# Activated HEMS for LBBB: Made the right call?



## snarff (Aug 5, 2013)

A little background. I a very new paramedic like 4 months. I currently work a flex time job in a rural county. Where you are the only medic and run a ALS chase car and hope one of the volunteer squad's meet you on scene. So this system is to say the least is not ideal. 

Now on to a call I had the other night. Chest pains difficulty breathing 70yo male. I arrive (30minute response.) Volunteers arrive maybe 5 minutes before me in a BLS ambulance. Pt is laying down in bed pale and diaphoretic, he says it just started when he "got a coke" no physical exertion or injury before the pain. rates it an 8 out of 10. and no radiation stays in center of chest. Waited 1 hour after pain to call 911.

He has history of high cholesterol, diabetes and hypertension. Vitals I cant remember but they were not wild or anything like that. Get him to the truck do a 12 lead and start an IV. 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.
 I Give him asprin and nitro. 45 minutes away from a hospital with a cath lab but no surgery and 1 hour and 30 minutes from a hospital with a cath lab and heart capabilities. So I call for the helicopter and that was pretty much the end of the call.

Anyways I am asking if this was a good call because some former employees used the helicopter for anything. So now when it gets call you pretty much have to justify why you did it. So next week I have to give justification when I go in. He did not meet heart alert criteria so what do you guys think?


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## RocketMedic (Aug 5, 2013)

I think you made the right choice. Not all cath labs are staffed or emergent cath labs, and if you felt acs, it is more appropriate to go to the Real Hospital.


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## Merck (Aug 5, 2013)

I'd say if anyone gives you a hard time about the helicopter tell them to pound it.

Does the closer cath lab hospital do PCI?  Or not without surg backup?  If they do and depending on actual time for helicopter arrival/load/transport/unload that still may be an option.

The patient himself, as you present it, is concerning enough to send if that's his persistent presentation over the hour since onset.  If a spray of nitro and he's all of a sudden feeling fine and dries up, then maybe not.  Otherwise, go for it.

And as an aside, I hate places that make people feel like crap for calling a helicopter.  That just makes people less likely to do it which hurts no one but the patient.


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## DrankTheKoolaid (Aug 5, 2013)

Yes. You made the right call. You can't fake skin signs.

You say he didn't exert himself, did he have a fridge next to the bed? Otherwise he did exert himself by walking to get the coke. 

Lung sounds? Pain resolved or changed with nitro?


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## snarff (Aug 5, 2013)

Merck said:


> I'd say if anyone gives you a hard time about the helicopter tell them to pound it.
> 
> Does the closer cath lab hospital do PCI?  Or not without surg backup?  If they do and depending on actual time for helicopter arrival/load/transport/unload that still may be an option.
> 
> ...



They do PCI without surgery backup. The patient stated very little relief after the nitro rated it a 7 out of 10. The helicopter was on the ground in 15 minutes after the call and Flew him to the main hospital the one that was an hour and half away.


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## snarff (Aug 5, 2013)

Corky said:


> Yes. You made the right call. You can't fake skin signs.
> 
> You say he didn't exert himself, did he have a fridge next to the bed? Otherwise he did exert himself by walking to get the coke.
> 
> Lung sounds? Pain resolved or changed with nitro?



Lungs clear. He stated after he got a coke he was standing there drinking it and noticed pain.


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## medicsb (Aug 5, 2013)

Ehhh, I'm going to disagree and say I don't really think it was needed, but that is without seeing the 12 lead or the patient - it's possible I might think different if I could have been there.  I've fallen behind in my readings on ECGs, but I believe the "new LBBB" criteria for MI has more or less been debunked as a reason for cath-lab activation (e.g. http://www.ncbi.nlm.nih.gov/pubmed/19857407), though it is still frequently cited as an indication for cath-lab alert.  Also, there have been a few studies showing that it is safe to do PCI without on site surgical backup (http://www.ncbi.nlm.nih.gov/pubmed/22443460).

And though "pale and diaphoretic" is always worrisome, it doesn't always mean "MI".  If it was a full-on STEMI (or because of the LBBB, met Sgarbossa's Critera) or the patient was quite unstable, then I think it would have been a good choice.


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## truetiger (Aug 5, 2013)

Its hard to say without being there. Do you have a copy of the 12 lead? Also it might be worth noting that most people with LBB or any BBB are not told they have one by their physicians.


