# A proper 12 lead would've done wonders.



## cm4short (Sep 27, 2009)

So, I'm on my internship and ran across a classic Atypical MI. I have to share this because I got a midnight code 3 transfer to a STEMI out of it while it was totally missed in the field due to... check this out... too much artifact in the  12 lead.

So, per initial transporting medic run report; the patient is a 57 year female walk-in patient to the fire station complaining of SOB x15 min, non provoked, "chocking on spit" per FD, negative CP, negative trauma, negative ABD, positive N/V. Cant tell what the lungs sounds are because of sloppy handwriting; only shallow was written under quality. No wheezes noted. Pt was in moderate distress. B/P 150's/90's, pulse ST in 120's, respiration's 24 initially 24, 18 after Tx. Blood sugar of 209. PT history of diabetes, HTN, Hep-C(Hx of Hyperlipedemia and smoking discovered in ER). NKA, unknown medications. On scene 12 lead is horrible; Wandering baseline in leads V1-V6, with some artifact in I, II and aVF(I'll upload all the ECG when I get to a scanner). They treat with a DUO-NEB and transported to basic receiving. Pt improvement in breathing after being "coached".

In ER ECG read Anterior infarction with initial ST elevation in III, aVF, V3, V4. Troponin came back at 3.47. A second ECG showed ST elevation in V1, V2, V3, V4, V5, V6. By then, the ER was running around like a circus. CP protocol, Bipap, Thrombolytic therapy, and GOMER. 

We were called to transport this patient to the Cath LAB. 35 minute transport with M.D. on board.

I say this all because... Well, once I get the 12 leads uploaded, you 'll see that this patient could've received better care by being transported to the most appropriate facility.


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## MrBrown (Sep 27, 2009)

Fire based EMS strikes again.

Although could have been worse, I mean, push a bit further out west and San Bernardino is run by AMR.


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## Aidey (Sep 27, 2009)

Not to defend the fire paramedics, but sometimes you just can not get a good 12 lead on scene. If the pt is panicky/anxious, breathing fast, dry heaving, shaking etc and you can't get them to hold still you may not be able to get a clear enough 12 lead to determine if there is elevation or depression. 

It's one thing if they only tried once, gave up and said "oh well". It's another if they tried multiple times, and tried to correct the problem and they still couldn't get a clear reading.


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## Sapphyre (Sep 27, 2009)

Mr Brown, what you don't realize is, AMR owns Riverside county.   Even more so than San Bernardino County....  My question to the OP is, who ran the initial 12 lead????


note, as stated under my training, I'm not even a medic student, just a lowly basic.


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## TomB (Sep 27, 2009)

Am I to understand that you have both 12-lead ECGs? The one from the field with poor data quality and the one taken in the ED that shows the STEMI? I hope so! That would be a great case study. Please upload them as soon as possible.

As for the fire-based EMS bashers, it's starting to remind me of Bush Derangement Syndrome. Time to find a hobby! 

Tom


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## cm4short (Sep 27, 2009)

Yes, I have both... And, I'm going to get 2 case studies out of this one. One on their transport, and the other on our transport.


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## VentMedic (Sep 27, 2009)

I know when L.A. county initiated their 12 lead program they were not taught anything about artifact if you can imagine that.  They also only had machine interpretation to rely on which in some cases made very poor interpretations.  

It is possible that the same situation lies in this county also.  

Generally if a person is distressed enough to where one can not get a decent 12-lead, further assessment is needed.


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## VentMedic (Sep 27, 2009)

TomB said:


> As for the fire-based EMS bashers, it's starting to remind me of Bush Derangement Syndrome. Time to find a hobby!
> 
> Tom


 
There are good fire based EMS departments. However, in some areas such as CA and FL, the FFs are forced to be Paramedics. Many of these patch holders should not be allowed to come near a patient even at a BLS level. They lack of interest in doing what is th best for the patient is generally obvious to other medical professionals.

Don't defend all just because you are a FF. The union and brotherhood need to recognize there is such a thing as professional patient care and not see it has just another cert or "skill". To just blindly defend a department solely on the fact that they are FFs does little for professionalism just as bashing all FDs or private ambulance services.


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## daedalus (Sep 27, 2009)

Sounds like a typical situation around Los Angeles. In fact, that narrative sounds kinda like the LA County/City way to write narratives (maybe it is taught to them??? They need to learn SOAP).

It does not surprise me at all. This is why the hospitals teach all the new ED nurses to never trust a paramedic. It literally a law of the emergency department.


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## medic417 (Sep 27, 2009)

Wonder if they properly prepped the skin?


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## MrBrown (Sep 27, 2009)

daedalus said:


> Sounds like a typical situation around Los Angeles. In fact, that narrative sounds kinda like the LA County/City way to write narratives (maybe it is taught to them??? They need to learn SOAP).
> 
> It does not surprise me at all. This is why the hospitals teach all the new ED nurses to never trust a paramedic. It literally a law of the emergency department.



My non medical education include part of a law degree and a bachelors degree in business and operation management so as you can immagine i can writes thems squiggles and dots pretty gosh darn goodly yup i tells ya and i struggle to fill out a PCR.

I can get a B on a 5,000 word essay but I can stand in ED smashing my head on the wall because I can't put the words together to document the little old lady with hyperglycemia we just bought in.

Just goes to show it's not just firemonkeys who can't write a damned narrative!



			
				VentMedic said:
			
		

> I know when L.A. county initiated their 12 lead program they were not taught anything about artifact if you can imagine that. They also only had machine interpretation to rely on which in some cases made very poor interpretations.



*Brownie falls over and hits head out of sheer shock and horror and being soooo suprised, quick, get the longboard and call medical control for orders! 

Oh I'm sorry guys that was pretty harsh but it doesn't suprise me.

To the OP may I'd love to see that 12-lead, I suggest this something you bring up in class as a learning exercise.


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## VentMedic (Sep 27, 2009)

MrBrown said:


> *Brownie falls over and hits head out of sheer shock and horror and being soooo suprised, quick, get the longboard and call medical control for orders!
> 
> Oh I'm sorry guys that was pretty harsh but it doesn't suprise me.


 
Here's some of the L.A. county training links:
http://ems.dhs.lacounty.gov/ManualsProtocols/RFTM/RFTM-Physical.pdf

Note: electronic reading states _____ check box.

http://ems.dhs.lacounty.gov/pdf/FallNewsletter1007.pdf


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## TomB (Sep 27, 2009)

VentMedic said:


> There are good fire based EMS departments. However, in some areas such as CA and FL, the FFs are forced to be Paramedics. Many of these patch holders should not be allowed to come near a patient even at a BLS level. They lack of interest in doing what is th best for the patient is generally obvious to other medical professionals.
> 
> Don't defend all just because you are a FF. The union and brotherhood need to recognize there is such a thing as professional patient care and not see it has just another cert or "skill". To just blindly defend a department solely on the fact that they are FFs does little for professionalism just as bashing all FDs or private ambulance services.




