# Cardiac monitoring



## rhan101277 (Feb 21, 2011)

I wanted to get some feedback on how many folks decide to for go cardiac monitoring.  In the following two scenarios you are less than 5 minutes from the ER.

This is limited to these two specific scenarios only.

You have a ped vs car less than 5mph.  AAOx3, pulse is regular, strong.

You have a bicycle vs car 25mph.  Initially unresponsive, then minutes after is responsive and AAOx3.  Pulse is regular, strong.

In both cases you decide to simply monitor the heart rate with pulse oximetry and occasional pulse checks at wrist.

I know it doesn't take long to put them on, but when you don't have much time and other things need accomplishing and are more important, it doesn't make since for me to put them on.

If any of the above scenarios resulted in difficulty finding pulses, patient not alert or irregular heart rate noticed on palpation, cardiac monitoring would be applied

Any feedback?


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## 8jimi8 (Feb 21, 2011)

Dont you have a partner who can apply electrodes while you all are packaging?  Monitoring doesn't take that long and you might miss important vital signs that only monitoring would provide.

how long does it take to put 3-5 leads on?  you need to expose the abdomen on mvcs anyway... why not throw the monitor on at the same time?


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## Mobey (Feb 21, 2011)

Honestly man, cardiac strip has become part of my routine vitals.

It is not very often I don't put one on.


One thing I teach my students is EVERY sick patients get 02, IV, cardiac monitor.

So to directly answer your question.... Yes both the above patients would have a monitor. Chances are, if I suspect chest trauma (which I already do based on height of peds vs hood) they would both get 12 leads too.


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## firecoins (Feb 21, 2011)

its required here.


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## rhan101277 (Feb 21, 2011)

Mobey said:


> One thing I teach my students is EVERY sick patients get 02, IV, cardiac monitor.



I know this, I guess I got in to much of a hurry to get off scene.  I always do this, don't know what I was thinking this time.


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## mc400 (Feb 21, 2011)

If you are running the PT in BLS then I do not think it is that big of a deal, getting the PT to definitive care is the big issue, plus if you find an irregularity you wont have time to treat it. 

With that said I get at least a 4 lead on pretty much everyone. Also pt may not need an IV if you have an extra medic yeas but rapid bls transport is key. Rapid assesment, expose/package, load and go. Secondary assesment E/R. Its all case dependant though. 

I am never 5 minutes from a hospital though. About 12 min is the closest from any area in my district.


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## TomB (Feb 21, 2011)

I see no indications for cardiac monitoring in either scenario.


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## MrBrown (Feb 21, 2011)

Maybe, nothing more than a 3 lead to identify rate and rhythm tho


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## JPINFV (Feb 21, 2011)

My biggest concern is the use of a pulse ox to measure the pulse. Does the monitor show a waveform or how are you confirming that the pulse ox is accurate?


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## CANMAN (Feb 21, 2011)

Mobey said:


> Honestly man, cardiac strip has become part of my routine vitals.
> 
> It is not very often I don't put one on.
> 
> ...




Routine vitals huh, you must work in a very slow jurisdiction. So a nosebleed gets a 4 lead strip??

I have to agree with TomB on this one. I don't see a need for either patient to be cardiac monitored. If both patients have normotensive vital signs to include pulse rate, and you palpate a regular pulse I think its VERY safe to say they are both in NSR. 12 lead for both patients????? I think is way overkill. Whats a 12 lead going to show you that is going to be something you can correct on scene? Nothing, therefore you have just wasted at least a minute placing more electrodes and obtaining said 12 lead. 

If anything the reason I would apply the monitor to the second pt. would be to check for possible cause to the unresponsiveness, maybe a medical issue? The fact that he was unresponsive and now has a GCS of 15 doesn't really add up to me after a trauma event. 

I may be a little laxed in treatments but I have always been aggressive with sick people and not so with stable patients. I don't practiced based on the fact of I do something because I can. I normally do interventions based off a need.... To each his own. No two medics will do everything the same. Thus why I love single ALS provider units


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## Shishkabob (Feb 21, 2011)

CANMAN13 said:


> Routine vitals huh, you must work in a very slow jurisdiction. So a nosebleed gets a 4 lead strip??



Preferably, yes, if the nosebleed was non-traumatic in nature.    Could be caused by HTN, which could be caused by a dysrhythmia.  



As for these scenarios?  Why WOULDN'T you have an EKG on the bike rider who was initially unresponsive?  



There's more than probably just you on scene.  Slap the stickies on and take the automatic printout.  Ta-da.   Granted I have a 45+ min transport from the closest facility, so I get more time to toy around with my assessments...


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## CANMAN (Feb 21, 2011)

IDK maybe its just me but I would tend to get a baseline set of vitals on a nosebleed/any call and go from there. If everything got cardiac monitoring then why don't we do away with BLS transport units, work everyone up, and bill ALS for everything. As an ALS provider you can link anything to a more serious condition if you think about it long enough. The fact that a nosebleed, could be caused by HTN, which could cause a cardiac issues is honestly not on my mind UNLESS the baseline vitals give me reason to think this way. 

