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Old 07-10-2011, 19:43   #1
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Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

You and your S/O are 50 miles from the nearest land. It is rough, wind is over 20kts, and s/he announces that they have a pain in their chest. What do you do?

There are myriad reasons for "chest pain" and most are not cardiac related. That said, if it is "the big one", time is of the essence. A cardiac event is a MAYDAY! Event at sea. How does the layman (or the professional for that matter) differentiate between typical and atypical chest pain?

Only sophisticated ECG and lab work can rule out a cardiac event... BUT medical history, history of this event, and patient presentation, can sway the field diagnosis. REMEMBER... IF YOU HAVE THE SLIGHTEST DOUBT THAT IT IS CARDIAC RELATED, CALL MAYDAY AND SEEK MEDICAL CARE!

Medical history: has the patient ever suffered a similar episode that WAS diagnosed as cardiac related? Is there family history of coronary disease? Is the patient a member of an "at risk" category?

History of this event: is the patient being (or has been) stressed physically, emotionally, or both? Is there trauma involved? (think chest pain localized ao a point of impact on the chest... Or possibly a torn muscle?) Was the onset fast or slow? How long has it been going on?

Patient presentation: is the patient sweating? How are they breathing? Is the pulse fast, slow, irregular? Is it weak, thready or bounding? Does the pain radiate? Is the pain reproducible by movement or touch? What is the level of pain?

So what do you do? Is it a heart attack or a torn intercostal muscle?


I'm typing on my iPhone waiting on my partner who is still typing his report in the hospital (we just transported a chest pain call).... More later from a real keyboard!
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Old 07-10-2011, 19:56   #2
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re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain!

Quote:
Originally Posted by capngeo View Post
You and your S/O are 50 miles from the nearest land. It is rough, wind is over 20kts, and s/he announces that they have a pain in their chest. What do you do?

There are myriad reasons for "chest pain" and most are not cardiac related. That said, if it is "the big one", time is of the essence. A cardiac event is a MAYDAY! Event at sea. How does the layman (or the professional for that matter) differentiate between typical and atypical chest pain?

Only sophisticated ECG and lab work can rule out a cardiac event... BUT medical history, history of this event, and patient presentation, can sway the field diagnosis. REMEMBER... IF YOU HAVE THE SLIGHTEST DOUBT THAT IT IS CARDIAC RELATED, CALL MAYDAY AND SEEK MEDICAL CARE!

Medical history: has the patient ever suffered a similar episode that WAS diagnosed as cardiac related? Is there family history of coronary disease? Is the patient a member of an "at risk" category?

History of this event: is the patient being (or has been) stressed physically, emotionally, or both? Is there trauma involved? (think chest pain localized ao a point of impact on the chest... Or possibly a torn muscle?) Was the onset fast or slow? How long has it been going on?

Patient presentation: is the patient sweating? How are they breathing? Is the pulse fast, slow, irregular? Is it weak, thready or bounding? Does the pain radiate? Is the pain reproducible by movement or touch? What is the level of pain?

So what do you do? Is it a heart attack or a torn intercostal muscle?


I'm typing on my iPhone waiting on my partner who is still typing his report in the hospital (we just transported a chest pain call).... More later from a real keyboard!
I'm older and all my friends are older. My first aid kit has aspirin in it.
I would never try to decide if someone is having a heart attack or not. I would not be thinking 'Patient presentation.' I'd call the Coast Guard and let them tell me what to do. I'd put out an all call. For all you know there's an MD out on his power boat five miles away.
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Old 07-10-2011, 19:57   #3
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re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain!

First thing , dissolve an aspirin under the tongue.
Second thing. Pray, if you think it will help.
Third thing, tell your S/O you love them.

If you are 50 miles from a large civilized country, you may make it.

If not:
Fourth: Bend over and kiss your %#* goodbye!

Two have died of a HA while aboard in anchorages I was in. One in the Bahamas, one in Mexico. Even if an MD is next door, likely there is nothing he can do. Really, even with 911 service on land, I understand there is a 3% survival rate in the US.
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Old 07-10-2011, 20:29   #4
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

MONA: 1: Chew 325mg Aspirin; 2: High flow (15 lpm) Oxygen 100%; 3: Nitroglycerin spray uner tongue; 4: Morphine - assuming Viagra not in use. SSB/VHF/911 cell emergency call. Attach AED if present. Monitor/doc vitals every 5 mins. Assume worst; hope for best. Document OPQRST. Prepare for chest compressions if no pulse.
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Old 07-10-2011, 20:35   #5
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Quote:
Originally Posted by Cheechako
First thing , dissolve an aspirin under the tongue.
Second thing. Pray, if you think it will help.
Third thing, tell your S/O you love them.

