Anterior Ischemia or Syncope?

[teedubbyaw]

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

 

[Medic Tim]

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

 

[teedubbyaw]

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

 

[GoldcrossEMTbasic]

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

"Whatcha Talkin' About Medic!":rofl:

 

[mycrofft]

Sorry I was mocking MedicTim and talking about diagnosing.

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

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


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

 

[Christopher]

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

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

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

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

Do not attempt to localize ischemia with ST-depression.

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

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

 

[Handsome Robb]

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

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

 

[teedubbyaw]

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

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

I don't think OP has taken cardiology.

 

[Christopher]

I don't think OP has taken cardiology.

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

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

 

[Handsome Robb]

I don't think OP has taken cardiology.

That was the point.

Thanks.

 

[Jon]

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

OP: Sounds like a VERY textbook syncope call.

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

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


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


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

 

[GoldcrossEMTbasic]

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

 

[Jon]

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

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

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

 

[Handsome Robb]

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

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

 

[GoldcrossEMTbasic]

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

 

[Handsome Robb]

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

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

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

 

[chaz90]

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

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

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

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


*Apologies for the off topic post by the way.

 

[mycrofft]

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

Thanks to a PODIATRIST.

 

[jrm818]

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

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

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

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

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

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

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

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

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

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

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

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

Come back with questions not opinions.

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

Good luck.

 

[chaz90]

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

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

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

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

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

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

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

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

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

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

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

Come back with questions not opinions.

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

Good luck.

^ This. Just this, +100.