# Anterior Ischemia or Syncope?



## GoldcrossEMTbasic (Mar 15, 2014)

I had a 49 year old female patient who had a syncopal episode at my church, This patient has a HX of elevated lipids and COPD and is on a NC @ 2 Liters per minute on home oxygen. Pt is slightly obese. Pt was just recently put on cholesterol medications. During the service the PT collapsed to the floor and 911 was called and PT was put on 10 LPM Via NRB Mask otherwise all of the measures for a possible cardiac arrest was implemented. On scene I had a cardiologist. Stated that her pulse was next to nothing when the syncope occurred. The Cardiologist wanted a 12 lead done on the pt. However all of the vitals were unremarkable. Pt stated that her O2 sats always ran in the mid 80s, PT states that she recently quit smoking and she states that she started smoking at the age of FIVE! But the ECG tracing showed a Anterior Ischemia on the strip. Normal sinus rhythm.  in the 80s and 70s BP was 120/85. And  the PT refused to go to hospital. Unfortunately Me and the cardiologist tried to talk to her and convince her that she needed to go to the hospital and get checked out. I was concerned of the 12 lead of what it showed and the cardiologist and I both agreed. And he stated that she may have had an MI or possibly started to go into V-fib. But after the incident she was alert and oriented X3. Can anybody tell me if this was an actual heart attack that she was starting to have or just a syncopal episode? Because this PT has a HX of Hypertension and Takes an extensive amounts of medications, PT is not a Diabetic no AKA. Otherwise HX of respiratory and abnormal elevated lipid profile. :unsure:


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## Brandon O (Mar 15, 2014)

How long was she out? Were there preceding symptoms (lightheadedness, palpitations, aura)? Had she just stood up? Does she have a history of syncope? What do you mean by "anterior ischemia" -- ST depression in anterior leads? What was her sat on scene? Did she have any persistent symptoms? Was this an ALS call or not? What's the administrative capital of Bolivia?


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## GoldcrossEMTbasic (Mar 15, 2014)

She was out for a few seconds, Just lightheadedness and dizziness. We sat her up and did orthostatic BP on her as well that was WNL. Sats were in mid 80s, 12 lead showed normal sinus rhythm but the strip showed a anterior ischemia, I was not sure if ST or VT were depressed or not all I saw was abnormal anterior Ischemia.


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## VFlutter (Mar 15, 2014)

Eh tell her to make an appointment with a Cardiologists and have an Echo and stress test as an outpatient. If she doesn't want to go that is her choice. "Anterior Ischemia" is a vague EKG term. It may not be acute or even accurate.


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## mycrofft (Mar 15, 2014)

Given that data and the description of her reactions and actions, I'd say that there's no way of knowing what happened without seeing and examining the patient.

Which is sort of the basic deal with medical care.

".otherwise all of the measures for a possible cardiac arrest was implemented".

They was? Such as…CPR? AED?

No way to know how recent or important the anterior issue was without labs, especially since her EKG was otherwise essentially normal and she resumed normalcy fairly soon…which people with heat attacks that knock them down rarely do. (About 70% of sudden onset MI's present with clinical death. Just saying..).

With a chronically low pulse-ox reading (question question), could she have fallen out due to positional asphyxia (is she obese?), or gone vaso-vagal (did she stand up suddenly up to a minute before the episode?)? 

Maybe this is better in the ALS section.


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## teedubbyaw (Mar 16, 2014)

Chase said:


> Eh tell her to make an appointment with a Cardiologists and have an Echo and stress test as an outpatient. If she doesn't want to go that is her choice. "Anterior Ischemia" is a vague EKG term. It may not be acute or even accurate.




Good ol'e anterior ischemia. :dunno:


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## GoldcrossEMTbasic (Mar 16, 2014)

Following up on your response, Yes the PT is obese about 280-320lbs. estimated. PT has Hypercholesterolemia as well just put on medication a week ago. With this type of medical HX Anterior Ischemia is still a possibility. ECGs sometimes are inaccurate, But her pulse dropped to Zero after the syncope occurred, but a few seconds later she regained a pulse. Then was transported routine to the ETC. While enroute all vitals were WNL Monitor showed a sinus 80 BPM. o2 Sats were in mid 80s.


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## NomadicMedic (Mar 16, 2014)

ODHG. Overdose of the Holy Ghost.