As said in my previous post, outta the two I would be more willing to workup the second dude based on the "unresponsiveness" but I am not going to delay transport to the hospital which is 5 MINS away to grab a 4 lead on a patient who now has a GCS of 15, normotensive VS, and regular pulse, just to confirm he is indeed in NSR??


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## Mobey (Feb 21, 2011)

> Routine vitals huh, you must work in a very slow jurisdiction. So a nosebleed gets a 4 lead strip??



Hmmm... I fail to see how adding a strip to a complete assessment correlates to call volume?
Perhaps it takes you alot longer than me (or my EMT partner) to put on a 4 lead.

Let's get real here, yes, every nosebleed. not every patient... but pretty well every patient.



> Whats a 12 lead going to show you that is going to be something you can correct on scene?



I assess for all lifethreats/injuries. Not just the ones I can correct onscene. 
Question for you; What CAN a 12 lead show us on a trauma pt? especially with chest injury?



> I have to agree with TomB on this one. I don't see a need for either patient to be cardiac monitored. If both patients have normotensive vital signs to include pulse rate, and you palpate a regular pulse I think its VERY safe to say they are both in NSR.



Wow, rhythm identification from a radial pulse. Impressive.
I prefer a thorough assessment.

No offence TomB, you know I truly appreciate your knowledgebase and your effort to share that info when it comes to ECG's.




> If anything the reason I would apply the monitor to the second pt. would be to check for possible cause to the unresponsiveness, maybe a medical issue? The fact that he was unresponsive and now has a GCS of 15 doesn't really add up to me after a trauma event.



THAT is the only reason?



> I don't practiced based on the fact of I do something because I can. *I normally do interventions based off a need*....




Ahhh... there is why we see this so different.
You practice reactive medicine.
I practice proactive medicine.


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## CANMAN (Feb 21, 2011)

Well I didn't mean to offend you, but like I said every Medic is different. I don't consider it Reactive vs. Proactive at all. I have yet to place myself in a "Reactive" situation on a call because of my lack to work someone up. Now have I worked someone up and had to react to changes sure, we all have, but never have I been lazy and had someone crump on me. I think call volume, experience, etc do have something to do with how aggressively I treat person. When I first came out of Paramedic school I wanted to work-up every single patient. Like I said before you CAN MAKE anything ALS and in a system where ALS resources are limited. I as a medic with plenty of experience both in and out of hospital have to make a medical decision on who really needs my services and what I should send BLS. If you are in a system that runs 20 calls a month its very easy to say sure we will work everyone up, but 20 calls a shift you have to know when to appropriately utilize ALS interventions. 

I never said that I could identify the rhythm based off a radial pulse, what I said was with normal VS (HR 60-100) and a regular radial pulse I would feel pretty confident they are in NSR. Not 100% but it's most likely a good bet. This would also R/O Tachyarrhythmias which is something I would be initally concerned with. Utilizing a 12 lead I would be looking for conduction disturbances or a possible CA occlusion following the blunt chest trauma. Aside from that Angiography- Blunt Aortic Injury, Thoracic Ultrasound- Pericardial effusion, tamponade, hemothorax, etc all to be done BASED ON assessment findings at the hospital. If you think that everyone that c/o chest pain after a MVC gets or should get an Angiogram then I just don't agree.

I am just saying that every medic will treat various situations differently. While I may opted to not put a 20 y.o. male who c/o productive cough x 1 week and now has chest pain on the monitor you may, and god bless ya for it.


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## medicdan (Feb 21, 2011)

Would you start a line on either of the patients? Are there any here that would BLS at least the first patient in to the hospital, aside from the cardiac monitoring? Do you consider that enough justification to bring the call to ALS1 billing? In some situations, that could be considered medicare fraud, no?


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## medicdan (Feb 21, 2011)

also think about whether or if either of these patients are going to be on a cardiac monitor at the ED. Different hospitals take different perspectives on this...


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## 8jimi8 (Feb 22, 2011)

I don't see how anyone is calling 2 pediatric mvcs bls.  

Also, why is everyone got such a boner for the GCS?

What does that tell you besides awake moving extremities and following commands?


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## rhan101277 (Feb 22, 2011)

To clarify these are adult pedestrians.

Both are normotensive, IV's are started and TKO'd.

No major trauma on either individual but both require the paramedic to ride the call due to MOI.

Our system is 1 EMT, 1 Paramedic per unit.  Some are 2 EMT but don't respond to 911.


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## TomB (Feb 22, 2011)

Linuss said:


> Why WOULDN'T you have an EKG on the bike rider who was initially unresponsive?



Why wouldn't you apply bilateral traction splints?


