A proper 12 lead would've done wonders.

[JPINFV]

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.

 

[cm4short]

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.

 

[cm4short]

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.

 

[medic417]

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.

 

[MSDeltaFlt]

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.

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.

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.

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.

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.

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.

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...

 

[Dwindlin]

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.

 

[atropine]

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.

 

[JPINFV]

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

 

[atropine]

^
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.

 

[JPINFV]

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.

 

[cm4short]

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.

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.

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)

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.

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.

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...

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

 

[MSDeltaFlt]

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.


The 2 hr wait was not due to ED saturation.

2.

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)

3.


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.

4.

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.



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

5.

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

 

[TomB]

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

 

[VentMedic]

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.

 

[VentMedic]

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

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.

 

[TomB]

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