There are good fire-based EMS systems and there are horrible third-service EMS systems. That's the point. All the world's troubles cannot be blamed on fire-based EMS. It's getting old and it's getting boring.

Tom


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## cm4short (Sep 27, 2009)

San Bernardino County FD ran the initial 12 lead


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## medic417 (Sep 27, 2009)

TomB said:


> There are good fire-based EMS systems and there are horrible third-service EMS systems. That's the point. All the world's troubles cannot be blamed on fire-based EMS.



You are right but the reason fire is jumped on is its big union has fought many advancements in EMS.


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## VentMedic (Sep 27, 2009)

cm4short said:


> San Bernardino County FD ran the initial 12 lead


 
If you mean in CA, that is nothing to brag about. Other parts of the country have been doing 12 lead ECGs for 20 years.

It is also sad that many counties in CA still do not have 12 lead capability and some of those that do rely on machine interpretation.


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## MrBrown (Sep 27, 2009)

VentMedic said:


> Here's some of the L.A. county training links:
> http://ems.dhs.lacounty.gov/ManualsProtocols/RFTM/RFTM-Physical.pdf
> 
> Note: electronic reading states _____ check box.
> ...



* puts boot on the gas pdeal

Man I gotta keep drivin' faster I make it to Portland or Reno the faster this killing pain in my chest can be evaulated! 

Again, that was haaaaarsh


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## VentMedic (Sep 27, 2009)

MrBrown said:


> Again, that was haaaaarsh


 
No, harsh is when those in these counties don't realize how sad this is and what a disserive they do the public by representing themselves as Paramedics and ALS.  It is one thing to be stuck in an area such as this and know how limited you are but to not have a clue that there is more to the story is just, well......


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## FFMedic75 (Sep 27, 2009)

TomB said:


> There are good fire-based EMS systems and there are horrible third-service EMS systems. That's the point. All the world's troubles cannot be blamed on fire-based EMS. It's getting old and it's getting boring.
> 
> Tom



Perhaps you should upload the wonderful patient care stories that are currently in the newspaper regarding the third party service in your county.  The Fire based systems in the area are clearly more concerned with patient care and being progressive than the EMS only systems.


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## Smash (Sep 27, 2009)

Quite aside from the FF/EMS pissing match and the suspected deficiencies in 12 lead ECG taking, does no one else find it somewhat odd that a patient with no reported history of respiratory disease and no wheezes recieved albuterol and atrovent?


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## Akulahawk (Sep 27, 2009)

cm4short said:


> So, I'm on my internship and ran across a classic Atypical MI. I have to share this because I got a midnight code 3 transfer to a STEMI out of it while it was totally missed in the field due to... check this out... too much artifact in the  12 lead.
> 
> So, per initial transporting medic run report; the patient is a *57 year female* walk-in patient to the fire station complaining of *SOB* x15 min, *non provoked*, "chocking on spit" per FD, negative CP, negative trauma, negative ABD, *positive N/V*. Cant tell what the lungs sounds are because of sloppy handwriting; only shallow was written under quality. No wheezes noted. Pt was in moderate distress. B/P 150's/90's, pulse ST in 120's, respiration's 24 initially 24, 18 after Tx. Blood sugar of 209. PT history of *diabetes*, HTN, Hep-C(Hx of Hyperlipedemia and smoking discovered in ER). NKA, unknown medications. On scene 12 lead is horrible; Wandering baseline in leads V1-V6, with some artifact in I, II and aVF(I'll upload all the ECG when I get to a scanner). They treat with a DUO-NEB and transported to basic receiving. Pt improvement in breathing after being "coached".
> 
> ...


No wheezing and some classic signs of MI in a female with history of Diabetes.... and the patient was treated with Albuterol/Atrovent? I get the feeling that the field 12-lead was done AFTER they gave the Duo-Neb... as one of those "Oh, yeah.... she might be having an MI..."


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## MrBrown (Sep 27, 2009)

Smash said:


> ...does no one else find it somewhat odd that a patient with no reported history of respiratory disease and no wheezes recieved albuterol and atrovent?



You're right! I read this originally about what, 5am and must have missed it; wow thats shonky.


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## Dwindlin (Sep 27, 2009)

cm4short said:


> So, I'm on my internship and ran across a classic Atypical MI. I have to share this because I got a midnight code 3 transfer to a STEMI out of it while it was totally missed in the field due to... check this out... too much artifact in the  12 lead.
> 
> So, per initial transporting medic run report; the patient is a 57 year female walk-in patient to the fire station complaining of SOB x15 min, non provoked, "chocking on spit" per FD, negative CP, negative trauma, negative ABD, positive N/V. *Cant tell what the lungs sounds are because of sloppy handwriting*; only shallow was written under quality. No wheezes noted. Pt was in moderate distress. B/P 150's/90's, pulse ST in 120's, respiration's 24 initially 24, 18 after Tx. Blood sugar of 209. PT history of diabetes, HTN, Hep-C(Hx of Hyperlipedemia and smoking discovered in ER). NKA, unknown medications. On scene 12 lead is horrible; Wandering baseline in leads V1-V6, with some artifact in I, II and aVF(I'll upload all the ECG when I get to a scanner). They treat with a DUO-NEB and transported to basic receiving. Pt improvement in breathing after being "coached".
> 
> ...



Could have been wheezing unless there was something I missed from another post.


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## MSDeltaFlt (Sep 27, 2009)

I'm holding my opinions until I see some 12 leads.


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## Smash (Sep 27, 2009)

atkinsje said:


> Could have been wheezing unless there was something I missed from another post.





			
				cm4short said:
			
		

> No wheezes noted



Yep, you missed something from the first post 

Oh well, I suppose it's a good stress test for the myocardium giving it a flogging with albuterol


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## FFMedic75 (Sep 27, 2009)

Things like this are happen all over the country, everyday, in every different type of setting.  It doesn't matter if it is fire based, private, or third service.  Every system has awful medics.  Not everyone has the problem solving skills that it truly takes to do this job.  Anyone can memorize anatomy, but what it takes to be a quality medic is problem solving, and assessment skills.  To develop and refine these it takes initiative and a strong will to excel at your chosen profession.  These problems begin with the medics themselves, when we screw up at work the person doesn't get the wrong hamburger, they die.  If you want to do this profession take every opportunity to better yourself.  The next problem is instructors around the country are getting worse and training is being cut.  I once helped with skills at a medic class and was told by the students that an instructor told them to give everyone SOB Albuterol and if it didn't work give them Lasix, because it must be pulmonary edema.  I promptly reported this but he still teaches at the same place, and probably teaches the same misinformation.  The last problem is, with the medic shortage that has existed till very recently systems were reluctant to address problems like this because it was all about having numbers to staff trucks.  The OT budget was more important than quality care, and that came from far above a fire chief or EMS director.  Until medical professionals take ownership in their skills and the care they provide, there is quality training readily available, and systems go for quality not quantity when hiring these situations will continue.