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## 8jimi8 (Feb 22, 2011)

TomB said:


> Why wouldn't you apply bilateral traction splints?



Tom with all due respect what is your rationale at ruling out cardiac monitoring on a patient involved in a major trauma?  We aren't talking about 15 and R 12 leads here. talking about simple 3-5 lead monitor.


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## Bieber (Feb 22, 2011)

First call, BLS; no monitor, no IV.  Just package and take to the hospital.

Second call, ALS; 3-lead (12-lead as well if age or complaints are suggestive of possible cardiac issues prior to or following the incident) and IV.

EDIT: Actually, realistically speaking, if I was less than five minutes away from the hospital, this stuff PROBABLY wouldn't get done.  Maybe the monitor, probably not the IV.  Ideally, it should, but when you're that close it would be pushing it.


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## medicdan (Feb 22, 2011)

Heck, if I get an MVC in the area I work, we'll spend more time waiting on triage than in transport. Perhaps we should attach the monitor then.
Kidding.


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## Dominion (Feb 22, 2011)

In my system:

Patient 1 would go BLS probably unless there was a medic on the truck. 

Patient 2 would be medic with lock, monitor and standard assessment.  I would also activate the trauma team.


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## johnrsemt (Feb 22, 2011)

What is wrong with continuing your patient workup while waiting in Triage?  If you have a short transport and have 15 min (or longer) wait at ED for a bed, continue to work up patient and check out patient. 
   We had a medic crew that had a 20 minute wait for a bed;  patient was talking to Nurse at Triage and was dead when he was put on the bed.  crew didn't notice that patient died.   Oops


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## boingo (Feb 22, 2011)

I wouldn't work up the first pt, I would the second.  I tend to place the monitor on ALS trauma patients, I find VS changes can be picked up upon quicker if I have a visual display of HR.  Plenty of my peers do not routinely do this, to each his/her own. 

I do have an interesting EKG taken on a pt w a GSW to the L chest that shows 5 mm ST elevation in II and III, pretty good evidence of cardiac injury, no?


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## CANMAN (Feb 22, 2011)

8jimi8 said:


> Tom with all due respect what is your rationale at ruling out cardiac monitoring on a patient involved in a major trauma?  We aren't talking about 15 and R 12 leads here. talking about simple 3-5 lead monitor.




This is my point, you guys aren't interested in doing a 12 lead to assess for the previous injuries I stated in my post. I would like someone to state their case as far as exactly what they are looking for when applying the monitor to these said patients......What is a 4 lead going to show you on both of these patients that a good set of vitals and a radial pulse check cannot???

Also I don't think anyone has a BONER for the GCS scale, it is just the most widely utilized and understood neuro assessment tool that I know of. GCS is one of the most important findings on a baseline trauma line consult most decent trauma center's are concerned about. I guess places like Johns Hopkins and Shock Trauma in Baltimore are doing it all wrong??? If you think GCS only tells you the pt. is alert, can follow commands, etc then you need to brush up on it. A pt. is a uncal herniation's GCS is going to obviously be vastly different then a pt. with a simple altered LOC, and a correct GCS scale number paints a pretty good picture along with other verbal assessment findings to both trauma and neuro docs....


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## reaper (Feb 22, 2011)

Actually our trauma docs want a trauma score, which is a combo of GCS and vitals. GCS alone cannot properly provide that. 

I can have an AMS diabetic with a GCS of 3. I can have an unresponsive trauma pt with a GCS of 3.  I can have a body that has been dead for a year, with a GCS of 3. This is where they are finding the flaws and moving away from GCS for neuro alone.


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## sir.shocksalot (Feb 22, 2011)

Dominion said:


> In my system:
> 
> Patient 1 would go BLS probably unless there was a medic on the truck.
> 
> Patient 2 would be medic with lock, monitor and standard assessment.  I would also activate the trauma team.



So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.

I would not place either pt on the monitor. Unless there was some hx from the pt that there was a cardiac event prior to the crash I don't see monitoring as necessary. I also am rather surprised that some of you would monitor a rhythm before starting an IV on a trauma pt. Also why isnt anyone suspecting a concussion as the cause of his unconsciousness PTA.

Also its worth noting that the 3-lead tells you nothing other than rhythm, and as others have said unless there is some cardiac hx chances are it's NSR. If you are going to work up any pt as cardiac than a 12-lead has to be done.

Every pt is different and I really detest blanket treatments of IV, O2, monitor. Pt's rarely fit the molds of protocols.


