A proper 12 lead would've done wonders.

[Akulahawk]

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.

No wheezing and some classic signs of MI in a female with history of Diabetes.... and the patient was treated with Albuterol/Atrovent? I get the feeling that the field 12-lead was done AFTER they gave the Duo-Neb... as one of those "Oh, yeah.... she might be having an MI..."

 

[MrBrown]

...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?

You're right! I read this originally about what, 5am and must have missed it; wow thats shonky.

 

[Dwindlin]

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.

Could have been wheezing unless there was something I missed from another post.

 

[MSDeltaFlt]

I'm holding my opinions until I see some 12 leads.

 

[Smash]

Could have been wheezing unless there was something I missed from another post.

No wheezes noted

Yep, you missed something from the first post

Oh well, I suppose it's a good stress test for the myocardium giving it a flogging with albuterol

 

[FFMedic75]

Things like this are happen all over the country, everyday, in every different type of setting. It doesn't matter if it is fire based, private, or third service. Every system has awful medics. Not everyone has the problem solving skills that it truly takes to do this job. Anyone can memorize anatomy, but what it takes to be a quality medic is problem solving, and assessment skills. To develop and refine these it takes initiative and a strong will to excel at your chosen profession. These problems begin with the medics themselves, when we screw up at work the person doesn't get the wrong hamburger, they die. If you want to do this profession take every opportunity to better yourself. The next problem is instructors around the country are getting worse and training is being cut. I once helped with skills at a medic class and was told by the students that an instructor told them to give everyone SOB Albuterol and if it didn't work give them Lasix, because it must be pulmonary edema. I promptly reported this but he still teaches at the same place, and probably teaches the same misinformation. The last problem is, with the medic shortage that has existed till very recently systems were reluctant to address problems like this because it was all about having numbers to staff trucks. The OT budget was more important than quality care, and that came from far above a fire chief or EMS director. Until medical professionals take ownership in their skills and the care they provide, there is quality training readily available, and systems go for quality not quantity when hiring these situations will continue.

 

[JPINFV]

Is it possible to motivate providers who view EMS as nothing more than a burden that they have to bear to do their dream job to care about their assessment and patient care ability?

 

[46Young]

Is it possible to motivate providers who view EMS as nothing more than a burden that they have to bear to do their dream job to care about their assessment and patient care ability?

there are plenty of individuals working in the privates, third service, and hospital based EMS who are only (barely) tolerating the job while they finish their degree, or are waiting for one of their civil service apps to come back with a job offer(fire, PD, sanitation, etc). It goes both ways.

I don't know about motivation, but I feel that many of these problems could be mitigated by strict QA/QI and equally strict accountability.

During our hiring process and recruit school, the importance of EMS and being a competent provider was repeatedly stressed. Anyone that comes here knows what's up.

 

[MrBrown]

... I once helped with skills at a medic class and was told by the students that an instructor told them to give everyone SOB Albuterol and if it didn't work give them Lasix, because it must be pulmonary edema....

Dude are you serious? .... that's like saying "well that patient is not moving, he must be dead because dead people do not move!"

I am horrified :sad:

 

[Smash]

Dude are you serious? .... that's like saying "well that patient is not moving, he must be dead because dead people do not move!"

I am horrified :sad:

You should probably push some narcan before you call it. You know, just in case...

 

[AZFF/EMT]

Some of you guys are funny with the FF=Horrible medic logic. Sad.

 

[AZFF/EMT]

Or maybe I am very blessed to work in an area where every single person realizes that ems is 80%+ of our workload and if not for EMS we would be volunteer's. Out here its the privates that are very scary, and of course there are scary fire medics as well, but the way some of you guys talk WE kill people daily and ems only guys are superhero's because only YOU care enough. I had 2 ems runs yesterday, helped extrication and treatment on an MVA rollover-X and had a house fire in the morning. I don't think being a dual role FF made popping a door, pulling drywall and providing quality ems something that is impossible.

 

[cm4short]

Got those 12 leads finally

FD Copy


ER Copy 1

ER Copy 2

"one of these 12 leads is not like the other":unsuresesame street song)

 

[VentMedic]

Or maybe I am very blessed to work in an area where every single person realizes that ems is 80%+ of our workload and if not for EMS we would be volunteer's.

Do you not think you are a little over assuming when you speak for ALL of your FFs? Do you not think that some of your FFs might just want to be a Fire Fighter and specialize as such to perfect that profession? Do you think EVERYONE of your coworkers are happy to be forced to be a Paramedic? They may realize that EMS is 80% of the workload but that still does not automatically make them enthusiastic to be a health care provider. But then, do any of them identify themselves as a health care provider?

How can you have 1000 FFs, all with a Paramedic patch, all equally happy about being a Paramedic and doing patient care or running medical calls all 24 hours? That is a tall task for even the most professional of FDs. At least if a Paramedic isn't up to par on a private ambulance, they can easily be replaced by someone who can do the job.

 

[cm4short]

Or maybe I am very blessed to work in an area where every single person realizes that ems is 80%+ of our workload and if not for EMS we would be volunteer's. Out here its the privates that are very scary, and of course there are scary fire medics as well, but the way some of you guys talk WE kill people daily and ems only guys are superhero's because only YOU care enough. I had 2 ems runs yesterday, helped extrication and treatment on an MVA rollover-X and had a house fire in the morning. I don't think being a dual role FF made popping a door, pulling drywall and providing quality ems something that is impossible.

It doesn't matter who you're employed by; it the motive behind it. Because there are too many people who got into this profession to put out fires. THe fact that most department primarily hire medics made everyone jump on the bandwagon for the wrong reason. Because of that, prehospital care is always a second priority for these guys. And, the ones that get hired, and don't get hired, bring the industry down primarily for that reason.

But I have also seen both quality FF's and single role medics.

 

[MrBrown]

If that 12 lead was acquired prehospitally here you'd be shot ... probably literally!

 

[AZFF/EMT]

I guess I cannot say every single person that would be foolish, most though. Not everyone is a paramedic or forced to be a paramedic. We are about 50/50. Everyone does have to be an EMT-B. For a while it was seen as easier to get hired in the metro phoenix area as a medic simply because if there are 500 applicants for 10 spots which will be 5 basics and 5 medics it is usually 450 basics testing and 50 medics. I feel sorry for departments who get the guys who became medics only to get on but dont want to do the job, these guys are usually turds altogether not just as medics. They want shirts that say FF, and union stickers for the lifted truck, ect.

 

[AZFF/EMT]

And man I really hope the medic with that poor 12 lead was having true trouble getting a good one, because man wewould also be in trouble for that.

 

[Aidey]

Can we please not turn this into a debate about Fire based EMS vs Private EMS?

It's hard to really look at the 12 leads because we can't zoom in. Even so, the ST elevation is obvious in the two from the ED. How long was the first one taken after the pt arrived at the ED? How long apart were they taken?

 

[AZFF/EMT]

Did they get a standard 4 or whatever monitor set-up they have basic ecg? Should have been able to see elevation in III and AvF