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## JPINFV (Sep 27, 2009)

Is it possible to motivate providers who view EMS as nothing more than a burden that they have to bear to do their dream job to care about their assessment and patient care ability?


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## 46Young (Sep 27, 2009)

JPINFV said:


> Is it possible to motivate providers who view EMS as nothing more than a burden that they have to bear to do their dream job to care about their assessment and patient care ability?



there are plenty of individuals working in the privates, third service, and hospital based EMS who are only (barely) tolerating the job while they finish their degree, or are waiting for one of their civil service apps to come back with a job offer(fire, PD, sanitation, etc). It goes both ways.

I don't know about motivation, but I feel that many of these problems could be mitigated by strict QA/QI and equally strict accountability. 

During our hiring process and recruit school, the importance of EMS and being a competent provider was repeatedly stressed. Anyone that comes here knows what's up.


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## MrBrown (Sep 27, 2009)

FFMedic75 said:


> ... I once helped with skills at a medic class and was told by the students that an instructor told them to give everyone SOB Albuterol and if it didn't work give them Lasix, because it must be pulmonary edema....



Dude are you *serious?* .... that's like saying "well that patient is not moving, he must be dead because dead people do not move!"

I am horrified :sad:


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## Smash (Sep 27, 2009)

MrBrown said:


> Dude are you *serious?* .... that's like saying "well that patient is not moving, he must be dead because dead people do not move!"
> 
> I am horrified :sad:



You should probably push some narcan before you call it. You know, just in case...


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## AZFF/EMT (Sep 27, 2009)

Some of you guys are funny with the FF=Horrible medic logic. Sad.


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## AZFF/EMT (Sep 27, 2009)

Or maybe I am very blessed to work in an area where every single person realizes that ems is 80%+ of our workload and if not for EMS we would be volunteer's. Out here its the privates that are very scary, and of course there are scary fire medics as well, but the way some of you guys talk WE kill people daily and ems only guys are superhero's because only YOU care enough. I had 2 ems runs yesterday, helped extrication and treatment on an MVA rollover-X and had a house fire in the morning. I don't think being a dual role FF made popping a door, pulling drywall and providing quality ems something that is impossible.


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## cm4short (Sep 28, 2009)

*Got those 12 leads finally*

FD Copy 
	

		
			
		

		
	






ER Copy 1 
	

		
			
		

		
	




ER Copy 2 
	

		
			
		

		
	




"one of these 12 leads is not like the other":unsuresesame street song)


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## VentMedic (Sep 28, 2009)

AZFF/EMT said:


> Or maybe I am very blessed to work in an area where *every single person* realizes that ems is 80%+ of our workload and if not for EMS we would be volunteer's.


 
Do you not think you are a little over assuming when you speak for *ALL* of your FFs? Do you not think that some of your FFs might just want to be a Fire Fighter and specialize as such to perfect that profession? Do you think *EVERYONE* of your coworkers are happy to be forced to be a Paramedic? They may realize that EMS is 80% of the workload but that still does not automatically make them enthusiastic to be a health care provider. But then, do any of them identify themselves as a health care provider? 

How can you have 1000 FFs, *all* with a Paramedic patch, *all* equally happy about being a Paramedic and doing patient care or running medical calls all 24 hours? That is a tall task for even the most professional of FDs. At least if a Paramedic isn't up to par on a private ambulance, they can easily be replaced by someone who can do the job.


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## cm4short (Sep 28, 2009)

AZFF/EMT said:


> Or maybe I am very blessed to work in an area where every single person realizes that ems is 80%+ of our workload and if not for EMS we would be volunteer's. Out here its the privates that are very scary, and of course there are scary fire medics as well, but the way some of you guys talk WE kill people daily and ems only guys are superhero's because only YOU care enough. I had 2 ems runs yesterday, helped extrication and treatment on an MVA rollover-X and had a house fire in the morning. I don't think being a dual role FF made popping a door, pulling drywall and providing quality ems something that is impossible.



It doesn't matter who you're employed by; it the motive behind it. Because there are too many people who got into this profession to put out fires. THe fact that most department primarily hire medics made everyone jump on the bandwagon for the wrong reason. Because of that, prehospital care is always a second priority for these guys. And, the ones that get hired, and don't get hired, bring the industry down primarily for that reason. 

But I have also seen both quality FF's and single role medics.


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## MrBrown (Sep 28, 2009)

If that 12 lead was acquired prehospitally here you'd be shot ... probably literally!


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## AZFF/EMT (Sep 28, 2009)

I guess I cannot say every single person that would be foolish, most though. Not everyone is a paramedic or forced to be a paramedic. We are about 50/50. Everyone does have to be an EMT-B. For a while it was seen as easier to get hired in the metro phoenix area as a medic simply because if there are 500 applicants for 10 spots which will be 5 basics and 5 medics it is usually 450 basics testing and 50 medics. I feel sorry for departments who get the guys who became medics only to get on but dont want to do the job, these guys are usually turds altogether not just as medics. They want shirts that say FF, and union stickers for the lifted truck, ect.


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## AZFF/EMT (Sep 28, 2009)

And man I really hope the medic with that poor 12 lead was having true trouble getting a good one, because man wewould also be in trouble for that.


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## Aidey (Sep 28, 2009)

Can we please not turn this into a debate about Fire based EMS vs Private EMS? 

It's hard to really look at the 12 leads because we can't zoom in. Even so, the ST elevation is obvious in the two from the ED. How long was the first one taken after the pt arrived at the ED? How long apart were they taken?


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## AZFF/EMT (Sep 28, 2009)

Did they get a standard 4 or whatever monitor set-up they have basic ecg? Should have been able to see elevation in III and AvF


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## Shishkabob (Sep 28, 2009)

Holy cow, did they have the patient jumping around while analyzing the 12-lead?


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## cm4short (Sep 28, 2009)

The times for the 12 leads are as follows. The initial 12 lead was taken at 2115. The ER copy was taken at 2139. The next ER copy wasn't taken till 2 hours later when the troponin levels came back at 3.47!!!. 