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## GoldcrossEMTbasic (Mar 16, 2014)

This what the cardiologist told me when I approached the PT. I have a Scanner APP on my phone. That's how I heard the report to Medical Control. But I agree with you, I think that the cardiologist may have jumped the gun. Because the patient was alert and did not show any chest pain or diaphoresis.


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## STXmedic (Mar 16, 2014)

Wow....


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## NomadicMedic (Mar 16, 2014)

Okay. Let's keep the snark dialed down. This can be a teaching point instead of a "berate the new guy" post.

Remember the first rule is "be nice". I've removed a "not so nice" post already.


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## teedubbyaw (Mar 16, 2014)

GoldcrossEMTbasic said:


> This what the cardiologist told me when I approached the PT. I have a Scanner APP on my phone. That's how I heard the report to Medical Control. But I agree with you, I think that the cardiologist may have jumped the gun. Because the patient was alert and did not show any chest pain or diaphoresis.




In other words, you have no training in cardiology and what you say you saw is actually what you were told? 

You're throwing us for a loop here.


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## Medic Tim (Mar 16, 2014)

you mentioned she refused then that she was transported???


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## Handsome Robb (Mar 16, 2014)

I'm guessing an ALS crew showed up and did a 12-lead and the printout said "anterior ischemia".


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## GoldcrossEMTbasic (Mar 16, 2014)

Yes the 12 lead did show that. They did it in a private area on scene, not on the rig. The off duty cardiologist ordered the 12 lead. One side of the strip printed normal sinus and then I saw the Anterior Ischemia. Printed on the other side. Used on a Phillips Lifepak.


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## GoldcrossEMTbasic (Mar 16, 2014)

Yes, she was refusing, The medics were wanting to leave, this agency had a really busy day. But It took the pastor and the doctor to get her checked out. Not the ALS crew.


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## Handsome Robb (Mar 16, 2014)

Alright bud. This all makes a lot more sense now.

First off Philips makes the MRx and PhysioControl makes the LifePak. 

If I show up on a 911 call and there's a physician on scene they don't order anything. It's my scene unless they want to do everything include riding in to the hospital and writing the report.

There's a reason good medics tear off the machine's interpretation and throw it away or fold it over and ignore it. 

We read it ourselves, the machine isn't reliable.

This is one of those cases where you're pretty far over your head bud. We're not gonna be able to tell you more without more information that you're not going to be able to provide.

This isn't an attack on you but a big part of medicine is recognizing when you do need help and don't know something then asking for it. Which it sounds like you did.


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## Medic Tim (Mar 16, 2014)

It is bad practice to use the printout ... Especially if you are ALS. They are usually wrong and give numerous false positives.

So the pt was transported. I think that is what you are saying.... It is difficult to understand some of your posts.

The crew would have ( school have ) done a 12 lead on their own. Where I am it makes no difference who or what the doctor is (unless it is the pts actual doctor) they are a bystander and should not effect my care. Not saying I am going to tell the guy to eff off but in this situation he was really not needed.


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## Ewok Jerky (Mar 16, 2014)

GoldcrossEMTbasic said:


> Yes the 12 lead did show that. They did it in a private area on scene, not on the rig. The off duty cardiologist ordered the 12 lead. One side of the strip printed normal sinus and then I saw the Anterior Ischemia. Printed on the other side. Used on a Phillips Lifepak.



#1- "anterior ischemia" is a general term and does not = infarct, STEMI or NSTEMI

#2- A lifepack printout interpretation is NOT a diagnosis.  In fact it is sometimes completely WRONG.

#3- I think most of us here would agree that without more information, an H&P or HPI, or actually seeing/talking to the patient, we cannot accurately help you figure this out.

however: if a syncopal episode was her only complaint...no N/V, no CP, no SOB, diaphoresis...then acute MI is unlikely.  She could have some underlying ischemia based on any number of things, and "fell out" for any number of other things.


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## GoldcrossEMTbasic (Mar 16, 2014)

The off duty cardiologist told the patient that there is a potential heart issue going on. And he told her that she needed to have further testing done. So to  clarify something, if the monitor shows Anterior Ischemia is it a false reading or a confirmed reading? I know what a AI is. It is a lack of o2 to the front part of the heart, due to a blockage possibly atherosclerosis.


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## GoldcrossEMTbasic (Mar 16, 2014)

Thanks, Machines sometimes are not reliable.


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## Medic Tim (Mar 16, 2014)

GoldcrossEMTbasic said:


> The off duty cardiologist told the patient that there is a potential heart issue going on. And he told her that she needed to have further testing done. So to  clarify something, if the monitor shows Anterior Ischemia is it a false reading or a confirmed reading? I know what a AI is. It is a lack of o2 to the front part of the heart, due to a blockage possibly atherosclerosis.




