Activated HEMS for LBBB: Made the right call?

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snarff

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A little background. I a very new paramedic like 4 months. I currently work a flex time job in a rural county. Where you are the only medic and run a ALS chase car and hope one of the volunteer squad's meet you on scene. So this system is to say the least is not ideal.

Now on to a call I had the other night. Chest pains difficulty breathing 70yo male. I arrive (30minute response.) Volunteers arrive maybe 5 minutes before me in a BLS ambulance. Pt is laying down in bed pale and diaphoretic, he says it just started when he "got a coke" no physical exertion or injury before the pain. rates it an 8 out of 10. and no radiation stays in center of chest. Waited 1 hour after pain to call 911.

He has history of high cholesterol, diabetes and hypertension. Vitals I cant remember but they were not wild or anything like that. Get him to the truck do a 12 lead and start an IV. 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.
I Give him asprin and nitro. 45 minutes away from a hospital with a cath lab but no surgery and 1 hour and 30 minutes from a hospital with a cath lab and heart capabilities. So I call for the helicopter and that was pretty much the end of the call.

Anyways I am asking if this was a good call because some former employees used the helicopter for anything. So now when it gets call you pretty much have to justify why you did it. So next week I have to give justification when I go in. He did not meet heart alert criteria so what do you guys think?
 
I think you made the right choice. Not all cath labs are staffed or emergent cath labs, and if you felt acs, it is more appropriate to go to the Real Hospital.
 
I'd say if anyone gives you a hard time about the helicopter tell them to pound it.

Does the closer cath lab hospital do PCI? Or not without surg backup? If they do and depending on actual time for helicopter arrival/load/transport/unload that still may be an option.

The patient himself, as you present it, is concerning enough to send if that's his persistent presentation over the hour since onset. If a spray of nitro and he's all of a sudden feeling fine and dries up, then maybe not. Otherwise, go for it.

And as an aside, I hate places that make people feel like crap for calling a helicopter. That just makes people less likely to do it which hurts no one but the patient.
 
Yes. You made the right call. You can't fake skin signs.

You say he didn't exert himself, did he have a fridge next to the bed? Otherwise he did exert himself by walking to get the coke.

Lung sounds? Pain resolved or changed with nitro?
 
Merck said:
I'd say if anyone gives you a hard time about the helicopter tell them to pound it.

Does the closer cath lab hospital do PCI? Or not without surg backup? If they do and depending on actual time for helicopter arrival/load/transport/unload that still may be an option.

The patient himself, as you present it, is concerning enough to send if that's his persistent presentation over the hour since onset. If a spray of nitro and he's all of a sudden feeling fine and dries up, then maybe not. Otherwise, go for it.

And as an aside, I hate places that make people feel like crap for calling a helicopter. That just makes people less likely to do it which hurts no one but the patient.
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They do PCI without surgery backup. The patient stated very little relief after the nitro rated it a 7 out of 10. The helicopter was on the ground in 15 minutes after the call and Flew him to the main hospital the one that was an hour and half away.
 
Corky said:
Yes. You made the right call. You can't fake skin signs.

You say he didn't exert himself, did he have a fridge next to the bed? Otherwise he did exert himself by walking to get the coke.

Lung sounds? Pain resolved or changed with nitro?
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Lungs clear. He stated after he got a coke he was standing there drinking it and noticed pain.
 
Ehhh, I'm going to disagree and say I don't really think it was needed, but that is without seeing the 12 lead or the patient - it's possible I might think different if I could have been there. I've fallen behind in my readings on ECGs, but I believe the "new LBBB" criteria for MI has more or less been debunked as a reason for cath-lab activation (e.g. http://www.ncbi.nlm.nih.gov/pubmed/19857407), though it is still frequently cited as an indication for cath-lab alert. Also, there have been a few studies showing that it is safe to do PCI without on site surgical backup (http://www.ncbi.nlm.nih.gov/pubmed/22443460).

And though "pale and diaphoretic" is always worrisome, it doesn't always mean "MI". If it was a full-on STEMI (or because of the LBBB, met Sgarbossa's Critera) or the patient was quite unstable, then I think it would have been a good choice.
 