Sorry about the siz, that was the only way I could figure out how to upload. But, the you should be able to see obvious in the V leads. Which all happened to be obscured in the initial 12 leads.

But, this should've been recognized without a 12 lead. There were multiple factors which scream out AMI along with the fact that we should treat the monitor and not the PT. 

The facts are as follows; If elderly, female diabetic doesn't ring a bell then onset of SOB, non provoked without wheezes should. The person had no Cardiac or Respiratory disease, But had high cholesterol and smoking. At they treated for Asthma/COPD. 

Our assessments should have had CP as a working Dx because our equipment is only to aide us. I mean, a 12 leads is used those Atypical AMI and not rule the out.


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## Aidey (Sep 28, 2009)

cm4short said:


> ....along with the fact that we should treat the monitor and not the PT.quote]
> 
> Um, I'm pretty sure the saying is the other way around. Which may go a long way in explaining why they did what they did.
> 
> ...


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## cm4short (Sep 28, 2009)

cm4short said:


> But, this should've been recognized without a 12 lead. There were multiple factors which scream out AMI along with the fact that we should treat the monitor and not the PT.



:excl::excl::excl: Oh :blush: I sure am dyslexic. It it was a typo. I meant to say *treat the patient and not the monitor* :excl::excl::excl:


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## TomB (Sep 28, 2009)

The first 12-lead ECG taken in the ED is suspicious, but it isn't an obvious STEMI. It's apparent the ED physician on duty didn't think so either. So what we have here is a prehospital 12-lead ECG with poor data quality. Not exactly a shocker, and certainly not evidence that fire-based EMS sucks. Frankly, I'd be more concerned about why the ED didn't perform serial ECGs or continuous ST-segment monitoring with poor R-wave progression and broad-based T-waves in the precordial leads. Must have been a fire-based emergency department.


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## medic417 (Sep 28, 2009)

Pre-hospital really suspect that they failed to properly clean/scuff the skin leading to a bunch of artifact.   I see it way to often even with the non fire EMS.  Wiping with an alcohol pad is not enough but is better than many who just place them over hair, dirt and all.  

To do it right you need hair shaved, wipe the skin, then scuff it.  Use something like 3m red dot skin prep.  A dry 4x4 does not scuff enough.

http://www.medexsupply.com/products/pid-34060/3MRedDotTraceSkinPrepRollwithD.htm

The next cause sadly is often the cables are not fully connected to the machine.  I have gotten into an ambulance and medics had artifact and I just reached over and pushed cable connector further into its socket and amazingly got a clean 12/15 lead.   

Another common cause is the cables developing cracks.  A busy service really should replace the cables every few months, while a slow rural service might need to replace every 1-2 years.  

And yet another problem especially with older machines is electrical interference.  With some machines you really needed everything off in the ambulance.  

Thats just a small list of causes.


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## VentMedic (Sep 28, 2009)

TomB said:


> The first 12-lead ECG taken in the ED is suspicious, but it isn't an obvious STEMI. It's apparent the ED physician on duty didn't think so either. So what we have here is a prehospital 12-lead ECG with poor data quality. Not exactly a shocker, and certainly not evidence that *fire-based EMS sucks.* Frankly, I'd be more concerned about why the ED didn't perform *serial ECGs* or *continuous ST-segment monitoring* with poor R-wave progression and broad-based T-waves in the precordial leads. Must have been a fire-based emergency department.


 
Why do serial ECGs when hospital labs can get some labs results within 5 - 10 minutes? EDs are not going to wait for an ECG to look text book. Ever hear of non-STEMI MIs? 
ECGs are not always the definitive and only diagnostic that is done. 

The hospital arranged for transport to a more appropriate hospital. Would you prefer the doctor admit the patient to tele until the ECG was perfect just like in the text book or the patient coded? 

Some Paramedics do get hung up on wanting the "STEMI" and miss other important signs or symptoms especially in a patient such as this who presented with the risk factors and signs/symptoms.

In the last several posts absolutely *NOTHING *was mentioned about fire-based EMS. You now seem to have something to prove that your department is perfect and know it all already. Get over it. Again, when you *force FFs* to be Paramedics, not all will be good or even barely adequate at that job. Being a FF is not what will help you learn the medicine to effectively treat a patient. Do you think you can stop with the FF stuff long enough to *look at this scenario as a health care professional?*


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## VentMedic (Sep 28, 2009)

cm4short said:


> :excl::excl::excl: Oh :blush: I sure am dyslexic. It it was a typo. I meant to say *treat the patient and not the monitor* :excl::excl::excl:


 
There are cases where you do have to treat the monitor as not all patients will appear with the classic signs and symptoms of an MI. Older people, diabetics, and women as well as some men will not have the obvious signs and may even be in denial as the monitor shows a text book perfect STEMI. Do you ignor the findings on the monitor and not initiate treatment?

We are now finding evidence of existing heart disease, especially in women, for those diagnosed with Chronic Fatique Syndrome.  For years no one bothered to do a 12 lead on these patients and just blew off  potential serious underlying causes.


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## TomB (Sep 28, 2009)

Don't take me so seriously, VentMedic. I've held my fire through numerous (and ridiculous) fire-based EMS bashing sessions and I'm just having a little light-hearted fun. As for the ECG, of course I've heard of NSTEMI, but we generally don't rush NSTEMI to the cath lab, and we certainly don't give thrombolytics. The treatment is different.

Point of care cardiac biomarkers are interesting, and I'm aware of emergency departments that incorporate them into critical pathways, but apparently that wasn't the case here. Even if it was, without the ECG showing STEMI, there would be no reason for immediate transfer PCI. 

As for my own department, I don't think I've ever mentioned it on this bulletin board. Regardless, there's no reason that people who dish it out on a regular basis shouldn't be able to take it, especially when I'm taking friendly jabs and not foaming at the mouth.

Have a nice day! 

Tom




VentMedic said:


> Why do serial ECGs when hospital labs can get some labs results within 5 - 10 minutes? EDs are not going to wait for an ECG to look text book. Ever hear of non-STEMI MIs?
> ECGs are not always the definitive and only diagnostic that is done.
> 
> The hospital arranged for transport to a more appropriate hospital. Would you prefer the doctor admit the patient to tele until the ECG was perfect just like in the text book or the patient coded?
> ...


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## VentMedic (Sep 28, 2009)

TomB said:


> Don't take me so seriously, VentMedic. I've held my fire through numerous (and ridiculous) fire-based EMS bashing sessions and I'm just having a little light-hearted fun. As for the ECG, of course I've heard of NSTEMI, but *we *generally don't rush NSTEMI to the cath lab, and *we* certainly don't give thrombolytics. The treatment is different.