The monitors use algorithms to interpret . They are suppose I be there to help and guide providers. The problem is they are usually wrong. If it spits out a stemi or acute mi it means nothing until I confirm it. In some systems the strip is sent to the hospital to be read. The machine doesn't diagnose. It is a tool we use in conjunction with a history and assessment to come to a diagnosis.


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## chaz90 (Mar 16, 2014)

GoldcrossEMTbasic said:


> Yes the 12 lead did show that. They did it in a private area on scene, not on the rig. The off duty cardiologist ordered the 12 lead. One side of the strip printed normal sinus and then I saw the Anterior Ischemia. Printed on the other side. Used on a Phillips Lifepak.



The point we're making is that monitor interpretations of "Anterior Ischemia" or "Abnormal EKG Unconfirmed" mean basically nothing. Monitors can be okay at determining quantitative measurements of PRI, QRS intervals, and axes, but rhythm interpretations and ischemia detections are notoriously inaccurate. This is why we still have doctors interpret rather than machines. 


Also, the bystander cardiologist didn't have to "order" a 12 lead for the responding ALS crew to do one. 




GoldcrossEMTbasic said:


> Yes, she was refusing, The medics were wanting to leave, this agency had a really busy day. But It took the pastor and the doctor to get her checked out. Not the ALS crew.



In the future, you might want to clarify that the patient initially refused and then changed her mind. This wording is slightly confusing, as patients who continue to refuse aren't transported unless there's a legal hold placed. 

I think the main point I'd like to make here that others have mentioned is that we can't have any idea what is going on. Any one of a number of things could have caused a syncopal episode, and having a non-diagnostic 12 lead with automated "anterior ischemia" interpretation does nothing to confirm or deny any of the potential differential diagnoses. Sounds like the patient eventually consented to transport and an ED evaluation, so hopefully they figured out what was going on.


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## Handsome Robb (Mar 16, 2014)

You experienced a very standard syncope call.

Like textbook syncope call...

Welcome to EMS. We do this same thing all day long. 

Don't worry about the monitor, you worry about your assessment skills and your base knowledge. The cool toys come later


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## Brandon O (Mar 16, 2014)

GoldcrossEMTbasic said:


> The off duty cardiologist told the patient that there is a potential heart issue going on. And he told her that she needed to have further testing done. So to  clarify something, if the monitor shows Anterior Ischemia is it a false reading or a confirmed reading? I know what a AI is. It is a lack of o2 to the front part of the heart, due to a blockage possibly atherosclerosis.



It's the kind of odd remark a computer would say.

Ischemia in the heart is usually described along an axis from "ischemia" (not enough oxygen, but it's not causing any damage) to "injury" (cells are damaged) to "infarction" (cells are dead). If you or I run some sprints we might get coronary ischemia. The sort of MI you learned about in school involves injury, and we try to catch it before it becomes infarction.

While "anterior ischemia" is as you describe, it's not an emergency. In fact, while some folks think you can use the ECG to localize ischemia to a specific region (like the anterior wall), you really can't, not like you can injury/infarction. Hence -> weird computer remark.

None of this means that somebody who suddenly passed out shouldn't get worked up further.


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## GoldcrossEMTbasic (Mar 16, 2014)

I agree, because all VS were within normal limits her only chief complaint was she was lightheaded and dizzy and then went to the floor. And then a few seconds later she was alert. And taking her pulse the off duty doc said, I had no pulse for a few seconds. But the PT is an obese PT. But she was breathing and respirations were 18 and her o2 sats were 85 and PT states that is normal for her since she has a HX of COPD and on a NC @ on 2 LPM on home oxygen. I think that she just had a plain syncopal episode.  Like I've said, everything was unremarkable and her skin, color and condition was WNL x3.


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## GoldcrossEMTbasic (Mar 16, 2014)

Yes, agree, and the only person to make that determination is the ER doc or the medical director, they are the ones who makes the call and tells us out in the field what to do. We attempt to treat the patients and get them to the ER STAT, and it is in the DOC's hands. EMT-B's or EMT-P's really cannot diagnose. We assess and follow orders and follow with the treatment protocols.