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## jwk (Aug 5, 2013)

snarff said:


> They do PCI without surgery backup. The patient stated very little relief after the nitro rated it a 7 out of 10. The helicopter was on the ground in 15 minutes after the call and Flew him to the main hospital the one that was an hour and half away.



So did he end up in the OR or with some type of PCI?

I guess it depends on your protocols, but there are a lot of hospitals out there (at least in my area) with cath labs with PCI capabilities, but of course not all of them are up 24/7.  As time goes by, we continue to see fewer and fewer CABG patients and far more with stents.  Also, we don't see that many failed PCI's from our cath lab either.  But you're the one on scene with the patient, and are aware of the particulars for your area, so regardless it's your call and I wouldn't second guess it.


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## Merck (Aug 5, 2013)

To me the point is the 12 lead is almost irrelevant.  Sounds like it was somewhat convincing for ACS and with the S&S it seems like a good call.

I think the real point is that for a new medic, on their own, with 4 months of experience, it's not the wrong call to err on the side of the patient.


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## mycrofft (Aug 6, 2013)

Merck said:


> I think the real point is that for a new medic, on their own, with 4 months of experience, it's not the wrong call to err on the side of the patient.


Works for me. Good one. See if you can find out the lab finding and the pt outcome.


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## TomB (Aug 6, 2013)

snarff said:


> 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.



Normally I make it a point to not comment on an ECG I haven't laid eyes on, but assuming this is true it may have been a STEMI. Typically LBBB has an upright QRS in lead aVL and negative QRS in leads III and aVF. So, ST-elevation in lead aVL would be concordant ST-elevation and ST-depression in leads III and aVF would be concordant ST-depression. Having said that, if you called for aeromedical transport based on a possible new LBBB (and that was your only ECG-based criterion) then I would suggest it was not in the patient's best interest. It's risk/reward. But then, something is wrong if paramedics are out there making these kinds of decisions in isolation without strategic-level folks working it out ahead of time in an organized system of care.


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## VirginiaEMT (Aug 6, 2013)

snarff said:


> A little background. I a very new paramedic like 4 months. I currently work a flex time job in a rural county. Where you are the only medic and run a ALS chase car and hope one of the volunteer squad's meet you on scene. So this system is to say the least is not ideal.
> 
> Now on to a call I had the other night. Chest pains difficulty breathing 70yo male. I arrive (30minute response.) Volunteers arrive maybe 5 minutes before me in a BLS ambulance. Pt is laying down in bed pale and diaphoretic, he says it just started when he "got a coke" no physical exertion or injury before the pain. rates it an 8 out of 10. and no radiation stays in center of chest. Waited 1 hour after pain to call 911.
> 
> ...



Did you do a V4R? I personally think you did the right thing. Our protocol states that if MI is suspected, and we are more than 30 MINUTES ( big difference from mileage in our area) then we fly them. I would rather justify why I did, then why I didn't.


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## Flight-LP (Aug 6, 2013)

Interesting case presentation, but is lacking the most informative aspect in a BBB differential. What did V1 reveal?

The inferior leads are not consistent as described for an MI, and a right sided EKG really wouldn't be a forethought in my mind at this point. 

Treat for ACS and transport expeditiously. Would have I called for air? They way this has been described, no. If it was truly a new onset LBBB, then yes I would have considered it. 

Be cautious with "erring on the side of the patient". Slapping someone with a $10-20k bill for simple angina and risking a valuable air resource is not in the best interest of anyone involved. Just like field activation of a cath lab, you have to be absolutely accurate in your assessment and findings.


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## Christopher (Aug 6, 2013)

snarff said:


> Get him to the truck do a 12 lead and start an IV. 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.



_New LBBB is not a STEMI._

LBBB with *primary ST-changes* is a STEMI.

_LBBB always has ST-changes_, just they are _secondary_ to the abnormal depolarization thru the bundle branches (think abnormal repol whenever you have abnormal depol, hence you should expect to see ST/T-wave changes in RBBB/LBBB).

If aVL was predominantly positive with concordant ST-elevation, I'd say you had a winner.