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## 8jimi8 (Feb 22, 2011)

CANMAN13 said:


> This is my point, you guys aren't interested in doing a 12 lead to assess for the previous injuries I stated in my post. I would like someone to state their case as far as exactly what they are looking for when applying the monitor to these said patients......What is a 4 lead going to show you on both of these patients that a good set of vitals and a radial pulse check cannot???
> 
> Also I don't think anyone has a BONER for the GCS scale, it is just the most widely utilized and understood neuro assessment tool that I know of. GCS is one of the most important findings on a baseline trauma line consult most decent trauma center's are concerned about. I guess places like Johns Hopkins and Shock Trauma in Baltimore are doing it all wrong??? If you think GCS only tells you the pt. is alert, can follow commands, etc then you need to brush up on it. A pt. is a uncal herniation's GCS is going to obviously be vastly different then a pt. with a simple altered LOC, and a correct GCS scale number paints a pretty good picture along with other verbal assessment findings to both trauma and neuro docs....



Do you fly with your hand on their radial or carotid pulse?  You may actually SEE a heart rate trend.  Sure a pulse oximeter will give you a visual on the heart beat, but I feel more comfortable seeing a rhythm strip than something that could have a variable waveform.  

What was that old example of the dead guy getting >8 on a GSC? i can't remember the exact score.. but the guy was DEAD.

I work in a trauma center and we don't use GCS except as the most minute of fleeting assessments.


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## usalsfyre (Feb 22, 2011)

GCS is considered a rather blunt tool by many people for neuro assessment. As for well understood, give a patient with anything lower than a 14 to five different providers and see how many scores you get.


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## usalsfyre (Feb 22, 2011)

First patient, a GOOD physical exam prior to transport. Assuming negative, BLS

Second patient, full workup including monitor, not delaying transport to do so. Activate trauma team if physical exam results warrant it.

Like 8jimi8 I want to be able to trend things real time, not every 5 or so minutes when I take a pulse.


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## 8jimi8 (Feb 22, 2011)

Thanks US, i was beginning to feel ignorant and stitious (not superstitious, just a little stitious)


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## usalsfyre (Feb 22, 2011)

sir.shocksalot said:


> So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.



Heretic! The Church of R Adams Cowley sentences you to 15 trauma activations and 5 air medical transports based in MOI as penace.



sir.shocksalot said:


> I would not place either pt on the monitor. Unless there was some hx from the pt that there was a cardiac event prior to the crash I don't see monitoring as necessary. I also am rather surprised that some of you would monitor a rhythm before starting an IV on a trauma pt. Also why isnt anyone suspecting a concussion as the cause of his unconsciousness PTA.



Concussion is my #1 differential. Epidural hematoma via a temporal artery injury is #2. If your not familiar with epidural hematoma, it's a bad mofo that often disguises itself as a concussion if your not doing good assessments.

I've monitored lots of patients and not initiated access. It's about watching what's going on more closely



sir.shocksalot said:


> Also its worth noting that the 3-lead tells you nothing other than rhythm, and as others have said unless there is some cardiac hx chances are it's NSR. If you are going to work up any pt as cardiac than a 12-lead has to be done.



Cardiac contusion often presents with dysrhythmia in addition to other signs of poor perfusion. Probably a useful assessment tool, right?  In addition I can trend a HR better off a strip than anything else.



sir.shocksalot said:


> Every pt is different and I really detest blanket treatments of IV, O2, monitor. Pt's rarely fit the molds of protocols.



I understand the blanket treatment hate. But you seem to go so far to the extreme the OTHER direction as to almost seem lazy. This stuff is useful. A monitor is a useful ongoing assessment tool and it's very hard to do much of anything (like pain management) besides transport without access. Agree with you about the O2 though. Unless they're hypoxicly hypoxic, O2s pretty pointless.


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## rhan101277 (Feb 22, 2011)

Every person that shows up in the ER doesn't get a 4 lead.

I think it is good not to throw the book at everybody.

If you have a simple slip/trip, no weakness before hand, no diabetes hx, no LOC.  Are you going to put them on cardiac monitor?  A glucose check would be considered just being extra cautious.  A cardiac monitor would not be warranted and it costs the pt when you do un-necessary procedures.

If it is needed by all means then do so.  If you do it anyhow I think it is cookbook medicine.


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## 8jimi8 (Feb 22, 2011)

In the hospital we have the benefit of being able to have a patient on the monitor without charging them for it.   Maybe its included in the room charge.

I have the benefit of caring for patients and not even knowing if they are funded or unfunded.  I do everything i deem necessary for the standard of care and If I think something needs to be done I call the physician and ask them for the order.   I rarely get turned down and often get exactly what I want.

In my world and ecg strip is a vital sign.  And no one has given any rationale as to why a VEHICLE vs PED (sorry i originally read it as pediatric) is not put on the monitor.  USALS gave several key pathologies that could result from such an event.


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## Bieber (Feb 22, 2011)

sir.shocksalot said:


> So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.


Mine does.  And there's no clause for paramedic discretion--in order to downgrade or upgrade, we have to call the hospital.  I don't like it either, but I'm not really in a position to change things.



> Every pt is different and I really detest blanket treatments of IV, O2, monitor. Pt's rarely fit the molds of protocols.


I completely agree.


