Shishkabob
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Holy cow, did they have the patient jumping around while analyzing the 12-lead?
A proper 12 lead would've done wonders.
- Thread starter cm4short
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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.
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.
Aidey
Community Leader Emeritus
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: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:
TomB
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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.
medic417
The Truth Provider
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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.
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.
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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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
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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
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
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.
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.
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.
TomB
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Show me the evidence that NSTEMI patients benefit from immediate PCI.
The ED physician and cardiologist can do whatever they please. That doesn't make it an evidence based practice.
Why would you? Even if it were possible to distinguish between UA and NSTEMI in the field?
Anything could be considered. I'm just not aware of any evidence that NSTEMI patients benefit from immediate PCI.
Whether they can or can't is irrelevant. It's not indicated for NSTEMI.
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!
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.
I don't recall bashing private EMS.
I don't recall discussing fire suppression.
I'm not sure where that came from, but okay.
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.
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.
TomB
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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
Thanks for the link.
Tom
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.
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.
medic417
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fma08
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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
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Not a medic, but hard for me to see and ST elevation??
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.
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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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.
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.