Here are some resources on LBBB + STEMI (bias alert, I was involved in some of these articles):

Video Lecture from Dr. Stephen Smith on LBBB+STEMI
Inappropriate Concordance in LBBB (STEMI)
Sgarbossa's Criteria
Identifying STEMI with LBBB Part I and Part II
An impressive LBBB (pacing) that is not a STEMI


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## Merck (Aug 6, 2013)

I think it's distressing to hear a new medic being told to be careful erring on the side of the patient.  Now, my particular bias here is that in Canada no one gets stuck with a bill, so there is that.

Paramedics love to play mini-cardiologist, Snarff.  Yes there is a ton to them and even when you think you're good at them there is still more to know.  I'd take this case as one that will prompt you to increase your knowledge of 12 leads to help you make decisions in the future.

However, a 12 lead is only part of the picture.  I have not attended many angina patients with unrelenting diaphoresis and pain not controlled by nitro.  At that stage I question whether it's a, MI or possibly a different diagnosis all together.  With what you've said, good job on the helicopter and I would never give a ground crew a hard time for calling us in for something like that.


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## Handsome Robb (Aug 6, 2013)

I was gonna mention the Sgarbossa criteria but Christopher beat me to it. 

From what you're saying I'd say you made the right call. Yea we have to think of finances at well but that the end of the day if we save the patient on a helo bill but he has a poor outcome due to the delay of definitive care have we really actually helped?


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## TomB (Aug 6, 2013)

Merck said:


> Paramedics love to play mini-cardiologist, Snarff.



By this logic knowing how to intubate means you like to play mini-anesthesiologist. But you'd never say that, right? Because you know how to intubate?


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## MSDeltaFlt (Aug 6, 2013)

snarff said:


> A little background. I a very new paramedic like 4 months. I currently work a flex time job in a rural county. Where you are the only medic and run a ALS chase car and hope one of the volunteer squad's meet you on scene. So this system is to say the least is not ideal.
> 
> Now on to a call I had the other night. Chest pains difficulty breathing 70yo male. I arrive (30minute response.) Volunteers arrive maybe 5 minutes before me in a BLS ambulance. Pt is laying down in bed pale and diaphoretic, he says it just started when he "got a coke" no physical exertion or injury before the pain. rates it an 8 out of 10. and no radiation stays in center of chest. Waited 1 hour after pain to call 911.
> 
> ...



I believe we're missing a lot of information here and it is sounding like people are wanting to treat a machine they haven't seen instead of treating a patient they haven't laid eyes on.

What were the vital signs?  What were the breath sounds?  Heart sounds?  Did the patient have a cough?  Productive?  For how long?  What color?  Any edema?  Pitting?  Where?  How deep?  What did the CP feel like?  What made it better?  What made it worse?

Basically what I'm asking is, if there was no 12 lead available, what clinical presentation was there that indicated cardiac?

Bare in mind I am in no way criticizing or second guessing your decision.


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## snarff (Aug 6, 2013)

MSDeltaFlt said:


> I believe we're missing a lot of information here and it is sounding like people are wanting to treat a machine they haven't seen instead of treating a patient they haven't laid eyes on.
> 
> What were the vital signs?  What were the breath sounds?  Heart sounds?  Did the patient have a cough?  Productive?  For how long?  What color?  Any edema?  Pitting?  Where?  How deep?  What did the CP feel like?  What made it better?  What made it worse?
> 
> ...



Vitals p89, BP 128/78, sp02 94%, lungs clear, didn't get heart sounds, no cough, no edema. Cp felt like pressure and he stated he felt it was hard to catch his breath. He stated nothing made his pain better or worse. He stated it stayed constant from onset throughout. Skin was pale and diaphoretic.

In my limited experience I felt it was cardiac before I saw a 12 lead. I guess I was looking for is what would a more experienced provider do given the same situation.

Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.


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## MSDeltaFlt (Aug 6, 2013)

snarff said:


> Vitals p89, BP 128/78, sp02 94%, lungs clear, didn't get heart sounds, no cough, no edema. Cp felt like pressure and he stated he felt it was hard to catch his breath. He stated nothing made his pain better or worse. He stated it stayed constant from onset throughout. Skin was pale and diaphoretic.
> 
> In my limited experience I felt it was cardiac before I saw a 12 lead. I guess I was looking for is what would a more experienced provider do given the same situation.
> 
> Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.



Okie doke.  Just checking.