 
That is patient dependent and you certainly can not make a blanket statement about them not going a cath lab.  

I'm not talking about what the EMS team will do. I am talking about what the ED and cardiologist might do. If it is a NSTEMI, you might not be able to call a "STEMI ALERT" as a Paramedic. However, if signs/symptoms are present, going to a more appropriate facility with appropriate diagnostics could still be considered. And correct, very few U.S. EMS agencies can give thrombolytics. 



TomB said:


> Point of care cardiac biomarkers are interesting, and I'm aware of emergency departments that incorporate them into critical pathways, but apparently that wasn't the case here. Even if it was, without the ECG showing STEMI, there would be no reason for immediate transfer PCI.


I never said anything about POC testing. Hospital labs are available 24/7 and in smaller hospitals some are within a quick walk of th ED. 




TomB said:


> As for my own department, I don't think I've ever mentioned it on this bulletin board. Regardless, there's no reason that people who dish it out on a regular basis shouldn't be able to take it, especially when I'm taking friendly jabs and not foaming at the mouth.


 
Friendly jabs?  You are now taking shots at thrashing the ED to make yourself look good.  Private EMS wasn't enough for your "jabs".

If you want to talk Firefighting there are plenty of forums. If you want to discuss medicine, you don't have to be a FF to do so.   If a FD or any agency is not aware of its flaws, then it will not improve.   Look within your own walls before thrashing others.


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## TomB (Sep 28, 2009)

VentMedic said:


> That is patient dependent and you certainly can not make a blanket statement about them not going a cath lab.



Show me the evidence that NSTEMI patients benefit from immediate PCI.



VentMedic said:


> I'm not talking about what the EMS team will do. I am talking about what the ED and cardiologist might do.



The ED physician and cardiologist can do whatever they please. That doesn't make it an evidence based practice.



VentMedic said:


> If it is a NSTEMI, you might not be able to call a "STEMI ALERT" as a Paramedic.



Why would you? Even if it were possible to distinguish between UA and NSTEMI in the field? 



VentMedic said:


> However, if signs/symptoms are present, going to a more appropriate facility with appropriate diagnostics could still be considered.



Anything could be considered. I'm just not aware of any evidence that NSTEMI patients benefit from immediate PCI.



VentMedic said:


> And correct, very few U.S. EMS agencies can give thrombolytics.



Whether they can or can't is irrelevant. It's not indicated for NSTEMI.



VentMedic said:


> I never said anything about POC testing. Hospital labs are available 24/7 and in smaller hospitals some are within a quick walk of th ED.



The only emergency departments I'm aware of that can have cardiac biomarkers drawn and read within 10 minutes are using the desktop Dade-Behring Stratus CS unit inside the ED. If your hospital can turn around labs in 10 minutes without POC testing then you need to teach the rest of the medical community because that's amazing! 



VentMedic said:


> Friendly jabs? You are now taking shots at thrashing the ED to make yourself look good.



I thought it was funny and clever, but I'm easily amused. Regardless, it's a huge fallout for that ED. There's no point in defending it. It has nothing to do with me and whether or not I look good.



VentMedic said:


> Private EMS wasn't enough for your "jabs".



I don't recall bashing private EMS.



VentMedic said:


> If you want to talk Firefighting there are plenty of forums.



I don't recall discussing fire suppression.



VentMedic said:


> If you want to discuss medicine, you don't have to be a FF to do so.



I'm not sure where that came from, but okay.



VentMedic said:


> If a FD or any agency is not aware of its flaws, then it will not improve. Look within your own walls before thrashing others.



Ding! Ding! Ding! Excellent advice for anyone, regardless of affiliation, which ironically, is sort of my whole point! Thank you. Don't suppose for a moment that I overlook flaws within my own organization.


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## Dwindlin (Sep 28, 2009)

TomB said:


> Show me the evidence that NSTEMI patients benefit from immediate PCI.



http://content.onlinejacc.org/cgi/content/full/50/7/652/FIG14

While this isn't immediate PCI but the research is swinging in favor of it.  This is from 2007 (most recent I could find this morning).  Much of the research is suggesting that even in absence of STEMI positive isoenzymes may warrant therapy as aggressive.


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## TomB (Sep 28, 2009)

Fair enough. I don't have a problem with early invasive strategy for select patients. I will however take issue with the suggestion that serial ECGs or continuous ST-monitoring is not the standard of care, especially when the initial ECG is suspicious.

Thanks for the link.

Tom


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## grich242 (Sep 28, 2009)

There are plenty of  so called "patch holders" in all areas of ems I'm sure we can all agree. It would be nice to see the 12 lead from the field and you said in the report the patient denied any cp? without the readable 12 lead ekg i cant say I would have done a whole lot different as in treat the patient not the monitor and have you thought about the infarct beginning after the field 12 lead? In recent months our department started a new program in which we transport all stemi patients directly the cath lab and the cardiologists have been really pushing the the fact that the ekg can be changed significantly  by the time we reach the cath lab usually 12 minutes from 911 call to on the table.


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## FFMedic75 (Sep 28, 2009)

I don't care what anyone says.  Every system has good and bad people regardless of what their patch says.  Lets forget the 12 Lead for a minute (it actually looks like it has bad cables), this medic apparently did not use any good judgment dealing with this patient.  They gave Albuterol and it wasn't indicated.  There were indicators that this may be a cardiac event, they should have been recognized.


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## medic417 (Sep 28, 2009)

Again to try and help get us on track are a list of possible causes of the bad EKG. 



medic417 said:


> Pre-hospital really suspect that they failed to properly clean/scuff the skin leading to a bunch of artifact.   I see it way to often even with the non fire EMS.  Wiping with an alcohol pad is not enough but is better than many who just place them over hair, dirt and all.
> 
> To do it right you need hair shaved, wipe the skin, then scuff it.  Use something like 3m red dot skin prep.  A dry 4x4 does not scuff enough.
> 
> ...


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## fma08 (Sep 28, 2009)

FFMedic75 said:


> I once helped with skills at a medic class and was told by the students that an instructor told them to give everyone SOB Albuterol and if it didn't work give them Lasix, because it must be pulmonary edema.



umm....... :blink:

In reference to the XII lead... Did they not know that they can actually take more than one pre-hospitally?? I just did yesterday for trending purposes. Lucky for the pt., nothing changed (for the worse).


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## thowle (Sep 28, 2009)

Not a medic, but hard for me to see and ST elevation??


