12 lead relative to SOB

[vquintessence]

Just a general question for fresh graduates/green providers:

When confronted with a c/c of SOB, a 12 lead is obviously warranted. Lets focus the situation further to describe that SOB is acute and LS are clear bilat. Upon evaluation pt refers to a sharp, pleuretic CP. {Going to stop description of further s/s there, to prevent muddling the coming question}
Regarding the 12 lead, there is no acute STE found in consecutive leads nor any reciprocal changes noted anywhere to point towards STEMI. What OTHER information beyond rhythm recognition, are you taught to look for on the 12 lead that could be pertinent to a c/c of SOB?

(Background: I'm trying to discern whether the lack of knowledge is a local education concern, or simply a change in the basic paramedic cirriculum) Your answers will help guide the focus/criteria of future application & orientation testing for my organization. Thanks in advance guys & gals!

 

[boingo]

arrhythmia, chamber enlargement, bundle branch blocks, and strain patterns for starters.

 

[VentMedic]

cor pulmonale and pulmonary embolus

 

[TomB]

Low voltage and electrical alternans.

 

[vquintessence]

Ok, nobody's really biting and I was pretty vague, so here's the trouble:

The c/c is acute SOB and LS are clear bilat. Upon evaluation pt refers to a sharp, pleuretic CP.

Then they're shown an ECG and asked to identify any abnormalities and asked give a brief ramble on a focused treatment. The significant findings on the ECG shows an incomplete RBBB, s wave lead I, q wave lead III with an inverted t wave.

Many will note the RBBB but don't associate it with the complaint. Additionally nobody picks up S1Q3T3 as being significant, nor even being related to the c/c. The only answers that are being seen are ACS algorithms, with a few mistaking the RBBB for inferior STEMI.

So here's my concerns... is this being taught still? Is the cirriculum still mentioning the possible ECG findings for PE? Is the question poorly worded or too misleading? It wouldn't be right to penalize somebody during an entrance exam if that's the case... instead would more appropriate to teach during orientation process?

 

[Ridryder911]

I wish I could say yes. There is so much differential in education and training. For example in 25 mile radius one Paramedic school teaches central lines, 15 leads, etc... then another does not even teach 12 leads.

I recently sat as an evalator for NREMT Paramedic test. It was well..... just embarrassing. Not able to identify SR w/PAC's simple 3'rd degee blocks and not knowing to cardiovert unstable VT. Out of 30+ 3 only passed the 1'st time. I do not what school or even what state they came from ( I was informed they might have been from out of state).

Actually, what has occurred is the curriculum never have covered such material. I, Vent and other(s) fortunately had well knowing professors and instructors that knew what we needed. We also had the fortitude to widened and increased our education. We also knew how they taught in medical school and expected the same method.

I am alike you, I am attempting to test and improve our education/hiring system. We are overhauling our FTO program.

What I have seen is newer graduates feeling intimidated if challenged or questioned. This was an assumption while I was in Paramedic school and was the usual passing thought of the day of quizzing each other. Each month, review of "bad calls" were review and one had to justify their treatment. It was not to criticize but to ensure that the Paramedic knew and understood the full reasons and actions what & why they did.

R/r 911

 

[TomB]

The most common ECG abnormality associated with PE is sinus tachycardia, not S1Q3T3. I'm not sure an ECG finding this obscure is particularly relevant to the prehospital environment (or even in emergency medicine). Just my opinion.

Tom

 

[vquintessence]

The most common ECG abnormality associated with PE is sinus tachycardia, not S1Q3T3.

Yep definitely agree there. S1Q3T3 specifically occurs less than 1/5th the time, even in the acute phase, but I'd consider ~20% significant enough to relate a question to, especially with the question provided with an obvious direction. I wish I could attach the physical copy of the ECG we use on the exam.

I'm not sure an ECG finding this obscure is particularly relevant to the prehospital environment (or even in emergency medicine). Just my opinion.

Sure it's uncommon, but I respectfully disagree about it being irrelevant. Some PE's can be easy to dismiss and can be lost in traffic between the pts initial complaint and arrival at definitive care. An ECG is far removed from any stand alone / definitive diagnostic value, but irrelevant is harsh. Having the ability to walk into an ED with the rational influence and suggestive evidence of a pts complaint is gold.

I am a strong believer that competent EMS plays a role in at least pointing the initial direction of definitive care a pt will receive at a hospital. We already do it for situations ranging from STEMI's via off-site cath activation; to taking geriatric psychs to facilities equipped to handle their special needs; to recognizing the severity of a 2nd degree circumferential burn to a pts hand then transporting to appropriate burn facility.

 

[paccookie]

I wish I could say yes. There is so much differential in education and training. For example in 25 mile radius one Paramedic school teaches central lines, 15 leads, etc... then another does not even teach 12 leads.