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## medicsb (Aug 6, 2013)

The question isn't so much cardiac or not, but STEMI (or, say, Sgarbossa equivalent) because that is where time might really matter.  NSTEMI, unstable angina, etc. do not need immediate PCI, so ground transport would be wholly appropriate.  For STEMI, it could, depending on the EMS/STEMI system be fine to go by ground if transport time is <60 minutes (assuming cath lab activation from the field).  It takes time for the team to get to the hospital and to set up to receive the patient.  Usually they have a 30 minute time frame to arrive at the hospital, and then it will take a certain amount of time to get everything set-up for the procedure.  During off hours, it could take over an hour for the team to be ready, so any gain from helicopter transport will likely not translate to any real gain in time saved since they'll be sitting in the ED.  Even during day hours, if there is a patient on the table, the STEMI will probably have to wait some time.


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## Christopher (Aug 7, 2013)

snarff said:


> Vitals p89, BP 128/78, sp02 94%, lungs clear, didn't get heart sounds, no cough, no edema. Cp felt like pressure and he stated he felt it was hard to catch his breath. He stated nothing made his pain better or worse. He stated it stayed constant from onset throughout. Skin was pale and diaphoretic.
> 
> In my limited experience I felt it was cardiac before I saw a 12 lead. I guess I was looking for is what would a more experienced provider do given the same situation.
> 
> Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.



_I'm a biased against helicopters when you've got the means to drive a patient somewhere...so ignore me if that is an issue _

1). With an equivocal 12-Lead, even with s/s of ongoing ACS, it would be best to go via ground. An echo or labs is going to rule this patient in/out most likely.

2). Flying somebody for "suspected new LBBB" is a bit like flying somebody for mechanism of injury alone.

I don't fault your decision, LBBB produces some damn impressive ECG changes, and we (EMS educators) haven't done the best job of properly informing new and old medics alike why "suspected new LBBB" isn't actually a big deal.

I certainly drove silly fast to the hospital with one too many patients when I was starting out :wacko: I wish I could go back and talk myself out of a lot of those decisions...

I look at helo usage like anything else, it has benefits and risks. The benefits from a helo are so unbelievably small in most cases that it does not really serve your patient. As long as you find yourself using this intervention as the exception rather than the rule, you're doing Ok!


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## TomB (Aug 7, 2013)

snarff said:


> Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.



Can you post the ECG?


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## snarff (Aug 7, 2013)

Ok talked to a medic from the helicopter that my friend knew. She was not on the crew that picked the guy up, but she did ask the other crew about it. Apparently the guy was having an MI "High lateral". They said the 12 lead from the helicopter never showed anything different than the one I ran. LBBB with st depression in III and aVF with 1mm of elevation in aVL. She didn't know what % of occlusion. 

Sounds like the guy is going to have a good outcome. This definitely puts me at ease. I certainly don't want to cost some guy thousands of dollars for nothing. So hopefully we both are happy lol.


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## DrankTheKoolaid (Aug 8, 2013)

*re*

There ya go.  A brand new Medic and you have already learned the lesson of Paramedic intuition.  Learn to listen to it.


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## Handsome Robb (Aug 8, 2013)

snarff said:


> Ok talked to a medic from the helicopter that my friend knew. She was not on the crew that picked the guy up, but she did ask the other crew about it. Apparently the guy was having an MI "High lateral". They said the 12 lead from the helicopter never showed anything different than the one I ran. LBBB with st depression in III and aVF with 1mm of elevation in aVL. She didn't know what % of occlusion.
> 
> Sounds like the guy is going to have a good outcome. This definitely puts me at ease. I certainly don't want to cost some guy thousands of dollars for nothing. So hopefully we both are happy lol.



I suck at deciding on using HEMS or not mostly because its rare that they're faster than us. All the times I've called for them they've launched when we were dispatched and the patient needed an airway and I can't RSI. 

I think you made the right call. You took the patients presentation and your qualitative and quantitative assessment tools/findings and came up with a solid working differential and then got the patient where he needed to be in the quickest fashion. One of the few cases that time does matter. Seconds? No minutes? I'd say so.

Pretty sure someone already said it but you can't fake skin signs. 

I'd be really interested to see the ECG. I'm not nearly as good as some of these guys are but I'd be interested to see whether it met the Sgarbossa Criteria. LBBBs always make me wonder... If I remember correctly you only had one ECG? Or didn't have dynamic changes after interventions? People always say "they're paced no bother doing a 12" but if you're watching the morphology change in serial ECGs I'd be worried...