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## chaz90 (Mar 16, 2014)

Also, out of genuine curiosity, what do you mean by "all measures for a possible cardiac arrest were implemented"? Cardiac arrests should either exist or not exist without any "possible" modifier when medically trained personnel (notably a cardiologist) have evaluated the patient. Did someone attempt compressions, AED application or BVM ventilations? It doesn't sound like it, so I wouldn't say anything about possible cardiac arrest. 

In many cases of syncope, temporary hypotension can cause a decrease in cerebral blood flow leading to loss of consciousness and a transiently difficult to palpate carotid pulse. Just because a pulse was hard to palpate for a few moments doesn't mean the patient arrested, though we can't rule anything out.

Like Robb said, this is a pretty darn basic and straightforward syncope call from what it sounds like. As you get more involved in EMS you'll see them all the time.


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## GoldcrossEMTbasic (Mar 16, 2014)

That's what I kind of thought. Thanks Robb for the help!


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## GoldcrossEMTbasic (Mar 16, 2014)

Let' me clarify that, What happened was the a bystander ran and got the AED another bystander called 911. And then we checked for responsiveness and the PT was responsive and came too. What I meant by cardiac measures, was the bystanders did what was supposed to be done in case of a cardiac arrest. AED and EMS activated. I hope that clarifies what I have stated.


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## chaz90 (Mar 16, 2014)

GoldcrossEMTbasic said:


> Yes, agree, and the only person to make that determination is the ER doc or the medical director, they are the ones who makes the call and tells us out in the field what to do. We attempt to treat the patients and get them to the ER STAT, and it is in the DOC's hands. EMT-B's or EMT-P's really cannot diagnose. We assess and follow orders and follow with the treatment protocols.



Some of this is so patently false! No doctor "makes the call" out in the field for our patients. They certainly write the protocols, give us authority to practice and give guidance when necessary, but they certainly don't make the day to day treatment decisions in our line of work. 

We attempt to treat the patients as is best for them, and we don't always need to get them to the hospital "STAT" or even at all. We wake up diabetics all the time who we gently treat, and if there is a known cause for the hypoglycemia (often took insulin and failed to eat) feed them a sandwich and send them on their way. 

Also, we absolutely diagnose. I'll add more to this later if I'm feeling ambitious and less cranky.


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## Medic Tim (Mar 16, 2014)

GoldcrossEMTbasic said:


> Yes, agree, and the only person to make that determination is the ER doc or the medical director, they are the ones who makes the call and tells us out in the field what to do. We attempt to treat the patients and get them to the ER STAT, and it is in the DOC's hands. EMT-B's or EMT-P's really cannot diagnose. We assess and follow orders and follow with the treatment protocols.




You have been misinformed. We absolutely diagnose. Diagnose simply means that you take the information you have available ( history, assessment, scene, etc ) and make a determination of what you think is going on. If we didn't diagnose you wouldn't know how to treat or what guideline / protocol to follow. We also operate under our own license with medical oversite.... This is different from working under a doctors license.
I you mess up it is on you not the doc.
Speed does not = good or quality care. Lights and sirens saves very little time and we see very few time sensitive injuries/illnesses. 

The higher you get the more you need to think and develop treatment plans. I am not saying don't follow protocols but realize what they are. They are not a list that has to be followed a-z every time no exception. It is not a cookbook. Not all pts fit into a protocol. Some have more leeway than others but know that following protocols blindly can harm pts .


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## Handsome Robb (Mar 16, 2014)

You guys are liars.

I do the same thing as the trauma team but with two people, an 1/8th of the space and going 90 miles per hour.

/being an ***.

OP while this call sounds relatively unremarkable sync opal episodes can have very deadly etiologies and need to get a thorough assessment. I'm not a huge fan of amazing syncope a unless I can truly peg down the cause with confidence.


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## GoldcrossEMTbasic (Mar 16, 2014)

What'cha talkin about Robb?


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## Medic Tim (Mar 16, 2014)

Robb said:


> You guys are liars.
> 
> I do the same thing as the trauma team but with two people, an 1/8th of the space and going 90 miles per hour.




LIVing it up I see.


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## Handsome Robb (Mar 16, 2014)

GoldcrossEMTbasic said:


> What'cha talkin about Robb?




Sorry I was mocking MedicTim and talking about diagnosing. 

EMS does diagnose, how do we decide what we're going to do for the patient without a differential diagnosis?


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## Handsome Robb (Mar 16, 2014)

Medic Tim said:


> LIVing it up I see.




I can't wait until people actually know what we're talking about when they get called an LIV lol


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## chaz90 (Mar 16, 2014)

Robb said:


> I can't wait until people actually know what we're talking about when they get called an LIV lol



It was a shameful moment for me when I had to ask to find that one out...