If you are 50 miles from a large civilized country, you may make it.

If not:
Fourth: Bend over and kiss your %#* goodbye!

Two have died of a HA while aboard in anchorages I was in. One in the Bahamas, one in Mexico. Even if an MD is next door, likely there is nothing he can do. Really, even with 911 service on land, I understand there is a 3% survival rate in the US.



The 3% survival rate is for a full cardiac arrest, not just a myocardial infarction (ie heart attack) in the field. This means your heart has stopped or is in fatal arrythmia, needing CPR and resuscitative attempts. Unless someone has a AICD on their boat, not much you can do.

A heart attack/myocardial infarction does not mean cardiac arrest, and many heart attacks are very survivable if they don't result in an arrythmia, especially if you have aspirin, nitroglycerin tablets, and some luck on your side. Take 325mg of aspirin, then nitroglycerin tablets every 3-5 minutes x 3 until chest pain goes away. Then relax, and call for help. Taking 325mg of aspirin for chest pain is almost never wrong, unless it is acid reflux in case it may make it worse. Few people die from reflux.

Best is to manage your risk factors ahead of time. If you have high cholesterol, high blood pressure, a family history of heart disease, are very overweight, or are a smoker, you should get on meds, and quit smoking, and lose weight, before you get out there. That way your friendly doctor (me) on a boat nearby gets to enjoy his cocktails and sunset rather than trying to put a bandaid on the results of a lifetime of cardiac risk. Of course if you call I will do my best to save your life....
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Old 07-10-2011, 20:37   #6
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

Too many burritos for lunch?
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Old 07-10-2011, 20:46   #7
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

i would pray it was the chiles in the dish i served for foods that day.

i cheat -i did cardiology nursing in cedars sinai med center for years, as well as other places . but, 50 miles from nearest port and that one isnt great vs X number of hours until a coast guard rescue for the person-- would have to be determined by what he said when we had a chat just before the call is made. if were me, i have bad allergy to aspirin,. do not ever give me any. if were my SO, i would call for uscg rescue. realistically--isnt anything i can do-- isnt anything on my boat to help him with, if is truly cardiac event--i would have to assess severity by number assigned to the pain and what i saw on his face and body language, what relieved it, if anything, and how long did it last. if the pain is longer than 30 min, is usually myocardial infarct. if diminishes prior to that, is angina, and should be treated. infarct should, as well--- survival rate diminishes in SEVERE myocardial infarct longer the wait for treatment.
uscg would be necessary under both conditions, as, in case of death, there needs to be a record of that.


if is crew and he didnt tell me about the angina, and i pat the clothes he is wearing down to find,,OMG!! NTG spray or sublingual tabs, he gets those, i record in ships log everything i do to aid him, and when the call is made for uscg rescue they will receive a professional report of the event. i will keep the log for my ships records.
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Old 07-10-2011, 21:52   #8
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Good Zee! I like it...myself I would evaluate patient get heart rate and pulses and check CRT (capillary refill time) give aspirin if felt indicated keep patient calm and make radio call. Not a lot of cardiac equipment or meds on most boats.

In the past on boats I have dealt with one drowning (revived her) one near drowning and a person with his arm nearly severed by prop with arterial bleeding none died despite severity of cases and slow emergency response all three I was very worried about.
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Old 07-10-2011, 22:57   #9
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

Lacking cardiac training I would be on the radio to my equivalent of the USCG ASAP, and get them to have a doctor walk me through the diagnostic / treatment process. Immediately start closing the land to get radio contact / because they are almost certain to want to evacuate / direct me to a port. Unless the patient is considerate enough to die quickly.

If not, make it clear that I want a medical evacuation, and crew will remain on vessel.