Its hard to say without being there. Do you have a copy of the 12 lead? Also it might be worth noting that most people with LBB or any BBB are not told they have one by their physicians.
 
snarff said:
They do PCI without surgery backup. The patient stated very little relief after the nitro rated it a 7 out of 10. The helicopter was on the ground in 15 minutes after the call and Flew him to the main hospital the one that was an hour and half away.
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So did he end up in the OR or with some type of PCI?

I guess it depends on your protocols, but there are a lot of hospitals out there (at least in my area) with cath labs with PCI capabilities, but of course not all of them are up 24/7. As time goes by, we continue to see fewer and fewer CABG patients and far more with stents. Also, we don't see that many failed PCI's from our cath lab either. But you're the one on scene with the patient, and are aware of the particulars for your area, so regardless it's your call and I wouldn't second guess it.
 
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To me the point is the 12 lead is almost irrelevant. Sounds like it was somewhat convincing for ACS and with the S&S it seems like a good call.

I think the real point is that for a new medic, on their own, with 4 months of experience, it's not the wrong call to err on the side of the patient.
 
Merck said:
I think the real point is that for a new medic, on their own, with 4 months of experience, it's not the wrong call to err on the side of the patient.
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Works for me. Good one. See if you can find out the lab finding and the pt outcome.
 
snarff said:
12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.
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Normally I make it a point to not comment on an ECG I haven't laid eyes on, but assuming this is true it may have been a STEMI. Typically LBBB has an upright QRS in lead aVL and negative QRS in leads III and aVF. So, ST-elevation in lead aVL would be concordant ST-elevation and ST-depression in leads III and aVF would be concordant ST-depression. Having said that, if you called for aeromedical transport based on a possible new LBBB (and that was your only ECG-based criterion) then I would suggest it was not in the patient's best interest. It's risk/reward. But then, something is wrong if paramedics are out there making these kinds of decisions in isolation without strategic-level folks working it out ahead of time in an organized system of care.
 
snarff said:
A little background. I a very new paramedic like 4 months. I currently work a flex time job in a rural county. Where you are the only medic and run a ALS chase car and hope one of the volunteer squad's meet you on scene. So this system is to say the least is not ideal.

Now on to a call I had the other night. Chest pains difficulty breathing 70yo male. I arrive (30minute response.) Volunteers arrive maybe 5 minutes before me in a BLS ambulance. Pt is laying down in bed pale and diaphoretic, he says it just started when he "got a coke" no physical exertion or injury before the pain. rates it an 8 out of 10. and no radiation stays in center of chest. Waited 1 hour after pain to call 911.

He has history of high cholesterol, diabetes and hypertension. Vitals I cant remember but they were not wild or anything like that. Get him to the truck do a 12 lead and start an IV. 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.
I Give him asprin and nitro. 45 minutes away from a hospital with a cath lab but no surgery and 1 hour and 30 minutes from a hospital with a cath lab and heart capabilities. So I call for the helicopter and that was pretty much the end of the call.

Anyways I am asking if this was a good call because some former employees used the helicopter for anything. So now when it gets call you pretty much have to justify why you did it. So next week I have to give justification when I go in. He did not meet heart alert criteria so what do you guys think?
Click to expand...

Did you do a V4R? I personally think you did the right thing. Our protocol states that if MI is suspected, and we are more than 30 MINUTES ( big difference from mileage in our area) then we fly them. I would rather justify why I did, then why I didn't.
 
Interesting case presentation, but is lacking the most informative aspect in a BBB differential. What did V1 reveal?

The inferior leads are not consistent as described for an MI, and a right sided EKG really wouldn't be a forethought in my mind at this point.

Treat for ACS and transport expeditiously. Would have I called for air? They way this has been described, no. If it was truly a new onset LBBB, then yes I would have considered it.

Be cautious with "erring on the side of the patient". Slapping someone with a $10-20k bill for simple angina and risking a valuable air resource is not in the best interest of anyone involved. Just like field activation of a cath lab, you have to be absolutely accurate in your assessment and findings.
 
snarff said:
Get him to the truck do a 12 lead and start an IV. 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.
Click to expand...

New LBBB is not a STEMI.

LBBB with primary ST-changes is a STEMI.

LBBB always has ST-changes, just they are secondary to the abnormal depolarization thru the bundle branches (think abnormal repol whenever you have abnormal depol, hence you should expect to see ST/T-wave changes in RBBB/LBBB).

If aVL was predominantly positive with concordant ST-elevation, I'd say you had a winner.