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## Brandon O (Mar 16, 2014)

chaz90 said:


> Some of this is so patently false! No doctor "makes the call" out in the field for our patients.



Well, in many areas, an on-scene physician can assume care, but usually with the stipulation that they provide identification, take full responsibility, and accompany the patient all the way to the ED. I think places vary on whether the EMS crew is "required" to follow the orders of the scene doc if they're willing to do all that, but it doesn't come up much.


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## chaz90 (Mar 16, 2014)

Brandon O said:


> Well, in many areas, an on-scene physician can assume care, but usually with the stipulation that they provide identification, take full responsibility, and accompany the patient all the way to the ED. I think places vary on whether the EMS crew is "required" to follow the orders of the scene doc if they're willing to do all that, but it doesn't come up much.



I meant more day to day on the vast majority of our calls. Yeah, if one of our ED docs or medical directors showed up and wanted to run a call, you'd better believe I'd step out of the way. Like you said, just doesn't happen often.


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## teedubbyaw (Mar 16, 2014)

I only diagnose if the monitor gives me it's diagnosis.


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## Medic Tim (Mar 16, 2014)

teedubbyaw said:


> I only diagnose if the monitor gives me it's diagnosis.


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## teedubbyaw (Mar 16, 2014)

Yep. Did a 12 lead for suspected croup and it didn't diagnose so I said the kid is fine.


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## GoldcrossEMTbasic (Mar 16, 2014)

teedubbyaw said:


> Yep. Did a 12 lead for suspected croup and it didn't diagnose so I said the kid is fine.


 "Whatcha Talkin' About Medic!":rofl:


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## mycrofft (Mar 17, 2014)

Robb said:


> Sorry I was mocking MedicTim and talking about diagnosing.
> 
> EMS does diagnose, how do we decide what we're going to do for the patient without a differential diagnosis?



Slavishly follow protocols decided upon by assessment. (HWGA*):rofl:
=============================================
OP, especially in an obese individual, a palpated pulse during syncope (the averages say either vasovagal or postural hypotension) may tell you "pulse=zero", when an auscultated apical pulse is detectable. If pulse was zero AED would say "Shock not advised, continue CPR". 


*HWGA= "Here we go again", the sign of one of EMTLIFE's Black Holes.


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## Christopher (Mar 17, 2014)

GoldcrossEMTbasic said:


> ...the ECG tracing showed a Anterior Ischemia on the strip...



Firstly, if you were measuring the J-point against the TP-segment you'll often get false positive ST-depression during sinus tachycardia. This is why you need to measure the J-point against the ST-segment's isoelectric segment, which is most accurately seen in the PR-segment. Atrial repolarization (Ta-wave) will get scoopier--that's an engineering term--which will naturally cause the J-point to fall below the TP-segment. This does not mean we have any ST-depression at all, just more pronounced atrial repolarization.

And more importantly, I need to jump in here to correct a misnomer:

*You cannot accurately localize ischemia via the surface ECG.* Using ST-depression to prognosticate the location of ischemia is erroneous and usually means providers will overlook subtle reciprocal ST-elevation.

Do not attempt to localize ischemia with ST-depression.

Instead, if you have localized ST-depression what you're actually seeing is a reciprocal change. You'd better go find that ST-elevation.

(I'm aware that cardiac monitors, paramedic textbooks, EKG textbooks, and many cardiology textbooks get this wrong. Doesn't mean we should get it wrong too.)


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## Handsome Robb (Mar 17, 2014)

So knowing what Christopher just wrote, where would you be looking for ST elevation in this 12-lead OP? 

That's for the OP not for you guys who think you're cute


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## teedubbyaw (Mar 17, 2014)

Robb said:


> So knowing what Christopher just wrote, where would you be looking for ST elevation in this 12-lead OP?
> 
> That's for the OP not for you guys who think you're cute




I don't think OP has taken cardiology.


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## Christopher (Mar 17, 2014)

teedubbyaw said:


> I don't think OP has taken cardiology.



I just realized the username includes "EMT", so we'll make this a given they were reading the interpretive statement.

My guess, from the statement, is that this is an LP12 or LP15 on the GE Marquette 12SL or Glasgow interpretation software. The ST-depression is probably simply due to pronounced Ta-waves during tachycardia and localized to some of the anterior precordials. If the ST-depression were in more than 2-3 leads the monitor would have produced the message, "consider subendocardial ischemia," instead (which would be the more accurate term).