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## 46Young (Sep 28, 2009)

I don't know, maybe it's just me, but whenever I discover a Hx of diabetes and HTN, my suspicion of an atypical MI as a differential jumps to the top of the list. Adding CAD to the Hx completes the deadly triad. From my experience and observations, these pts are ticking time bombs waiting for an MI or CVA. When working IFT, I've noticed that rarely will a pt have a Hx of both diabetes and HTN and not have CAD, MI's or CVA/TIA's in their Hx, particularly if they're past 50 y/o.

As far as the prehospital PCR, I would take choking on spit with diminished L/S bilat to be APE all the way up. Pink and frothy perhaps? Elevated BP, pulse, RR, + N/V, high chol Hx as well? No wheezing noted. A new and sudden onset of asthma caught late in the game where the pt now has silent L/S at this pt's age is unlikely. Maybe emphysema, but with frothy sputum (I'm assuming) and N/V? Probably not.

Some use an albuterol neb as a diagnostic (not me). Some also say that it's more important to open up surface area for gas exchange in the presence of bronchoconstriction with a neb, and deal with flash APE if and when it comes. I'd like to hear Ventmedic's thoughts in regards, as well as others. In this case, I'm willing to bet that the diminished L/S are from the pt's lungs being full of fluid, and maybe shallow breathing due to tiring from the increased resp. effort.

A wise man once told me "All that wheezes is not asthma". 

As far as the FD vs single role medic bickering, every time something bad from (usually) CA or FL comes up, the FBEMS lynch mob weighs in and extends that particular dept's ineptitude to the entire fire service. It's already been established that there are agencies/depts ranging from stellar to horrible on both sides of the FBEMS/single role EMS split. Why can't we just leave it at that?

Make the medic curriculum harder, and mandating it nationally, thus phasing out medic mills should produce a higher quality provider who is serious about the profession, no matter which road they go down. The inept providers should eventually be phased out, or at least be allowed to drop their medic to make room for more qualified providers. Speaking of that, it would be a good idea for a FD to require a firemedic to keep their cert current as a condition of employment, at least until they promote out of it.


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## cm4short (Sep 28, 2009)

*OK, These should be readable*

For those who aren't trained in 12-lead. All you need is 1mm elevation in 2 or more contiguous lead views. If you're unsure of how to tell what contiguous, look up the acronym SALI as it pertains to 12-lead interpretations. 

Remember, the transporting medic's report at the turn-over of care does have an impact on the patient's treatment plan. 

Also, the reason you transport to a STEMI center instead of a basic hospital is because they have a Cardiologist. A basic ED physician doesn't specialize in AMI's. 

I mean, if you think they can handle a STEMI, then maybe you should try transporting critical traumas there too. They'll have the same Oh S:excl::excl::excl: face with either call.


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## JPINFV (Sep 28, 2009)

cm4short said:


> Also, the reason you transport to a STEMI center instead of a basic hospital is because they have a Cardiologist. A basic ED physician doesn't specialize in AMI's.



I'd argue that it has more to do with having a cath lab than a cardiologist. All hospitals have cardiologists, but not all hospitals have a cath lab.


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## cm4short (Sep 28, 2009)

*If anyone's seen a catheritization done propetly*

Then you understand why the STEMI system is so important. We all have the basic principles of Time is Muscle and we want to get the arteries perfused so the tissue doesn't progress for ischemic to necrotic.

The procedure is not as invasive as you'd think. The person is usually awake as the use a local anesthetic to progress up the femoral artery. Using a dye and X-ray similar to a contrast CT; they flush the dye through the arteries to see if the dye doesn't follow the normal pathways as it circulates. This is done to the majur arteries individually and results are verified with medical records and findings. Backflow, narrowing or Complete stoppage are the indicators to look for(there are more of course). 

If you ever get a chance to see the procedure; DO IT WITHOUT HESITATION.


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## cm4short (Sep 28, 2009)

JPINFV said:


> I'd argue that it has more to do with having a cath lab than a cardiologist. All hospitals have cardiologists, but not all hospitals have a cath lab.



That statement was in reference to an ED M.D. vs. a Cardiologist. Cardiologist aren't on staff on a regular basis at basic facilities. They'll usually have to be called in. Also, their 12 interpretations aren't always up to standard, and will often be on par with most medics. The 12 lead in this instance show'd ST elevation. But it wasn't recognized until 2 hours later.


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## medic417 (Sep 28, 2009)

cm4short said:


> That statement was in reference to an ED M.D. vs. a Cardiologist. Cardiologist aren't on staff on a regular basis at basic facilities. They'll usually have to be called in. Also, their 12 interpretations aren't always up to standard, and will often be on par with most medics. The 12 lead in this instance show'd ST elevation. But it wasn't recognized until 2 hours later.



There is no cardiologist closer than 2 hours from the hospital in the town I work at.  The other area I work it is 3.5-4 hours to the nearest cardiologist.


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## MSDeltaFlt (Sep 28, 2009)

cm4short said:


> So, I'm on my *internship* and ran across a classic Atypical MI. I have to share this because I got a midnight code 3 transfer to a STEMI out of it while it was *totally missed in the field* due to... check this out... too much artifact in the 12 lead.
> 
> So, per initial transporting medic run report; the patient is a 57 year female walk-in patient to the fire station complaining of SOB x15 min, non provoked, "chocking on spit" per FD, negative CP, negative trauma, negative ABD, positive N/V. Cant tell what the lungs sounds are because of sloppy handwriting; only shallow was written under quality. No wheezes noted. Pt was in moderate distress. B/P 150's/90's, pulse ST in 120's, respiration's 24 initially 24, 18 after Tx. Blood sugar of 209. PT history of diabetes, HTN, Hep-C(Hx of Hyperlipedemia and smoking discovered in ER). NKA, unknown medications. On scene 12 lead is horrible; Wandering baseline in leads V1-V6, with some artifact in I, II and aVF(I'll upload all the ECG when I get to a scanner). They treat with a DUO-NEB and transported to basic receiving. Pt improvement in breathing after being "coached".
> 
> ...


 
I can see where the original medic might have benefited from thinking silent MI.  Those little old ladies scare me.  However, your desription of the scenario does not mention what actually transpired in the back of the truck.  What I mean is what actually went on that never made it to the chart.  I wasn't there.  I don't think you were either.



cm4short said:


> *The times for the 12 leads are as follows. The initial 12 lead was taken at 2115. The ER copy was taken at 2139. The next ER copy wasn't taken till 2 hours later* when the troponin levels came back at 3.47!!!.
> 
> The facts are as follows; If elderly, female diabetic doesn't ring a bell then onset of SOB, non provoked without wheezes should. The person had no Cardiac or Respiratory disease, But had high cholesterol and smoking. At they treated for Asthma/COPD.
> 
> Our assessments should have had CP as a working Dx because our equipment is only to aide us. I mean, a 12 leads is used those Atypical AMI and not rule the out.