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## VFlutter (Aug 8, 2013)

Robb said:


> People always say "they're paced no bother doing a 12"



Please :censored::censored::censored::censored::censored: slap anyone who says that, thanks.


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## grub (Aug 8, 2013)

*Good Job*

First of all, good job on doing the 12 lead! I'm a 12 lead instructor and believe in them highly. An ST depression in II & III with an ST elevation in AVL and a ??new?? LBBB tells me you may have had a NEW MI on the left ventricle? PAced Pts. still need 12 leads ALWAYS>>  Being a Diabetic throws all the cards out the window and really makes it more urgent. Second....  The fact that your even thinking about the helicopter being abused tells me you followed the right path. There is a lot of abuse in calling a helicopter I have seen it many times. Your pt. had an obvious MI and you did your best to get him reperfused at the correct facility! read up on Sgarbossa’s criteria.... it will help you with paced,LBBB (imposters) and give you a prospective on IDing the real rhythm........ GOOD JOB 


Sgarbossa's criteria: 

Here is the criteria. A patient is presumed to be experiencing an evolving AMI if any of the following are present.
 1.ST segment elevation = or > 1 mm that is concordant with the QRS complex.
 2.ST segment depression = or > 1 mm in leads V1, V2, or V3.
 3.ST segment elevation = or > 5 mm that is discordant with the QRS complex.


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## grub (Aug 8, 2013)

Chase said:


> Please :censored::censored::censored::censored::censored: slap anyone who says that, thanks.



YES!!!   You are so correct!


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## Brandon O (Aug 8, 2013)

Just to point out another way of looking at this, calling somebody a STEMI and mobilizing the cavalry BECAUSE they show an isolated LBBB is probably wrong. However, if they give a clinical impression of STEMI, and the ECG shows a LBBB, and you're thinking, "I'm just not comfortable ruling a STEMI in or out in the presence of LBBB, because it makes interpretation difficult (heck, I'll keep learning, maybe one day!), so I'm basically going to pretend I never even acquired this, and treat based on signs and symptoms"... it may be quite sensible to handle it as a STEMI.

The Bayesian way of looking at this: the pre-test probability was high, and the ECG was equivocal and changed nothing, so the post-test probability remained high.

The "is this okay?" way of looking at this: as an empirical approach this is supported by the AHA and is widely practiced by many EDs and interventionalists.

The "punt" way of looking at this: although you should strive to always be able to glean useful data from the ECG, if you honestly can't (and although possible, it is tricky in LBBB!), "treat the patient, not the monitor" is a somewhat defensible approach.

Just recognize that no matter how you approach it, this is NOT the same as assuming all "new" LBBBs are STEMIs. Not by a long shot.


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## Christopher (Aug 8, 2013)

Brandon Oto said:


> Just to point out another way of looking at this, calling somebody a STEMI and mobilizing the cavalry BECAUSE they show an isolated LBBB is probably wrong. However, if they give a clinical impression of STEMI, and the ECG shows a LBBB, and you're thinking, "I'm just not comfortable ruling a STEMI in or out in the presence of LBBB, because it makes interpretation difficult (heck, I'll keep learning, maybe one day!), so I'm basically going to pretend I never even acquired this, and treat based on signs and symptoms"... it may be quite sensible to handle it as a STEMI.



Considering the NNC (number needed to cath, I just made that up) in order to get a "new or suspected new LBBB" with an actual occlusion is big...way big, even with clinical signs supporting it; I think in the absence of primary ST-changes you should not make this call.


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## Brandon O (Aug 8, 2013)

Christopher said:


> Considering the NNC (number needed to cath, I just made that up) in order to get a "new or suspected new LBBB" with an actual occlusion is big...way big, even with clinical signs supporting it; I think in the absence of primary ST-changes you should not make this call.



As a global recommendation, I would agree, but there are probably constellations of clinical findings and other circumstances where it would be beneficial (or at least reasonable).

Trying to find that threshold could be tricky, of course. It really comes down to the point where a skilled provider would, after obtaining the H&P, say "I don't need to rule this patient _in_ -- I need to rule him _out_. And it'll have to be pretty friggin' convincing."


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## Christopher (Aug 8, 2013)

Brandon Oto said:


> As a global recommendation, I would agree, but there are probably constellations of clinical findings and other circumstances where it would be beneficial (or at least reasonable).
> 
> Trying to find that threshold could be tricky, of course. It really comes down to the point where a skilled provider would, after obtaining the H&P, say "I don't need to rule this patient _in_ -- I need to rule him _out_. And it'll have to be pretty friggin' convincing."