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## Handsome Robb (Mar 17, 2014)

teedubbyaw said:


> I don't think OP has taken cardiology.




That was the point.

Thanks.


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## Jon (Mar 18, 2014)

GoldcrossEMTbasic said:


> Let' me clarify that, What happened was the a bystander ran and got the AED another bystander called 911. And then we checked for responsiveness and the PT was responsive and came too. What I meant by cardiac measures, was the bystanders did what was supposed to be done in case of a cardiac arrest. AED and EMS activated. I hope that clarifies what I have stated.


OP: Sounds like a VERY textbook syncope call.

So... you were off duty (attending church) and saw most of what was going on as an interested bystander? (given that you didn't even check the pulse yourself).

I'd also suggest you familiarize yourself with the rules pertaining to onscene physicians in your state. Here in PA, the only doc onscene I can accept orders from is a Medical Command physician. If there's any question, they get to chat by phone with medical command, and I'll keep going though my standard of care... which includes a 12 lead on darn near everyone with vague signs and symptoms.


Root question of a syncope assessment - Has this ever happened to you before? Why? What happened next?


Oh, and in a church? I've heard that referred to as TMJ "Too Much Jesus"


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## GoldcrossEMTbasic (Mar 18, 2014)

The off duty cardiologist, was the one who checked the Patient's pulse. He told me that the Patient's pulse was zero. But the patient came too. A few seconds later. The off duty cardiologist, wanted this and that done and he seemed like he was in control. The medics were kind of upset that he was in charge. I think if I was on duty I would be calling medical direction for the orders not the off duty doctor. !2 lead was done on scene and PT was put on O2 at 10 LPM via NRB mask. Vitals were within normal limits. Everything was unremarkable and patient denied any chest pain or other symptoms except lightheaded and dizzy. I do agree with you, I think it was a plain syncope type call myself as well. Patients pulse was in the 80s and on the monitor did show a normal sinus at 75-80 BPM. Her skin color and condition was also unremarkable. But the two paramedics who did respond did get the doctor's name and they did state on the radio report. "Per cardiologist on scene PT shows an abnormal rhythm on the monitor. And I suggest that the PT be seen in the ETC. So I did help with O2 and primary assessment and secondary assessment on scene. I did ask PT if she ever passed out before and she stated, "NO!" however she was placed on a medication for elevated lipids a week prior to the syncope incident. Maybe a possible medication reaction, but PT denied SOB or Tightness in the throat. No hives were present during assessment. But you are right, I would've went with the medical directions orders instead of the off duty cardiologist.


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## Jon (Mar 18, 2014)

GoldcrossEMTbasic said:


> The off duty cardiologist, was the one who checked the Patient's pulse. He told me that the Patient's pulse was zero. But the patient came too. A few seconds later. The off duty cardiologist, wanted this and that done and he seemed like he was in control. The medics were kind of upset that he was in charge. I think if I was on duty I would be calling medical direction for the orders not the off duty doctor. !2 lead was done on scene and PT was put on O2 at 10 LPM via NRB mask. Vitals were within normal limits. Everything was unremarkable and patient denied any chest pain or other symptoms except lightheaded and dizzy. I do agree with you, I think it was a plain syncope type call myself as well. Patients pulse was in the 80s and on the monitor did show a normal sinus at 75-80 BPM. Her skin color and condition was also unremarkable. But the two paramedics who did respond did get the doctor's name and they did state on the radio report. "Per cardiologist on scene PT shows an abnormal rhythm on the monitor. And I suggest that the PT be seen in the ETC. So I did help with O2 and primary assessment and secondary assessment on scene. I did ask PT if she ever passed out before and she stated, "NO!" however she was placed on a medication for elevated lipids a week prior to the syncope incident. Maybe a possible medication reaction, but PT denied SOB or Tightness in the throat. No hives were present during assessment. But you are right, I would've went with the medical directions orders instead of the off duty cardiologist.


What's an off-duty cardiologist? I didn't know they were ever "on duty"

News flash. Doc wasn't in charge. He was probably just acting like it.


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## Handsome Robb (Mar 18, 2014)

I've pissed off my fair share of physicians telling them politely to piss off. 

Hey, you might know more about medicine than me but I have no idea who you are and am ultimately responsible for this scene so...what I say goes.