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## rhan101277 (Feb 22, 2011)

A bad epidural hematoma should cause unequal pupils and if bad enough cushings triad should be starting to show.


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## 8jimi8 (Feb 22, 2011)

rhan101277 said:


> A bad epidural hematoma should cause unequal pupils and if bad enough cushings triad should be starting to show.



cushings triad is a late sign.


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## usalsfyre (Feb 22, 2011)

Epidural hematoma sometimes (around 20% of cases) presents with an initial brief loss of consciousness immediately post-injury (i.e. right after he got mowed over on the bike), followed by a lucid period which then deteriorates into unconsciousness later. If it deteriorates into unconsciousness mortality is appx 20%. More than one provider has been too complacent in assessment and chalked this injury to concussion.

Loss of consciousness should give any provider a very high index of suspicion for serious head injury.


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## reaper (Feb 22, 2011)

Also need to remember that there are different grade concussions.
Epidurals do not always present with unequal pupils and cushings is a very late sign.

Do your assessment, Look at ALL the vitals, treat as needed!


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## sir.shocksalot (Feb 23, 2011)

Bieber said:


> I don't like it either, but I'm not really in a position to change things.


I hear you, I know I have other equally annoying protocols. I swear every time I have to get out of the rig so we can back up 2 feet makes me want to throw things 

Usalfyre, I hope you weren't assuming I wasn't thinking of those things, I was just throwing out an example . Kinda like the the when you hear hooves think of horses, not centaurs. In these trauma pts unconsciousness is far more likely to be from a head impact than some weird cardiac rhythm.

Also I completely agree about considering head bleed stuff, or even cardiac contusion stuff, if there is some indication based on MOI that such injuries may exist. A cyclist flung over a car hood probably won't have much blunt chest trauma depending on how they hit. Where as a dude that hit the steering wheel might have some pulmonary or cardiac contusions.

I think a lot of people have forgotten the transport time. 5 minutes really isn't a tremendous amount of time, but in 5 minutes with a trauma pt I have other things to do than place them on the monitor to confirm that its NSR. Assume that you start a line and do a secondary assessment before you reach for the monitor, you would realistically only have, like, 3 minutes of strip. That doesn't seem like much time to really have a decent trend in HR. Heck even 5 minutes isn't much.

It's not about being lazy, it's about time management. I'm guessing you come from a system that has fairly long transports? I work in a system where transport times can be as low as 30 seconds to drive across the street. I have to walk into the ER with the same assessment and the same critical interventions (such as a line, meds, tube, you name it) but all of it must be done in less than 5 minutes. I'm not saying one is better (I think long transports require smarter medics), it's just that sometimes I have to skip doing certain secondary things (like a monitor) to get a good assessment done and make sure I'm not missing any occult life threats.


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## usalsfyre (Feb 23, 2011)

sir.shocksalot said:


> I hear you, I know I have other equally annoying protocols. I swear every time I have to get out of the rig so we can back up 2 feet makes me want to throw things
> 
> Usalfyre, I hope you weren't assuming I wasn't thinking of those things, I was just throwing out an example . Kinda like the the when you hear hooves think of horses, not centaurs. In these trauma pts unconsciousness is far more likely to be from a head impact than some weird cardiac rhythm.
> 
> ...



I see what your saying, I think it's a semantics difference. I consider the cardiac monitor less of an intervention and more of an assessment tool, one that helps me in making the correct transport decision (local ED in town that's 30sec-5 minutes away, or trauma/stroke/STEMI centers 25-30 minutes away in the "big city"). As such it gets applied pretty quickly. Usually before lines, ect. All of this is stuff that I pretty well consider can wait till the ED if I'm going around the corner, the nurses may not like it, but they'll live. 

If I'm doing airway management I'm usually planning on adding between 5 and 10 minutes to a scene time, and you won't see me tube with out monitoring devices applied. It's just to high-risk to wing it. 

I'm good with the horses, I LIKE horses, as zebras and centaurs have an annoying habit of biting you in the :censored: . In my personal practice I just put a lot more stock in good assessment than intervention.


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## TomB (Feb 23, 2011)

8jimi8 said:


> Tom with all due respect what is your rationale at ruling out cardiac monitoring on a patient involved in a major trauma?  We aren't talking about 15 and R 12 leads here. talking about simple 3-5 lead monitor.



With all due respect, what is your rationale at ruling out bilateral traction splinting?


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## 8jimi8 (Feb 23, 2011)

TomB said:


> With all due respect, what is your rationale at ruling out bilateral traction splinting?




Wow, Tom unwilling to teach this morning.  No biggie, just a surprise.


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## vquintessence (Feb 23, 2011)

Eh, you more or less got an answer.  You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma.  It's akin to the teacher provoking a thought so the student can answer their own question.


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## 8jimi8 (Feb 23, 2011)

vquintessence said:


> Eh, you more or less got an answer.  You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma.  It's akin to the teacher provoking a thought so the student can answer their own question.





