I had a routine call with my preceptee today — an obese patient with sudden onset of reproducible chest pain. Lots of cardiac risk factors, but also a history of recent bronchitis. 12-lead looked good. Stable vitals. Some response to nitro. What was really going on with the patient? What was the real source of the chest pain? Who knows? We discussed what a medic should put down for their “clinical impression” in such cases.

Now as far as “clinical impression” goes, I used to love filling out this box, so I could declare what I thought was going on. Nowadays I like the box less because I really can’t say I know what is going on. All I can do is treat the patient appropriately by the protocols mixed with common sense, be nice to them and get them to the hospital safely, both from the perspective of a safe ride and by not doing harm with my medicine.

In this case, my preceptee wanted to write ACS (Acute Coronary Syndrome). I questioned it because I thought it was likely more a muscle skeletal or pleuritic problem, but I admitted I didn’t know for sure. I told him unless I had a STEMI or at least a far better cardiac story, I usually either wrote “?cardiac/?muscleskeletal” or just wrote simply “chest pain” as my “field impression.”

Afterwards, back at the base I was trying to look up the study I had read about where it was shown nitro (because it is a muscle relaxant)works as well at alleviating non-cardiac chest pain as it does cardiac chest pain, meaning you cannot use nitro as a diagnostic to determine what is causing the pain.

One of the sites I found on my search turned out to be a newsletter called the QUEAS-E Update, which is a newsletter from the Wesley Medical Center in Wichita, Kansas written by a Dr. Mark Mosley. What a treasure trove of information and thought! QUEAS-E by the way stands for (Quality, Uniformity, Education, Attitude and Service in Emergencies.)

I found confirmation of the nitro study I had read about as well as some other interesting “cardiac myths.” Best of all was the suggestion to write “chest pain indeterminate” when you don’t what is causing the pain. Problem solved.

In addition to finding this information, in this and other issues I looked up, there was much fascinating content, including a provocative discourse on the cost to the health care system of mandatory CPR training(and retraining), lessons after spending a night in a hospital unit as a patient, and a plea for EMS to think of themselves as “emergency treaters” as opposed to “emergency responders” when dealing with patients in pain when there is a short transport time to the hospital.

Myths About Chest Pain

QUEASE-E Newsletter July 2008 (CPR is a Waste of Resources)

Pain Management Issue

I am bookmarking the QUEAS-E Update and will make it regular reading.

Archive on On-line Issues


  • RT Scribe says:

    Thanks. That looks like a really good newsletter.

  • Mystery Medic says:

    This was a great newsletter. Good find.

  • Anonymous says:

    just to add on the subject of nitro being used diagnostically, esophageal spasm often presents similarly to an MI (similar location, quality, and radiation of pain), and being that the esophagus is smooth muscle the spasm is normally relieved by nitrates.

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