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## GoldcrossEMTbasic (Mar 18, 2014)

Robb, you have put the words into my mouth. I 100% agree. These big shot doctor's think that they are in control. And they think when they see the rhythms, the first thing is, oh well you better get in the hospital now! I think they do that just to save their behinds, because they pay allot in medical malpractice insurance. We sure as hell don't!


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## Handsome Robb (Mar 18, 2014)

GoldcrossEMTbasic said:


> Robb, you have put the words into my mouth. I 100% agree. These big shot doctor's think that they are in control. And they think when they see the rhythms, the first thing is, oh well you better get in the hospital now! I think they do that just to save their behinds, because they pay allot in medical malpractice insurance. We sure as hell don't!



I will never be rude to a physician on scene and I will gladly listen to their input provided they produce appropriate credentials or I know them. I just make it known that even though I'm the age of their son, I am still in charge. 

Hasn't really gone south on me yet. Sure, hurt a few feelers but whatever.


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## chaz90 (Mar 18, 2014)

GoldcrossEMTbasic said:


> Robb, you have put the words into my mouth. I 100% agree. These big shot doctor's think that they are in control. And they think when they see the rhythms, the first thing is, oh well you better get in the hospital now! I think they do that just to save their behinds, because they pay allot in medical malpractice insurance. We sure as hell don't!



Medical malpractice doesn't apply if they're not at work and don't make their presence known. I don't think that has anything to do with it. I would imagine the vast majority of physicians on scene, like anyone else, have the patient's best interests at heart. Maybe I'm an optimist, but that's been my experience. 

As I said before, I will gladly defer to a physician's knowledge and experience on scene. If they want to take control of a patient and ride in, I'll consult with med control and make it happen. I've never had this happen to me, but that should be where we step back. 

For the most part, I can't imagine many non-emergency specialists want anything to do with a critical patient. If an ED doc, cardiologist, surgeon, or anesthesiologist wants to intervene, more power to them. If I see some kind of gross incompetence I'd intervene, but otherwise I'm a happy passenger and stretcher operator.


*Apologies for the off topic post by the way.


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## mycrofft (Mar 19, 2014)

Had a Doctor Whosis tell us a patient was fine after a two car collision ,just a little bloody nose, he had her lay down in her car….a '66 Mustang…rear seat.
We got to her, ℅ stiff and sore neck. So the simple evac turned into an extrication.

Thanks to a PODIATRIST.


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## jrm818 (Mar 19, 2014)

GoldcrossEMTbasic said:


> Robb, you have put the words into my mouth. I 100% agree. These big shot doctor's think that they are in control. And they think when they see the rhythms, the first thing is, oh well you better get in the hospital now! I think they do that just to save their behinds, because they pay allot in medical malpractice insurance. We sure as hell don't!



This is over the top. Goodcross, I think you need some direct (I'l try to keep it non-snarky) guidance.  

You are very very new to medicine.  Your medical knowledge is extremely small.  Everyone here was once new, and everyone here once had a very small level of knowledge.  That's OK.  

Just know that the mountain of medical knowledge you *don't* have is so high that you can not see the peak.  "you don't know what you don't know" is a commonly repeated phrase in medicine and you should take it to heart - there is great danger in overestimating your knowledge or abilities.

That said, your role is to basically keep quiet and keep learning.  It is inappropriate for you to make judgement about a physician's medical decision making.  I assure you, you do not have the knowledge, perspective, or experience to critique a cardiologist's evaluation of syncope.  There are doubtless bad physicians, but you are not in a position to decide who they are yet.

The cardiologist in question has seen thousands of patients and been individually responsible for making long term life altering decisions for them.  (Many of them probably about syncope!)  As near as I can tell, you have not yet been responsible for making even the most trivial of decisions for a single patient during a short transport.  Do not underestimate the lack of perspective you have.

There is a temptation as a new EMT to try to become "part of the club" by parroting things you've heard, criticizing others, and basically coming off as a jaded, experienced provider.  Many here, including myself, have probably fallen in to it.  So have you.  

The problem is it doesn't work - for example, it is very clear from your posts on this thread that you don't have the slightest idea what you are talking about when it comes to: evaluating syncope, cardiology, arrythmias, how ECG's work, the way your state EMS system works, medical liability, medical decision making, or the idea of defensive medicine.  You aren't coming off as anything but arrogant and frankly a little crazy.

You need to refocus on learning.  Listen more, talk less.  Stay humble.

A good approach is to take this call and try to learn as much as possible about it.