We get a number of "convincing" LBBB chest pains that we see during QA. At my department we've done a pretty good job of educating our providers when you need to activate (e.g. clear benefit) vs when you should not (e.g. no clear benefit).

However, every now and then we get a "new or suspected new LBBB" inappropriately activated.

For the topic here, I find it all moot without an actual ECG to look at. STEMI criteria _should_ be solidly based on findings in the ECG which correlate to clinical findings. LBBB is not a finding in the ECG which suggests STEMI.


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## Brandon O (Aug 8, 2013)

You know I'm with you for the most part. The problem is that many providers take this same tack, but have a far-too-low threshold for it (and their ability to interpret is weak enough that they have to punt on a regular basis).

But no matter how good you are, sometimes you don't know, and I think there is room for a decision that acknowledges one's own inability to interpret the ECG and makes a reasonable call on empiric grounds.

You walk in the room, think "dang, he looks like he's about to code," throw him on the monitor, and the bloomin' thing doesn't turn on. Now what?

You always consider risk/benefit, of course. Maybe you don't call the bird or activate the cath lab, but you divert ten minutes farther. Weigh what you know (not what you wish you knew) and do your best.

The fact that you should strive to minimize your "fallback" decision-making doesn't mean that you shouldn't have those mental protocols in place. When you don't know what to do, you've still gotta do something...


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## grub (Aug 8, 2013)

*I agree*

Brandon, you hit it on the head...! This guy had a very high probability of an MI. ST elevation in 2 or more contiguous leads with reciprocal changes, is what we need to fit the criteria for STEMI. he only gave us 1 lead with ST elevation but we had the inferior reciprocal changes in II&III we needed the whole 12 lead to see to make a good DX.
Treating the Pt. is always the best path to follow. Symptoms and ECG's get twisted by the diabetic pt. anyway. In this situation, I'm glad he felt the pt. was in a serious situation. The Pt.s symptoms were pretty convincing of a cardiac emergency. I do however, feel that the big STEMI imposters like BBB,LVH,paced.....ect can leave you feeling dumb and blank with the only thing left to treat being the Patient. I've had many 12 leads show normal with none or minimal symptoms and then get pos cardiac enzymes and a pos MI dx. at the ER. I DON'T PLAY WITH DIABETICS, THEY WILL FOOL YOU...! We have to do the best with what we have and right now, the average medic in the field hasn't mastered the 12 lead because it takes training and lots of practice. We do treat the Pt. different by what we see on the 12 lead and we do save lives by being able to read a 12 lead appropriatly. We are the Doctor,nurse,respiratory therapist,xray and psychologist, all in one. To be good at what we do, takes training and lots of it. We can carry our profession on our sleeve or in our hearts, it our choice. Good post Brandon


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## Christopher (Aug 8, 2013)

Brandon Oto said:


> But no matter how good you are, sometimes you don't know, and I think there is room for a decision that acknowledges one's own inability to interpret the ECG and makes a reasonable call on empiric grounds.



I don't doubt the likelihood of ACS, I doubt the need for activation of a STEMI without changes (or with LBBB alone). You still make for the appropriate facility and run it up the ACS ladder.



grub said:


> Brandon, you hit it on the head...! This guy had a very high probability of an MI. ST elevation in 2 or more contiguous leads with reciprocal changes, is what we need to fit the criteria for STEMI. he only gave us 1 lead with ST elevation but we had the inferior reciprocal changes in II&III we needed the whole 12 lead to see to make a good DX.



The traditional criteria of elevation in 2 or more contiguous leads only applies to non-LBBB ECGs. _(don't read too much into this statement, I'm by far the least 'criteria based' person around)_

Regardless, as you note without an ECG to view it is hard to determine if the activation is appropriate, since an ECG is required to make an activation


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## grub (Aug 8, 2013)

If you want to see an ER doc get excited, show him your 12 lead that you did before to started treatment 45 mins. ago with ST elevations and obvious sign's of MI... right after he just read the nurses 12 lead she did 2 minutes ago that was normal after all your fine treatment that reversed all the sign's and symptoms ; )  He'll thank you for it with a look of serious interest!