The question being that we've already discussed pathologies that monitoring would readily identify, post vehicle vs ped.

It isn't like arrhythmias are a consistent and contiguous injury like a femur fracture would be.

You don't go in and out of femur fracture.  You don't have a "normal sinus femur fracture" that suddenly becomes "bradycardic femur fracture" or "superventricular femur fracture."  Your femur fracture doesn't really change from a greenstick fracture to a comminuted fracture.  

Say your patient goes into SVT after you check their pulse, which was previously normal.  Is it possible that because the patient doesn't present in a decompensated state that you may do a q15 minute vital recheck versus a q 5 minute vital check?  What if the patient threw a PE from their bilateral femur fractures?  Would they warrant a monitor IF they had bilateral femur fractures?  Wouldn't you want them on the monitor so that you might notice the tachycardic trends as they bleed out 8 liters into BLE?  

Just sayin.  I can assess pretty physically well for a fracture, ruling out bilateral traction splints.

A radial pulse does not tell me what your rhythm is.

Hey maybe i'm gonna be a cookbook medic...  But it seems like the standard of care to me.  Are you a standard of care (general you)  medic or are you a MINIMUM standard of care medic?  I know they test at NREMT to the MINIMUM...


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## Dominion (Feb 23, 2011)

sir.shocksalot said:


> So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.
> 
> I would not place either pt on the monitor. Unless there was some hx from the pt that there was a cardiac event prior to the crash I don't see monitoring as necessary. I also am rather surprised that some of you would monitor a rhythm before starting an IV on a trauma pt. Also why isnt anyone suspecting a concussion as the cause of his unconsciousness PTA.
> 
> ...



Yea my system activates trauma team on MOI alone.  This is how it goes in my system, you bring a trauma patient in, you've already activated the trauma team based on MOI and loc prior to your arrival.  You roll into trauma room and the residents with the attendants overlooking will do a quick assessment and decide if the patient needs to be seen or if they can be seen in triage. 

Now if I DON'T activate the system myself, when I roll in and tell the nurse there that he was biking, struck by a car at approx 25mph, loc prior to arrival, now alert and orients.  She will go ahead and activate the trauma team and we go through the above process.  

It's not perfect, but we work with it.



Bieber said:


> Mine does.  And there's no clause for paramedic discretion--in order to downgrade or upgrade, we have to call the hospital.  I don't like it either, but I'm not really in a position to change things.



We have discretion to activate or not, it just gets reversed sometimes the second we get to the hospital.  In addition we do get a chance to NOT go if we call ahead.  Generally if I had patient two I would make the call something like "We have a <x> year old male, riding a bike, struck by a car, thrown <x> feet, positive loc prior to our arrival, currently conscious, alert, and oriented.  Vitals stable......" at that point if you think he really needs the trauma room I just say "I'll see you in the trauma room in x minutes" if I don't think he needs it and I want to forgo it before I arrive I'll say something like "do you want to see this patient in trauma room or am I ok for triage?".  

Sorry if that explanation doesn't make sense ;P.


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## usalsfyre (Feb 23, 2011)

vquintessence said:


> Eh, you more or less got an answer.  You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma.  It's akin to the teacher provoking a thought so the student can answer their own question.



Why do so many think of cardiac monitoring as an intervention (which it's not) instead of an assessment? Maybe because that's the way EMS bills it?

What your advocating is not only not applying bilateral traction splints, but not even looking at the legs.


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## Shishkabob (Feb 23, 2011)

vquintessence said:


> Eh, you more or less got an answer.  You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma.  It's akin to the teacher provoking a thought so the student can answer their own question.



Femurs are their own "system".  If you break your finger, that doesn't mean your legs will be hurt.


However, the cardiovascular system is not independent.  If you're involved in trauma, there's a VERY good chance your heart is doing something.


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## Dominion (Feb 23, 2011)

Linuss said:


> Femurs are their own "system".  If you break your finger, that doesn't mean your legs will be hurt.
> 
> 
> However, the cardiovascular system is not independent.  If you're involved in trauma, there's a VERY good chance your heart is doing something.



This is part of my ALS assessment for any trauma I go on.  That's part of the tiered system I'm in.  Our BLS crews are very good and we have very liberal BLS protocols.  I tend to get canceled on many different calls, so when I do go a cardiac monitor is just ONE assessment I do.  I may not keep them on it, I may take it off when we arrive at the ER, but it is part of what I do while I"m with that patient.  We also typically have longer transport times (10-20+ minutes) depending on where we're coming from.


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## 8jimi8 (Feb 23, 2011)

Dominion said:


> This is part of my ALS assessment for any trauma I go on.  That's part of the tiered system I'm in.  Our BLS crews are very good and we have very liberal BLS protocols.  I tend to get canceled on many different calls, so when I do go a cardiac monitor is just ONE assessment I do.  I may not keep them on it, I may take it off when we arrive at the ER, but it is part of what I do while I"m with that patient.  We also typically have longer transport times (10-20+ minutes) depending on where we're coming from.