Less sure what low-tech things I can do immediately with the patient, so perhaps Zee has some more tips. Aspirin? Treat as per shock, to max blood supply?
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Old 07-10-2011, 23:30   #10
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

OK I'll take a stab at this one.
Lie person down.
Loosen restrictive clothing. Belts etc.
Get the patient to describe the pain on a scale of one to ten. Ten being bad
Get them to describe the location of the pain. Above or behind the ribs
Does the pain radiate out the limbs
Check the pulse. Strong and regular or weak and fast / irregular
How is their breathing deep and normal or shallow and quicker.
how is the persons skin colour normal or pale and sweaty. (Take into consideration the local climate)
Is there anything that causes pain to get worse
Do they have a past history of heart issues. Are they on Nitro
How long have they had the pain
What were they doing prior to the on set of pain
Apply Oxygen if you happen to have on board. Does it relieve pain
Mayday call if you even have the slightest thought that it might be a heart attack.
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Old 07-10-2011, 23:42   #11
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

We carry Mylanta an antacid/ gas relief or equivalant, If it doesn't help pray so far it has worked.
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Old 07-10-2011, 23:45   #12
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

Sorry guys, been one of those shifts, and I haven't seen the station for long since starting this (still on the iPhone typing). Considering the weather mentioned in my OP, med-evac by helo is unlikely. The situation occurred to a buddy of mine off New Orleans; it was his brother who had the MI. He did not survive. USCG chopper arrived but due to the heaving sea and rigging, they aborted the rescue by air and sent a 41' boat.

The aspirin is one of those "can't hurt" things in most cases (unless allergic like Zee). BUT one 325mg tablet doesn't reverse a lifetime of bad habits. All aspirin does is limit the "stickiness" of blood platelets (the solids in blood) which help to prevent clots. A heart attack is usually caused by a blocked vessel in the cardiac muscle... Many times by a clot that lodged in a narrowed artery. The aspirin is a bit like closing the barn after the horse has already bolted. But I digress.....

Chest pain that is attributable to injury from trauma or even coughing, lifting, etc. absenting profuse sweating, shortness of breath, abnormal heart rate or rhythm, and is reproducible by palpation or movement is TYPICALLY NOT cardiac event. A MAYDAY is not indicated.

Oxygen is always good and should not be withheld. Laying the conscious patient supine, elevating the feet is another good thing to do.... BUT look at the feet and ankles; if they are swollen and the patient is also having difficulty breathing DO NOT ELEVATE! Likely the patient presenting with swollen lower extremities and shortness of breath will not allow you to lay them flat.

Nitroglycerine is a handy thing to have in your med kit. It will lower blood pressure by dilating the blood vessels. This accomplishes two things: allows more blood flow (oxygen) to the heart, as well as lessens the workload of pumping. One pill or spray under the tongue is your starting dose. If you have the equipment and training, monitor the patient's blood pressure. Do not allow the top number to go below 110. As long as the BP holds up, you can repeat the dose in 3-5 minutes. DO NOT USE NTG IF THE PATIENT HAS USED ERECTILE DYSFUNCTION MEDS IN THE LAST 24 hrs! If you do not have equipment to monitor BP check for a pulse at the wrist. Mark the spot that you felt the pulse with a pen and note how strong the pulse was. If the pulse strength lessens or disappears do not give NTG again.

CRAP! another alarm! More later!,, gotta go
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Old 07-10-2011, 23:57   #13
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

I had a small heart attack with pain in the chest, numbness and pain in the arms and shortness of breath. First thing I did was to lie down and undo my bra. Last thing I was able to do is cry out for help. What do you do in those moments?

I will have nitro tablets and aspirin easily accessible but also some sort of a horn or panic device to call out for help I can easily wear as a necklace.
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Old 08-10-2011, 02:33   #14
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

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Originally Posted by surforcycle View Post
MONA: 1: Chew 325mg Aspirin; 2: High flow (15 lpm) Oxygen 100%; 3: Nitroglycerin spray uner tongue; 4: Morphine - assuming Viagra not in use. SSB/VHF/911 cell emergency call. Attach AED if present. Monitor/doc vitals every 5 mins. Assume worst; hope for best. Document OPQRST. Prepare for chest compressions if no pulse.
Welcome to C.F. surforcycle.....

(and may you never have to experience such a situation in real life.....)
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Old 08-10-2011, 04:13   #15
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Re: Challenge: Thinking Outside the Medical Box | I'm Having Chest Pain !

Not an answer to the OP, but related...

When doing an offshore passage, I had each crew member write down their pertinent medical history, any drugs being taken, and emergency contacts back home. This was sealed in an envelope and put a ziplock bag with their passport and wallet. The ziplocks went in the ditch bag.

If a crew had to be evacuated, the ziplock bag would be taped to his chest before putting them in the helo basket. That would give the EMTs as much info as possible in case the patient wasn't able to fill them in.
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