 
A 2 hr wait with a MD at bedside... or at least in the same ER speaks volumes here people.



TomB said:


> *The first 12-lead ECG taken in the ED is suspicious, but it isn't an obvious STEMI*. It's apparent the *ED physician on duty didn't think so either*. So what we have here is a prehospital 12-lead ECG with poor data quality. Not exactly a shocker, and certainly not evidence that fire-based EMS sucks. Frankly, I'd be more concerned about why the ED didn't perform serial ECGs or continuous ST-segment monitoring with poor R-wave progression and broad-based T-waves in the precordial leads. Must have been a fire-based emergency department.


 
I'm siding with Tom on this one.



cm4short said:


> For those who aren't trained in 12-lead. *All you need is 1mm elevation in 2 or more contiguous lead views*. If you're unsure of how to tell what contiguous, look up the acronym SALI as it pertains to 12-lead interpretations.
> 
> Remember, the transporting medic's report at the turn-over of care does have an impact on the patient's treatment plan.
> 
> Also, the reason you transport to a STEMI center instead of a basic hospital is because they have a *Cardiologist*. A basic ED physician doesn't specialize in AMI's.


 
As Tom said, it's not obvious ST elevation.  The computer may have called it that, but it's not obvious.

Also, cardiologists don't make STEMI centers; not even the *interventional cardiologists*.  Although I'm assuming that's whom you are referring.  Granted they are the ones doing most of the work, but you can't do interventional cardiology without a cardiothoracic surgeon on standby.  Because if the interventional cardiologist pops an artery while doing the PTCA, or angioplasty, or whatever, then said pt could lose his/her VS in less than a minute.  Translation: you don't have minutes before they die.  You have seconds before the CV surgeon is cracking open the chest.



cm4short said:


> Then you understand why the STEMI system is so important. We all have the basic principles of Time is Muscle and we want to get the arteries perfused so the tissue doesn't progress for ischemic to necrotic.
> 
> *The procedure is not as invasive as you'd think*. The person is usually awake as the use a local anesthetic to progress up the femoral artery. Using a dye and X-ray similar to a contrast CT; they flush the dye through the arteries to see if the dye doesn't follow the normal pathways as it circulates. This is done to the majur arteries individually and results are verified with medical records and findings. Backflow, narrowing or Complete stoppage are the indicators to look for(there are more of course).
> 
> If you ever get a chance to see the procedure; DO IT WITHOUT HESITATION.


 
And what most don't see is the CV surgery suite ready and waiting.

What I'm saying is that this particular thread has gone on for several pages saying how crappy this thing is or that thing is when in reality we don't have all of the information.

This whole thing sounds very negative.

I'm just saying...


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## Dwindlin (Sep 28, 2009)

cm4short said:


> That statement was in reference to an ED M.D. vs. a Cardiologist. Cardiologist aren't on staff on a regular basis at basic facilities. They'll usually have to be called in. Also, their 12 interpretations aren't always up to standard, and will often be on par with most medics. The 12 lead in this instance show'd ST elevation. But it wasn't recognized until 2 hours later.



Standard cardiologist won't do you much good with a STEMI pt.  Interventional cardiology is a separate branch of training (I think 5 year fellowship vs. 3).  Most STEMI centers are such due to the availability of a 24/7 cath lab.  Also I would like to see any medic who truly believes they can interpret a 12 lead better than ANY physician, not just EM trained.

I know of no programs (in this area anyways) that even bother covering axis deviations or QTc interval abberancy.  Even the nuances of T-wave abberancy is often left at hyper-acute can be a sign of hyperkalemia.


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## atropine (Sep 28, 2009)

Well all I can say is that this woman should have been in LA, there is such a thing known as the perfect fire department in the worl and it's LA City.


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## JPINFV (Sep 28, 2009)

^
The only question that LA City paramedics could ask is if the machine printed out ***Acute MI Suspected***


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## atropine (Sep 28, 2009)

JPINFV said:


> ^
> The only question that LA City paramedics could ask is if the machine printed out ***Acute MI Suspected***



Yeah, so but this is why ems will not change as far as more skills, I mean we in ems don't have labs or access to any lbs in the field, this lady had to waite several hour in an ED before any real Rx was done, if they can't treat properly in the ED, how can we with limited stuff in field make higher wages or whatever people think were worth when we can't provide a dollar worth service for are patients.


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## JPINFV (Sep 28, 2009)

1. Point of care testing is coming. It's already here in limited form with the iStat, but I imagine that the near future will have faster and cheaper testing.

2. The ability to get lab values has nothing to do with relying on a machine interpretation.


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## cm4short (Sep 28, 2009)

MSDeltaFlt said:


> I can see where the original medic might have benefited from thinking silent MI.  Those little old ladies scare me.  However, your desription of the scenario does not mention what actually transpired in the back of the truck.  What I mean is what actually went on that never made it to the chart.  I wasn't there.  I don't think you were either.



Actually I was there, I have both the sending facilities chart and the FD run sheet, so I do know what went on. This is in addition to our run sheet. 




MSDeltaFlt said:


> A 2 hr wait with a MD at bedside... or at least in the same ER speaks volumes here people.



The 2 hr wait was not due to ED saturation. 



MSDeltaFlt said:


> I'm siding with Tom on this one.



How much elevation must be present for it to be obvious? I mean, is 1mm not good enough for you? I loaded new, larger 12 leads for those of you having trouble seeing the 1st ones in a previous post(pg 6)




MSDeltaFlt said:


> As Tom said, it's not obvious ST elevation.  The computer may have called it that, but it's not obvious.



The Interpretation I listed is from the ED physician, not from the machine. The computers interpretation should be noted, but it is our job to give our own interpretation and make a determination on the direction of care.



MSDeltaFlt said:


> Also, cardiologists don't make STEMI centers; not even the *interventional cardiologists*.  Although I'm assuming that's whom you are referring.  Granted they are the ones doing most of the work, but you can't do interventional cardiology without a cardiothoracic surgeon on standby.  Because if the interventional cardiologist pops an artery while doing the PTCA, or angioplasty, or whatever, then said pt could lose his/her VS in less than a minute.  Translation: you don't have minutes before they die.  You have seconds before the CV surgeon is cracking open the chest.



I'll leave this one alone; as you do need both the proper staffing AND equipment/facility to properly address the needs of the patient.



MSDeltaFlt said:


> And what most don't see is the CV surgery suite ready and waiting.
> 
> What I'm saying is that this particular thread has gone on for several pages saying how crappy this thing is or that thing is when in reality we don't have all of the information.
> 
> ...