Exactly, its a tool, just like a sphygmomanometer.


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## Shishkabob (Feb 23, 2011)

8jimi8 said:


> Exactly, its a tool, just like a sphygmomanometer.



Us uneducated EMS folk say "Bloodpressure cuff"


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## Dominion (Feb 23, 2011)

Linuss said:


> Us uneducated EMS folk say "Bloodpressure cuff"



I usually just say that squeezy thing attached to the monitor.  h34r:


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## jjesusfreak01 (Feb 23, 2011)

Linuss said:


> Us uneducated EMS folk say "Bloodpressure cuff"



Just make it bloodpressurecuff. Now you know German.


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## Shishkabob (Feb 23, 2011)

jjesusfreak01 said:


> Just make it bloodpressurecuff. Now you know German.



I ALREADY know German.


Was machst du in deiner freizheit?  Das ist duff.


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## JPINFV (Feb 23, 2011)

jjesusfreak01 said:


> Just make it bloodpressurecuff. Now you know German.



Just before the final exam in my EMT class, being the smart donkey I am I asked if a sphygmomanometer was going to be on the final and about half the class turned white.


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## MasterIntubator (Feb 24, 2011)

Linuss said:


> I ALREADY know German.
> 
> 
> Was machst du in deiner freizheit?  Das ist duff.



Es ist eigentlich "Freizeit". Haben sie auch dumm, anstelle von duff?


We have protocols stating that an ECG will be done if any ALS proceedure is being done.  Does it always get done?  Nope.  Good sound judgement should help guide ya.


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## 8jimi8 (Feb 24, 2011)

MasterIntubator said:


> Es ist eigentlich "Freizeit". Haben sie auch dumm, anstelle von duff?
> 
> 
> We have protocols stating that an ECG will be done if any ALS proceedure is being done.  Does it always get done?  Nope.  Good sound judgement should help guide ya.



And would you monitor either of these patients?


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## Shishkabob (Feb 24, 2011)

MasterIntubator said:


> Es ist eigentlich "Freizeit". Haben sie auch dumm, anstelle von duff?



Meh, kann ich nicht buchstabieren. Duff ist was wir in den Jahren meines Deutsch unterrichtet. Es hat vier Jahren auch.

My syntax will always be a bit off 



Really, no reason to NOT have a strip on these people.  Takes what, 15 seconds to put on the electrodes?  If you need a line THAT badly, just do an IO.


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## 18G (Feb 24, 2011)

Honestly, with a 5min ETA why **** around ne longer then you really have to? Just load and go. Load and go will be the most important intervention you will give either of these patients in the absence of life-threatening, need corrected right now problems.

I had an MVC patient the other day that was literally 2mins from the hospital on the same street. He had a cardiac hx and was having anxiety and chest discomfort suspected to be from seatbelt. He got a cardiac monitor and 12-lead and right as the 12-lead was done we were backing in. I wasn't gonna spend extra time onscene asking 20 million questions, starting an IV, etc. when I could have this patient in the ED where he really needed to be. 

Point being... regardless of ETA it takes very little time to throw electrodes on. But at the same time with a young patient, no PMH, and <5min ETA, the monitor really isnt a big deal in my opinion. 

And if the radial pulse check correlates with the rate display on the pulse ox and patient is perfusing well, then I would trust the pulse ox in a stable patient for the short amount of time as described. 

Everyone has their own thought and decision making process. The common thing to do is O2, IV, monitor, vitals... hmmm... really? We all know what the research says about everyone getting O2 so we can take that out. Does everyone really need an IV? Really? The same can be said about the monitor. Yes, its good to have it on for trauma patients to monitor rate and for ectopy but I certainly would not hammer someone for not applying it if they were busy doing an assessment or tending to actual patient injuries with a less than 5min ETA.


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## usalsfyre (Feb 24, 2011)

18G said:


> Honestly, with a 5min ETA why **** around ne longer then you really have to? Just load and go. Load and go will be the most important intervention you will give either of these patients in the absence of life-threatening, need corrected right now problems.
> 
> I had an MVC patient the other day that was literally 2mins from the hospital on the same street. He had a cardiac hx and was having anxiety and chest discomfort suspected to be from seatbelt. He got a cardiac monitor and 12-lead and right as the 12-lead was done we were backing in. I wasn't gonna spend extra time onscene asking 20 million questions, starting an IV, etc. when I could have this patient in the ED where he really needed to be.
> 
> ...



5 minutes to a Level 1 center with cardiac capabilities is one thing. 5 minutes to a community ED that is not able to handle an emergent patient is another. In this case it makes a lot more sense to spend a few extra minutes on scene to ensure you make the correct transport decision than doom the patient to an hour plus hour wait and possible death in the wrong ED


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## MasterIntubator (Feb 24, 2011)

8jimi8 said:


> And would you monitor either of these patients?