Another 12 lead point:
If I get a Pt. (especially females and diabetics) that are 50 or older and c/o flu like symptoms, they get a 12 lead. diabetics and silent MI's fall into this catagory. Diabetics have neuropathy and loose pain sensation where non-diabetics will have complants. Silent MI's are just that, SILENT! The only way you will know what you have, is a 12 lead to confirm it. It's real embarrasing to bring in a flu pt. and then see them get rushed to the cath lab:sad:


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## Benjamin (Aug 8, 2013)

I am just a basic, but I think you made the right choice for your patient in this situation.  You have the right to be proactive.  Thank you for all you do.  God bless and be confident in your assessment.


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## Carlos Danger (Aug 8, 2013)

Brandon Oto said:


> Just to point out another way of looking at this, calling somebody a STEMI and mobilizing the cavalry BECAUSE they show an isolated LBBB is probably wrong. *However, if they give a clinical impression of STEMI, and the ECG shows a LBBB, and you're thinking, "I'm just not comfortable ruling a STEMI in or out in the presence of LBBB*, because it makes interpretation difficult (heck, I'll keep learning, maybe one day!), so I'm basically going to pretend I never even acquired this, and treat based on signs and symptoms"... it may be quite sensible to handle it as a STEMI.
> 
> The Bayesian way of looking at this:* the pre-test probability was high, and the ECG was equivocal and changed nothing, so the post-test probability remained high.*



This is exactly how I see it. ^^^^

You were perfectly correct to assume an AMI and get this guy to a cath lab ASAP, given the clinical presentation and the non-reassuring EKG finding. A presumably new LBBB _in the presence of convincing clinical s/s of an MI_, is always an AMI until proven otherwise.

As for calling the helicopter? Well that's really a separate issue. Using HEMS was the right thing to do IF they could get the patient to the cath table significantly quicker than you (I'd say 20 minutes quicker; others may argue slightly shorter or slightly longer), or if they have the ability to do some important intervention that you don't (probably not applicable to this specific case, but in general).

On the whole, I'd say you did right.


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## medicsb (Aug 8, 2013)

Christopher said:


> Considering the NNC (number needed to cath, I just made that up) in order to get a "new or suspected new LBBB" with an actual occlusion is big...way big, even with clinical signs supporting it; I think in the absence of primary ST-changes you should not make this call.



I agree with this.

To the OP, do NOT let the outcome justify the transport decision, though your bosses may now be pleased.  Think to yourself how you'd feel if he didn't get cathed - lets say he got discharged after a 23 hour observation.  What then?

The appropriateness of your decision should be based on the information that you knew at the time, which many of us have argued was not sufficient to support a flight.  However, based on your description of the ECG, it does sound like there may have been signs of MI according to Sgarbossa's Criteria, which should cause you to seek out a copy and look it over closely.  If it did meet Sgarbossa's criteria, make note of it, and keep an eye out for it in the future, and be happy that you accidentally made the right decision.  

Anyhow, it really does sound like you did an overall good job.  You identified someone who looked sick, you did an appropriate work-up, and initiated the right treatment, mostly (only because I would argue that flying was a type of treatment).   Live and learn.


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## TomB (Aug 9, 2013)

Halothane said:


> You were perfectly correct to assume an AMI and get this guy to a cath lab ASAP, given the clinical presentation and the non-reassuring EKG finding. A presumably new LBBB _in the presence of convincing clinical s/s of an MI_, is always an AMI until proven otherwise.



It's definitely not my intent to be argumentative, and medicsb's last comment nails it IMHO, but consider this. I agree that LBBB with s/s of ACS is AMI until proven otherwise, but the issue at hand is whether or not it's STEMI until proven otherwise. That's an important distinction because there's no evidence that immediate cath for NSTEMI/LBBB confers a benefit. Almost 50% of patients with LBBB in the Larson study had no clear culprit artery.

Once again, this isn't about whether or not the treating paramedic in this case made a good call or a bad call. It sounds like s/he did the best s/he could in a tough situation for which he was not adequately trained and where there was insufficient protocols, policies, procedures, and supervision.

Welcome to rural EMS you might say, and perhaps you'd be right. But that's the real issue. Not the actions of one individual.