Here are some resources on LBBB + STEMI (bias alert, I was involved in some of these articles):
 
I think it's distressing to hear a new medic being told to be careful erring on the side of the patient. Now, my particular bias here is that in Canada no one gets stuck with a bill, so there is that.

Paramedics love to play mini-cardiologist, Snarff. Yes there is a ton to them and even when you think you're good at them there is still more to know. I'd take this case as one that will prompt you to increase your knowledge of 12 leads to help you make decisions in the future.

However, a 12 lead is only part of the picture. I have not attended many angina patients with unrelenting diaphoresis and pain not controlled by nitro. At that stage I question whether it's a, MI or possibly a different diagnosis all together. With what you've said, good job on the helicopter and I would never give a ground crew a hard time for calling us in for something like that.
 
I was gonna mention the Sgarbossa criteria but Christopher beat me to it.

From what you're saying I'd say you made the right call. Yea we have to think of finances at well but that the end of the day if we save the patient on a helo bill but he has a poor outcome due to the delay of definitive care have we really actually helped?
 
Merck said:
Paramedics love to play mini-cardiologist, Snarff.
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By this logic knowing how to intubate means you like to play mini-anesthesiologist. But you'd never say that, right? Because you know how to intubate?
 
snarff said:
A little background. I a very new paramedic like 4 months. I currently work a flex time job in a rural county. Where you are the only medic and run a ALS chase car and hope one of the volunteer squad's meet you on scene. So this system is to say the least is not ideal.

Now on to a call I had the other night. Chest pains difficulty breathing 70yo male. I arrive (30minute response.) Volunteers arrive maybe 5 minutes before me in a BLS ambulance. Pt is laying down in bed pale and diaphoretic, he says it just started when he "got a coke" no physical exertion or injury before the pain. rates it an 8 out of 10. and no radiation stays in center of chest. Waited 1 hour after pain to call 911.

He has history of high cholesterol, diabetes and hypertension. Vitals I cant remember but they were not wild or anything like that. Get him to the truck do a 12 lead and start an IV. 12 lead shows a LBBB, st depression in III and AVF with ST elevation of 1mm in AVL. He stated he has never been told he has a LBBB so this could be new.
I Give him asprin and nitro. 45 minutes away from a hospital with a cath lab but no surgery and 1 hour and 30 minutes from a hospital with a cath lab and heart capabilities. So I call for the helicopter and that was pretty much the end of the call.

Anyways I am asking if this was a good call because some former employees used the helicopter for anything. So now when it gets call you pretty much have to justify why you did it. So next week I have to give justification when I go in. He did not meet heart alert criteria so what do you guys think?
Click to expand...

I believe we're missing a lot of information here and it is sounding like people are wanting to treat a machine they haven't seen instead of treating a patient they haven't laid eyes on.

What were the vital signs? What were the breath sounds? Heart sounds? Did the patient have a cough? Productive? For how long? What color? Any edema? Pitting? Where? How deep? What did the CP feel like? What made it better? What made it worse?

Basically what I'm asking is, if there was no 12 lead available, what clinical presentation was there that indicated cardiac?

Bare in mind I am in no way criticizing or second guessing your decision.
 
MSDeltaFlt said:
I believe we're missing a lot of information here and it is sounding like people are wanting to treat a machine they haven't seen instead of treating a patient they haven't laid eyes on.

What were the vital signs? What were the breath sounds? Heart sounds? Did the patient have a cough? Productive? For how long? What color? Any edema? Pitting? Where? How deep? What did the CP feel like? What made it better? What made it worse?

Basically what I'm asking is, if there was no 12 lead available, what clinical presentation was there that indicated cardiac?

Bare in mind I am in no way criticizing or second guessing your decision.
Click to expand...

Vitals p89, BP 128/78, sp02 94%, lungs clear, didn't get heart sounds, no cough, no edema. Cp felt like pressure and he stated he felt it was hard to catch his breath. He stated nothing made his pain better or worse. He stated it stayed constant from onset throughout. Skin was pale and diaphoretic.

In my limited experience I felt it was cardiac before I saw a 12 lead. I guess I was looking for is what would a more experienced provider do given the same situation.

Anyways one of the flight medics is going to call me tomorrow and let me know what happened, so when I find out I will let you guys know.
 
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