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Reader Questions Pulmonary Embolism Case

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Freaking Out Questions
This month, readers asked questions about “Freaking Out,” the first installment of the new column Back to Basics, written by Dennis Edgerly, BS, EMT-P, and appearing in the October issue. This month we also heard from a paramedic who attended one of the first nationally accredited paramedic programs outlined in Edgerly’s October article “Birth of EMS.” Finally, a reader comments on Thom Dick’s October Tricks of the Trade column, “Visual Problems,” relaying his own experience of calling in sick because he needed a mental health day.

I enjoyed Dennis Edgerly’s October Back to Basics column, “Freaking Out.” It just goes to show us how we as medics need to be looking beyond the obvious. However, I do have a few questions: How come you didn’t explain the difference in readings between the pulse oximetry and the capnography, and how is pulse oximetry valuable in the setting? Also, why wasn’t a complete physical exam stressed in this situation? Maybe the deep vein thrombosis (DVT) might have been discovered. Thirdly, why didn’t you write more about the use of the ECG in helping discover the possible problem? Lastly, what does the latest science say about the use of aspirin in this situation?

David C.
Via email

Author Dennis Edgerly, BS, EMT-P, responds: Great questions, David. For most of your questions the answer is: the scope of the article (attempting to keep it more basic) and the length allowed for publication.

I intentionally identified the physical exam as being unremarkable because I did not want her to have a potential DVT. A DVT is a common cause of pulmonary embolism (PE) but there are other origins commonly overlooked, as the article states, and in some cases the origin of the PE is unknown. I wanted to present an atypical situation.

I made mention of the pulse oximetry and capnography readings to offer an application to the presentation of a PE. But, based on length and scope of the article, I didn’t delve into additional details regarding these two tools. The same is true with the ECG reading. I mentioned the ECG changes that may appear but even if a provider is proficient at recognizing the changes, the same changes can be seen with a posterior wall MI so it’s not a conclusive finding. And, there is a lot of discussion surrounding the prevalence of these changes with a PE.

As for aspirin (ASA), I know patients may be placed on an aspirin regiment (or other platelet aggregation inhibitor like Plavix/clopidogrel) when released from the hospital but I’m not aware of any study showing benefit of ASA in the emergency setting when suspecting PE. I’m interested if you or any JEMS readers are aware of a study looking at this treatment plan.

Paving the Way
Great article that you wrote for the October issue of JEMS “Birth of EMS.” This article was particularly interesting to me due to the fact that my wife and I attended Eastern Kentucky University and graduated from the program with degrees in 1981.

We were both reviewed as well as all of the students and faculty by an accreditation team including Dr. Norman McSwain of Tulane University. I don't think we realized at the time how important it was with our University receiving one of the first accreditations in the nation.

My wife recently retired as chief of our local county EMS service and I'm still working at a ALS non-transport fire service.

Rich D.
Via email

Personal Days
I really appreciated Thom Dick’s article in the October issue, “Visual Problems.” I worked for an EMS service that had vacation days and sick days. There were no personal days. I had called in sick once in two years. I had 72 hours of vacation saved and 200 hours of sick leave.

A couple of months ago I needed a personal day. I called in sick the night before my shift and already had a name of a co-worker that said he would work for me. The director of the agency called me and told me that I did not sound sick. I said I needed a personal day. He advised me to use vacation time and chastised me for calling in sick when I wasn’t actually sick. I told him I was stressed out, I had a couple of rough calls and needed a shift off. He said if I can’t handle the job to think about a new career.

I hung up the phone in tears. I wanted to save the vacation to visit my brother who just returned home from military duty in Kuwait. I quit a couple of months later because I didn’t feel valued and lost those 200 hours of vacation time. I now work for a company that views sick and personal days the same. I feel valued and even make more money!

Rachel E.
Via email

 

Correction
In the September JEMS article, “Bus Rollovers: Knowing & overcoming the challenges of MCIs involving passenger coaches,” by A.J. Heightman, MPA, EMT-P, we omitted San Manuel (Calif.) Medic Truck 241, one of the first units to arrive on scene, in the column titled “Medic Ladder” in the Unit Response section on p. 44. We regret the omission and give extra thanks to the crew of San Manuel Medic Truck 241 for their special effort in lighting the nighttime scene like daylight and caring for the victims of this horrific bus crash.

 

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