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## grub (Aug 9, 2013)

*STEMI or ?*

American heart standards say that :

 Signs and symptoms of a STEMI include:

 •Chest pain or discomfort
 •Shortness of breath
 •Dizziness or light-headedness
 •Nausea or vomiting
 •Diaphoresis (sweatiness) unexplained by ambient temperature
 •Palpitations (uncomfortable awareness of the heart beat)
 •Anxiety or a feeling of impending doom

If you get any or all of these symptoms as a guideline and an ST elevation in two (2) contiguous leads, reciprocal changes.. then the criterai for EMS observed STEMI has been met in the field.
NOW I say Field and not cath lab.
 In the field, Paramedics only have so many tools to go by, 12 lead and experience being the other. The guide lines are there and there will always be false positives in the cath lab.
 As I mentioned before, Diabetics will fool you and toss the whole STEMI rules out the window!
 Error on the side of caution and train to the best of your abilty with the 12 lead and signs and symptoms are the best path to follow.
NOW, New guidlines show that a new or unknown LBBB is not criteria for a STEMI. This hasn't been diseminated down to all protocols as of yet I'm sure but it has come from extensive studies and there are more to come.

  Answering the question of if this Pt. should have gone by helicopter? The pt was very symptomatic 12 lead or not! Prior Hx. that was significant and although poor information on the 12 lead, it bring you back to treat your pt. If this was my pt., i'd want him in a cardiac facility to cover my bases.

 Reading a 12 lead and studying your MI pt. is an art. Paramedic could train for another 6 months alone on just cardiac. Like I mentioned in other posts, 12 lead is under taught in EMS and area's that are using telemetry, have stopped 12 lead training all together : (   Sad but true. 

Sorry for the long post  .........


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## Christopher (Aug 9, 2013)

Not to nitpick but...



grub said:


> American heart standards say that :
> 
> Signs and symptoms of a STEMI include:
> 
> ...



Those are s/s of ACS, not just STEMI (e.g. all squares are rectangles, but not all rectangles are squares). By definition, STEMI requires an ECG.



grub said:


> If you get any or all of these symptoms as a guideline and an ST elevation in two (2) contiguous leads, reciprocal changes.. then the criteria for EMS observed STEMI has been met in the field.



Reciprocal changes are not required for activation in most systems. Anterior Wall STEMI's frequently do not have reciprocal changes. The converse of this is Inferior Wall STEMI's always have reciprocal changes (where "always" is like 6 9's of sensitivity). High lateral STEMI's rarely have 2 contiguous leads of elevation, yet are no less a STEMI.


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## Brandon O (Aug 9, 2013)

Halothane said:


> This is exactly how I see it. ^^^^
> 
> You were perfectly correct to assume an AMI and get this guy to a cath lab ASAP, given the clinical presentation and the non-reassuring EKG finding. A presumably new LBBB _in the presence of convincing clinical s/s of an MI_, is always an AMI until proven otherwise.



With that said, let me backpedal a bit and reemphasize that the optimal approach to managing such patients should be to develop your ability to interpret the ECG until you DO know how to "read through" a left bundle.

We should have a plan for when things fail, but our real priority should be to avoid failure altogether next time around.


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## Summit (Aug 9, 2013)

Christopher said:


> (where "always" is like 6 9's of sensitivity)



I haven't heard this one?


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## Christopher (Aug 9, 2013)

Summit said:


> I haven't heard this one?



Sorry, this is a Dr. Smith thing, "inferior STEMI virtually always has reciprocal ST-depression in aVL". If ST-depression in aVL (or T-wave changes) is not present, "you should think of something else, like early repolarization or pericarditis".

Reference: Bischof J.  Thompson RP.  Tikkanen J.  Porthan K.  Huikuri H.  Salomaa V.  Smith SW.  ST-segment depression in lead aVL differentiates benign ST elevation from inferior Acute STEMI.  ACEP Research Forum 2012.  Annals of Emergency Medicine 60(4 Suppl):S8-S9; October 2012.


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## medic109 (Aug 18, 2013)

Not a lot of what sounds like real rural experience (40+years inner city/suburban) but why not utilize some on-line medical control, also I'm personally not a big put them in a loud scary bird and scare the :censored::censored::censored::censored: out of them as an aggressive stress stress advocate. And for the record the DANAMI study supports the safety and efficacy of early 1/2 lytic then transport further for PCI. And another opinion what's a four month old Medic with limited responses doing as a sole ALS responder who doesn't access some higher or more experienced back-up


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