A proper 12 lead would've done wonders.

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cm4short

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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.
 
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.
 
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.
 
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.
 
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
 
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.
 
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.
 
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
Click to expand...

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.
 
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.
 
Wonder if they properly prepped the skin?
 
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.
Click to expand...

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.
Click to expand...

*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.
 
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.
Click to expand...


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
 
San Bernardino County FD ran the initial 12 lead
 
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.
Click to expand...

You are right but the reason fire is jumped on is its big union has fought many advancements in EMS.
 
cm4short said:
San Bernardino County FD ran the initial 12 lead
Click to expand...

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.
 
MrBrown said:
Again, that was haaaaarsh :)
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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......
 
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
Click to expand...

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.
 
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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