I recently sat as an evalator for NREMT Paramedic test. It was well..... just embarrassing. Not able to identify SR w/PAC's simple 3'rd degee blocks and not knowing to cardiovert unstable VT. Out of 30+ 3 only passed the 1'st time. I do not what school or even what state they came from ( I was informed they might have been from out of state).

Actually, what has occurred is the curriculum never have covered such material. I, Vent and other(s) fortunately had well knowing professors and instructors that knew what we needed. We also had the fortitude to widened and increased our education. We also knew how they taught in medical school and expected the same method.

I am alike you, I am attempting to test and improve our education/hiring system. We are overhauling our FTO program.

What I have seen is newer graduates feeling intimidated if challenged or questioned. This was an assumption while I was in Paramedic school and was the usual passing thought of the day of quizzing each other. Each month, review of "bad calls" were review and one had to justify their treatment. It was not to criticize but to ensure that the Paramedic knew and understood the full reasons and actions what & why they did.

R/r 911

I would LOVE to find an environment where constructive criticism is welcomed and encouraged. At my service, it's almost discouraged to critique someone else's calls. I always want to know if someone else can offer an opinion on something I may have done better or differently or something I might have missed. We all like to hear what we've done right, but no one wants to hear about what they've done wrong.

 

[usafmedic45]

At my service, it's almost discouraged to critique someone else's calls.

Trust me, it's not a lot of fun to be "that guy" at a service. It was my job for a long time. Needless to say, it's a necessary evil and I would not work in any system where critique was not encouraged. Actually I would not work in one where it was not mandatory for certain types of cases.

 

[paccookie]

Trust me, it's not a lot of fun to be "that guy" at a service. It was my job for a long time. Needless to say, it's a necessary evil and I would not work in any system where critique was not encouraged. Actually I would not work in one where it was not mandatory for certain types of cases.

I didn't mean that no one QA's the calls. Certain calls - trauma, chest pain, no transport, cardiac arrests, a few others I can't remember - are ALWAYS gone over with a fine-toothed comb. Lately they've focused on narrative writing and documenting interventions. What I meant was that it's not encouraged to pick apart calls amongst the medics or EMTs. Of course we talk, but when the talk becomes critical, they tend to hush it up. I know it sucks to be on the receiving end when your call went wrong, but how else can you learn to correct those mistakes next time?

 

[medic3416]

I agree with Tom, very uncommon findings for PE. Most PE patients present with a combination of these signs and symptoms:, tachypnea, anxiety, oxygen refractory hypoxia, low SpO2, and cyanosis, tachycardia, hypotension, diaphoresis, sharp pleuritic CP usually worse with inspiration, all these coupled with risk factors such as obesity, recent surgery or trauma, PMHX of A-Fib and or DVT’s.

I might consider a 12-lead more so to rule out cardiac related CP and SOB. A 12-lead might be otherwise useful pre-hosp if there is time, however these pt’s tend to crash quickly. Not to mention that it is near impossible to get a decent tracing on these pt’s due to anxiety.

All that being said, I was taught the above mentioned signs and symptoms in general for PE recognition as well as the fact that in addition to tachycardia the most common changes seen on EKG with PE were ST-segment changes (non-specific) and T-wave inversion in V1-V4 as well as right heart strain and signs such as atrial enlargement RVH, axis deviation and new or paroxysmal atrial tachycardia’s.
I have to admit however, that although I have read about the S1Q3T3 on my own, I don’t believe I was taught that in medic school and I have not looked for it in PE patients.

Very cool thread! B)

 

[TomB]

Yep definitely agree there. S1Q3T3 specifically occurs less than 1/5th the time, even in the acute phase, but I'd consider ~20% significant enough to relate a question to, especially with the question provided with an obvious direction. I wish I could attach the physical copy of the ECG we use on the exam.

Sure it's uncommon, but I respectfully disagree about it being irrelevant. Some PE's can be easy to dismiss and can be lost in traffic between the pts initial complaint and arrival at definitive care. An ECG is far removed from any stand alone / definitive diagnostic value, but irrelevant is harsh. Having the ability to walk into an ED with the rational influence and suggestive evidence of a pts complaint is gold.

I am a strong believer that competent EMS plays a role in at least pointing the initial direction of definitive care a pt will receive at a hospital. We already do it for situations ranging from STEMI's via off-site cath activation; to taking geriatric psychs to facilities equipped to handle their special needs; to recognizing the severity of a 2nd degree circumferential burn to a pts hand then transporting to appropriate burn facility.

I guess I'm looking at it this way. S1Q3T3 is neither particularly sensitive nor specific for PE. I don't have any objection to teaching it, but it seems to me a relatively obscure ECG abnormality to concentrate on when viewed in the context of how many critical concepts there are for paramedics to master when it comes to ECG interpretation. That's all!

Tom