing; perhaps there’s a reason?

            I’m used to a place where the docs are available on the radio within seconds.  Is there a longer delay in your area, that would actually delay treatment?

          • http://roguemedic.com/ Rogue Medic

            Ted,

            For instance, I don’t think medics should call for orders for synchronized cardioversion.  Either these patients are stable (in which case medical management is more appropriate)

            Medical management?

            We should be sedating these patients in preparation for cardioversion, not giving them cardiotoxic drugs that are going to be followed by cardioversion because they fail most of the time. Unless you are referring to procainamide, which is the one antiarrhythmic available in the US that does not fail most of the time.

            The issue I have with your offline NTG protocol is that it’s a massive dose of a medication with very serious potential side effects that is given OVER TIME (I assume you are not seriously recommending an initial, immediate treatment of 20 sprays of NTG).

            Of course not. We should be giving 5 or 6 sprays at a time. We should be repeating 5 or 6 sprays every few minutes.

            It would be much better for the patient to receive 1 mg or 2 mg IV boluses of NTG. We should be repeating that every few minutes.

            I can’t think of a good reason not to talk to a doctor after the initial dosing (say, 3 tabs or so) but before proceeding to the massive doses discussed here.

            Gee, Doc, the patient’s blood pressure hasn’t budged after the first group of 6 NTG, won’t you please stay on the line and hold my hand through this. Remember, the answers are – if the pressure doesn’t drop, keep it up every few minutes – if the pressure does drop, decrease or hold the NTG depending on how much it drops. 

            There are different guidelines that can be used for how much NTG can be given based on systolic blood pressure. We can always get one of these for the doctor to read from, so that you feel good about this.

            On-line medical command is not ” just an excuse for medical directors to authorize dangerous medics. “

            I’m still waiting for some evidence that on line medical command permission requirements provide any benefit.

            I don’t have any problem with medical oversight. 

            I think we do not have enough medical oversight in EMS.

            Mother-May-I permission requirements are certainly NOT oversight.

            .

          • Ted

            I guess we’re just going to have to agree to disagree.

          • http://roguemedic.com/ Rogue Medic

            Oh, good.

            Medicine is just opinion and research doesn’t mean anything.

            You couldn’t find any research to support any of your statements, so your opinion is supposed to be as valid as the research that contradicts your opinion. 

            .

          • Anonymous

            Okay boys, let’s play nice here.

            Kelly Grayson

          • http://roguemedic.com/ Rogue Medic

            I was just responding with the professionalism that “I guess we’re just going to have to agree to disagree” deserves.

            Tell me that I am wrong but support that criticism with something credible.

            I was providing research in response to his criticism.

            I was asking for some sort of research to support his criticism.

            I received opinion and “I guess we’re just going to have to agree to disagree.”

            Where do I need to go to have a medical discussion about medical treatment based on medical research?

            If high dose IV NTG is so dangerous, show me something more than “everybody knows . . . ”

            It isn’t as if I called anyone “obtuse.” ;-)

            .

          • Anonymous

            LOL, touché.

            But she WAS being obtuse. ;)

            Kelly Grayson

          • http://roguemedic.com/ Rogue Medic

            When I can just go back and cut and paste my earlier responses, because she was repeating what she was saying, that pretty much defines obtuse. :-)

            .

          • Idahomomofmany1

            Ted. I see your point, I live for the high dose treatment. I also have been doing this many years. I think the point that most people are missing in this post.. is Treat your pt not the protocols. I am certainly not going to douche my pt with nitro then assess them, I am going to asses them with each dose given. Our company allows us to use IV nitro.. via pump.. and if you know your pumps you can suspend the dose rate and bolus them.. And dont forget, that Even with a pt on CPAP, you always have your Nitro paste… My intubation counts have dropped drastically by increasing my nitro use. And in the regaurds of treating non CHF , that actually have some other thing going on.. AGAIN treat your pt.. If you give nitro.. and there is no improvment.. No harm no foul.

          • Idanomomofmany1

            PS, I agree you need to contact medical command, But I also believe that our protocols, as important as they are, are a guidline, Again, treat your pt, and contact your medical command. But I also Believe that you need to treat your pt first and formost!

  • Inertia67

    I am an EMS LT. Mother and I would be the first one to smack her down for going on an unsecured scene and her police officer brother the second to smack her down. Don’t make the wrong decision twice. Stay safe so you can save a councilman life one day. Remember, you wil always be able tgo save a life while the councilman would never be able to stand tall again,because of his ignorance. Thanks I am a very proud Mom. Stay safe and come home.

    • Anonymous

      Uummm… Wrong comment thread?

      Kelly Grayson

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