Go read about syncope.  Try to figure out what the cardiologist was thinking.  Learn to make a differential diagnosis for syncope.  What are the possible causes?  How can you rule every indiviudal cause in or out?  Which causes are dangerous today, this week, or this year?  What is the immediate treatment (at your level and beyond) for each of the causes?  

What is "vasovagal" syncope?  what is the vagus?  What are the parasympathetic and sympathetic systems?  etc. etc. 

Come back with questions not opinions. 

Once you have done that, rinse and repeat.  Don't think you are done.  Keep in mind that the physician you are so happy criticizing can do this effortlessly without looking anything up.  This is barely scratching the surface of his/her level of knowledge.

Good luck.


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## chaz90 (Mar 19, 2014)

jrm818 said:


> This is over the top. Goodcross, I think you need some direct (I'l try to keep it non-snarky) guidance.
> 
> You are very very new to medicine.  Your medical knowledge is extremely small.  Everyone here was once new, and everyone here once had a very small level of knowledge.  That's OK.
> 
> ...



^ This. Just this, +100.


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## NomadicMedic (Mar 19, 2014)

chaz90 said:


> ^ This. Just this, +100.



Agreed. THAT is a good "teaching point" post.


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## cprted (Mar 20, 2014)

jrm818 said:


> This is over the top. Goodcross, I think you need some direct (I'l try to keep it non-snarky) guidance.
> 
> You are very very new to medicine.  Your medical knowledge is extremely small.  Everyone here was once new, and everyone here once had a very small level of knowledge.  That's OK.
> 
> ...


Best post in this thread, hands down.


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## mycrofft (Mar 20, 2014)

No comment on that reply.


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## Handsome Robb (Mar 20, 2014)

jrm818 said:


> This is over the top. Goodcross, I think you need some direct (I'l try to keep it non-snarky) guidance.
> 
> You are very very new to medicine.  Your medical knowledge is extremely small.  Everyone here was once new, and everyone here once had a very small level of knowledge.  That's OK.
> 
> ...



/thread


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## Jon (Mar 20, 2014)

GoldCross: Just for the record - We aren't trying to gang up on you or make you feel bad... We are trying to help you keep your foot out of your mouth, especially at work.


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## Wheel (Mar 20, 2014)

jrm818 said:


> This is over the top. Goodcross, I think you need some direct (I'l try to keep it non-snarky) guidance.
> 
> You are very very new to medicine.  Your medical knowledge is extremely small.  Everyone here was once new, and everyone here once had a very small level of knowledge.  That's OK.
> 
> ...




Great advice, and as a somewhat new provider it's something that I need to be reminded of occasionally myself. Thank you for taking the time to write that out.


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## Melclin (Mar 24, 2014)

I was just so confused by this entire thread until jrm piped up.


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## teedubbyaw (Mar 24, 2014)

Scared them away. LOL


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## GoldcrossEMTbasic (Mar 24, 2014)

I did not get scared away, I am just learning folks. I am just a probie. I never said that I the cardiologist was wrong. I just think he jumped the gun. I know about syncope and patients passing out. I apologize I discussed the wrong information. All I did on the scene is give the patient O2 and asked the patients medical HX and I saw the strip of the 12 lead and I saw anterior ischemia. Thats all. And all I wanted to know if this patient was having a MI or V-FIB being that the doctor said that he felt no pulse a few seconds after the patient passed out. I am just a EMT-B not a paramedic, I know I have go within:angry: my scope of practice. I am supposed to do what he or she orders me to do. I hope I have kind of cleared up this mess in this discussion.<_<


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## teedubbyaw (Mar 24, 2014)

Good for you for taking constructive criticism. We were all there.


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## GoldcrossEMTbasic (Mar 24, 2014)

Thanks Man!


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## mycrofft (Mar 24, 2014)

Goldcross is buying!  

Good on ya!


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## GoldcrossEMTbasic (Mar 24, 2014)

May I ask what I am buying?


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## Christopher (Mar 25, 2014)

GoldcrossEMTbasic said:


> ...and I saw the strip of the 12 lead and I saw _*anterior ischemia*_...



If you take one minor thing away from this it is to throw away that term. Forget you ever saw it or heard it! 

(Either there was diffuse subendocardial ischemia or there was a reciprocal change. Ischemia cannot be localized on the surface ECG.)



GoldcrossEMTbasic said:


> May I ask what I am buying?



I'll buy your next round if you promise when you go to paramedic school to correct anybody who tells you otherwise!


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## GoldcrossEMTbasic (Mar 25, 2014)

Not a problem.


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