As there may be a few facts left out; there is enough to know that CP *should have* been the working diagnosis. I'll admit that we don't know the whole story. But as prehospital providers, how often do we ever? But, we are still able, given an assessment and knowledge, able to come up with the best working Dx. 

Given this scenario; does anyone agree with the prehospital treatment? Or would you have taken another working Dx. Also, If your 12 lead does come out in the manner in which it did; How many would leave as is opposed to trying to correct the reason for artifact/wandering baseline, and get a repeat 12 lead. 

You already should suspect this person is having an MI. The 12 lead is showing where is is approximately. Not, if it is present or not. 

Also, there is a reason why a patient should go to a STEMI if it is suspected, opposed to a Basic Receiving ER. No explanation should be necessary for this


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## MSDeltaFlt (Sep 29, 2009)

cm4short said:


> Actually *I was there, I have both the sending facilities chart and the FD run sheet, so I do know what went on*. This is in addition to our run sheet.
> 
> 1.
> 
> ...


 
1. What I'm saying is you were not there in the back of the truck on the 911 call. How was the pt acting in the back of the truck. Was he unable to keep her calm enough to get a clear reading?  And, yes, I would have redone the ECG.

2. I'm not talking about ED saturation. I'm talking about the MD waiting 2 hrs. That is what is speaking volumes here.

3. Granted. III and aVF are 1mm elevated. I'll retract.

4. Again. Retracted.

5.And that, my friend, is what I'm trying to get you to understand. We don't know the whole story. Odds are we probably never will. The fact is you are the student, not the one in charge (and the power of the authority is humbling when you think about it). You are learning. One thing that we all need to learn, and keep learning I might add, is that we will all make mistakes in our career. We will all fall short. We will all screw up. And having a third party who posts our mistakes in a negative manner on a public forum could be quite counterproductive to learning. 

When you point a finger at somebody, you usually have 3-4 fingers pointing right back at you. 

In the immortal words of my mother to my older Southern Baptist preacher brother when he was in college and getting a little cocky. She wrote him a letter stating that his "sh*t still stinks". He showed that to all of his friends at the BSU.

Again, my humble 0.02


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## TomB (Sep 29, 2009)

cm4short said:


> How much elevation must be present for it to be obvious? I mean, is 1mm not good enough for you? I loaded new, larger 12 leads for those of you having trouble seeing the 1st ones in a previous post(pg 6)



It depends on where you measure the ST-elevation. Generally, the further from the J-point, the higher the sensitivity and the closer to the J-point, the higher the specificity. 

According to the Universal Definition of Myocardial Infarction (PDF) Circulation 2007; 116: 0-0, you measure at the J-point. It also requires 1.5 mm of STE in leads V2 and V3 for women and 2 mm of STE in leads V2 and V3 for men. In the first ECG taken in the emergency department, the J-points are ambiguous and do not appear elevated. But the ECG is still suspicious for injury. The R-wave progression in the anterior leads is poor, the ST-segments are straightened (non-concave), and the T-waves are broad-based and hyperacute-looking in the left precordial leads. Is it a home-run STEMI? No, but it would bear very close observation.

The 1 mm or more of STE in two or more contiguous leads criterion is problematic for several reasons, not the least of which is that AMI is not the most common cause of STE in chest pain patients. Granted, you can rule out LVH, LBBB, and paced rhythm quite easily in this ECG, which leaves BER and ventricular aneurysm as your competing explanations for the ST/T wave abnormality in the precordial leads. In the absence of reciprocal changes (none present on the ECG in question) the best thing to do is look for changes on serially obtained ECGs and obtain cardiac biomarkers as quickly as possible.

The biggest problem with the poor data quality in the prehospital 12-lead ECG is that it could have been the baseline ECG. A concerned ED physician could have compared the prehospital ECG to the admission ECG and seen a difference between the two. Instead, the first ECG taken in the ED became the baseline ECG, and no further ECGs were taken until 2-hours later. I suspect another ECG taken as soon as 5 minutes later would have shown at least subtle changes to suggest the dynamic supply vs. demand characteristics of ACS. I guess we'll never know.

As for whether or not board certified emergency physicians specialize in heart attacks, of course they do! It's the number 1 killer in the industrialized world, and 50% of STEMI patients self-report to the hospital. ED physicians deal with STEMI all the time, whether they work in an ED at a hospital with a cath lab or not. All board certified emergency physicians specialize in the emergency treatment of heart attacks. This was just an honest mistake (by all parties) I'm sure.

Tom


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## VentMedic (Sep 29, 2009)

atropine said:


> Well all I can say is that this woman should have been in LA, there is such a thing known as the perfect fire department in the worl and it's LA City.


 
If you look back at my earlier post on this thread you will see the links for LA and their own admitance of a less than perfect way of doing things.  It is not secret as the results have been published several times to see if there is even an ounce of improvement.


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## VentMedic (Sep 29, 2009)

TomB said:


> It depends on where you measure the ST-elevation. Generally, the further from the J-point, the higher the sensitivity and the closer to the J-point, the higher the specificity.
> 
> According to the Universal Definition of Myocardial Infarction (PDF) Circulation 2007; 116: 0-0, you measure at the J-point. It also requires 1.5 mm of STE in leads V2 and V3 for women and 2 mm of STE in leads V2 and V3 for men. In the first ECG taken in the emergency department, the J-points are ambiguous and do not appear elevated. But the ECG is still suspicious for injury. The R-wave progression in the anterior leads is poor, the ST-segments are straightened (non-concave), and the T-waves are broad-based and hyperacute-looking in the left precordial leads. Is it a home-run STEMI? No, but it would bear very close observation.
> 
> ...


 

So essentially some are arguing that there is only ONE possible cardiac condition that this patient could have and it all centers around the MI?

There are so many more conditions concerning the whole cardiovasular system that may have to be addressed and it may need to be done at a specialty center. ECG changes are also indicative of many other issues and some may mimic the MI in appearance. It also may be a condition that is time sensitive so while some are just waiting for the ST segments to elevate, this woman's condition may not be getting any better. ED physicians should know when to consult and/or refer the patient to a higher level of care as was done here. Get over the short sightedness of just one possible diagnosis.

You are also assuming this hospital only did 1 or 2 ECGs. You are also assuming the time lapse if from them waiting when it could be difficulty with finding hosptial acceptance and appropriate transportation.

We don't have the whole story, the timeline or what all was done to this patient in the ED.


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## TomB (Sep 29, 2009)

Hind-sight is 20/20, but clearly this patient was experiencing STEMI. I thought the person who posted the ECGs stated that the second ECG wasn't taken until 2 hours later when the biomarkers came back positive.

Tom


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