Yes.  #1 is stable, I would have time to complete a good assessment and get ahead of the ball ( if needed )

#2 - based on presenting info, is also stable, so I would have time to complete a good assessment.  Being whacked at 25mph can be quite significant, and with the syncope... gonna look at that closer.


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## cruiseforever (Feb 25, 2011)

rhan101277 said:


> I wanted to get some feedback on how many folks decide to for go cardiac monitoring.  In the following two scenarios you are less than 5 minutes from the ER.
> 
> This is limited to these two specific scenarios only.
> 
> ...


With a short transport time.  I make sure the ER is notified first and then do what I can get done.  Monitor is pretty low on my list with a good pulse and AxOx3.


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## Mex EMT-I (Mar 1, 2011)

I just love to read this posts because here in my town we don´t even have ALS ambulances. 1 in 10 ambulances has a cardiac monitor.

With that said.

None of this patients need cardiac monitoring. The ETA is absurd. The correct thing to do is finish up with the BLS stuff, like a full assesment, set of vitals, focused exam, etc. And then if there is time think ALS.


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## usalsfyre (Mar 1, 2011)

Mex EMT-I said:


> I just love to read this posts because here in my town we don´t even have ALS ambulances. 1 in 10 ambulances has a cardiac monitor.
> 
> With that said.
> 
> None of this patients need cardiac monitoring. The ETA is absurd. The correct thing to do is finish up with the BLS stuff, like a full assesment, set of vitals, focused exam, etc. And then if there is time think ALS.



I'm amazed by the number of people who want to scoop and run doing assessment enroute without knowing anything about the ED. That's fine if your hospital is an academic level I I guess. My local ED is a level IV with a small blood blank, surgery and anesthesia not immediately available, no cardiology or neuro services, and no provision to care for the the critically ill post-surgical patient. I've bypassed to a different facility when I was literally 30 seconds away for these reasons. My patients get a thorough assessment prior to transport (including "ALS"'stuff like cardiac monitors and EtCO2) so I can make the appropriate transport decision. Outside of securing an airway, everything else is done enroute.

Or do your systems not allow you to bypass and refer the patient to an appropriate facility? If this is the case I can maybe see the scoop and run plan. But practicing this way is EMS circa 1985...


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## vquintessence (Mar 2, 2011)

usalsfyre said:


> ... Or do your systems not allow you to bypass and refer the patient to an appropriate facility? If this is the case I can maybe see the scoop and run plan. But practicing this way is EMS circa 1985...


This is the case in MA, and making a reasonable assumption is similar w/ other states.  BLS is allowed to deviate up to 10 minutes to a "further hospital" if pt meets a checklist stable criteria; ALS is allowed 20 minutes w/ similar criteria.  Of course there are trauma & STEMI point of entry protocols that trump all.

The state even permits services to put into a charter (or by-law?) for "mandatory" hospital designations for EVERY pt.  Many Fire Depts and 3rd Services implement these.  I assume privates do not because it leaves more happy customers (and more mileage means more money)?


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## Mobey (Mar 2, 2011)

Mex EMT-I said:


> I just love to read this posts because here in my
> None of this patients need cardiac monitoring. The ETA is absurd.



You're right, they don't NEED cardiac monitoring.
Nor do they NEED vitals taken.
Really, they dont NEED an ambulance.

I do not make it a habit to only treat/assess people with what they NEED.
Otherwise my narc pouch would never open.... I mean really, no one dies from pain, so no one really NEEDS pain control.


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## AndyK (Mar 2, 2011)

Dominion said:


> I usually just say that squeezy thing attached to the monitor.  h34r:



Aye, that's the wotsit.. right next to the fingery thing and the machine that goes bleep


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## Mex EMT-I (Mar 2, 2011)

I stand in my position.

The don´t need it.

When you have very limited resources one of the first things you learn is not to waste those resources just because you can do something.

I really like what TomB says about the traction splints.


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## Mobey (Mar 2, 2011)

Mex EMT-I said:


> I stand in my position.
> 
> The don´t need it.
> 
> When you have very limited resources one of the first things you learn is not to waste those resources just because you can do something.



No where in this scenario did it say anything about limited resources. So again, your theory fails.


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## usalsfyre (Mar 2, 2011)

Mex EMT-I said:


> I stand in my position.
> 
> The don´t need it.
> 
> ...



I guess I've been lucky. I've worked in and around some pretty flat broke systems, but the cost of three electrodes for an assessment tool has never been a concern (it's not an intervention, the traction splint analogy doesn't apply).

I guarantee patient #2 will be on a cardiac monitor in the ED with a loss of consciousness.


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## Mex EMT-I (Mar 2, 2011)

You are right nobody said that you had limited resources in that senario.

Still. They don´t need.


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