Cardiac Associated Symptoms

[Masenko]

An ER doctor I spoke with the other day has a theory that generally, paramedics can spot associated symptoms of cardiac issues, and therefore start treatment for cardiac emergencies quicker, than ER doctors can. Even in the ER.

My take (as a new paramedic student) is that paramedics 12-lead very often anyway, and that is why they can start earlier.
But now that I think about it that's more of a factor outside rather than inside the ER. And 12-leading is cheating if we are just talking assessments and recognition of associated symptoms only... but I'm getting off track

I mentioned this but he still thinks it has to do with the way paramedics think through assessments for various reasons.

Any thoughts? It seems like this would be difficult to study.

 

[JPINFV]

Well, in general I'm being handed a 12 lead before I can even ask, "What can we help you with today?" if the complaint can be even vaguely cardiac related. The 12 lead is, at the latest, done before I can even complete an HPI. Many hands, light work.

 

[Masenko]

Interesting! Still I wonder where that theory is coming from then.
It's interesting how technology is relied so heavily upon these days. It might be cool to see how these issues will be handled when the lights go out!

 

[Aprz]

Jesus Christ, why do people still want to diagnose a STEMI without a 12-lead?

 

[VFlutter]

Sure, whatever helps you sleep at night.

Any type of "I can do ____ better than the ER physician" mentality is dangerous.

 

[MSDeltaFlt]

An ER doctor I spoke with the other day has a theory that generally, paramedics can spot associated symptoms of cardiac issues, and therefore start treatment for cardiac emergencies quicker, than ER doctors can. Even in the ER.

My take (as a new paramedic student) is that paramedics 12-lead very often anyway, and that is why they can start earlier.
But now that I think about it that's more of a factor outside rather than inside the ER. And 12-leading is cheating if we are just talking assessments and recognition of associated symptoms only... but I'm getting off track

I mentioned this but he still thinks it has to do with the way paramedics think through assessments for various reasons.

Any thoughts? It seems like this would be difficult to study.

Negative, Ghostrider. Paramedics can diagnose cardiac related symptoms with or without 12-leads faster, generally, because the paramedic only has one patient and usually has himself and his partner to perform assessments, skills, and give meds. Whereas the ER physician typically has 10, 15, or 20+ patients at one time at least that he has to assess, order tests to be done, procedures to be performed, and meds to be given. Orders are given and/or written then he/she waits for results.

There are very few hospitals where assessments, 12-leads, IV's, and meds can be completed from the very moment patient contact is made faster than EMS. It's logistics, poloicy, and personnel.

 

[JPINFV]

It's interesting how technology is relied so heavily upon these days. It might be cool to see how these issues will be handled when the lights go out!

1. Well, the only other way to diagnose a STEMI is in the cath lab.

2. If the lights went out, then so does the lab, which means no enzymes, and there's way too many causes of chest pain than to just assume that all chest pain is cardiac.

3. If the lights go out, so does radiology/PACS, and I can't read films. They're kinda of helpful for ruling out some major causes of chest pain.

4. When there's 2 nurses, a tech, a medical student, and a physician in the room, multiple things go on at the same time.

5. You say "wow" to that? When anything vaguely neurological comes in we call a Code Stroke. I've had to stop my exam because CT was ready and continue when the patient came back.

 

[JPINFV]

Negative, Ghostrider. Paramedics can diagnose cardiac related symptoms with or without 12-leads faster, generally, because the paramedic only has one patient and usually has himself and his partner to perform assessments, skills, and give meds. Whereas the ER physician typically has 10, 15, or 20+ patients at one time at least that he has to assess, order tests to be done, procedures to be performed, and meds to be given. Orders are given and/or written then he/she waits for results.

There are very few hospitals where assessments, 12-leads, IV's, and meds can be completed from the very moment patient contact is made faster than EMS. It's logistics, poloicy, and personnel.

Our interventions are riskier as well. We're not going to throw every chest pain patient on heparin or run them to the cath lab just because they have chest pain. Seriously, what's the worse you're going to do with a little aspirin and nitro?

 

[Jambi]

For the OP:

It might do good to remember that people will find what's expected. Kind of like stereotyping. We've been trained to have an incredibly high index of suspicion when it comes to chest pain so we tend to categorize complaints that could be cardiac related into ACS, thus it's only natural that we catch so many, so often, in the system we have setup in most parts of the country. Yes this is a broad brush I'm painting with, but I think it's fairly accurate. In a sense we practice the medical version of shot-them-all-and-let-god-sort-them-out, but in this case it's the emergency physician that's ultimately stuck holding the ball having to make the hard decision while everyone else on down the line to the volunteer that showed up in his POV after being voted into the squad 15 minutes ago, saying, "I can do that too."

We're good at catching cardiac events because that's what we assume is going on, and then continue to assume that's what's going on even if we don't have supporting evidence outside of patient complaints. It's easy to decide someone COULD be having a cardiac event, but it's hard to decide the opposite.

This sums up EMS' approach to many things and is a great example of a technician type approach to something as opposed to a clinical approach.

 

[mycrofft]

Do your protocols say "Do this if the pt seems to you to have condition X going on"?

You get an intuitive sense, (ours are all skewed to what we know and what we carry) but some people's are always skewed wrong. Get the objective to support your subjective, but always treat the pt and not your preconception or a protocol.

 

[Masenko]

Sure, whatever helps you sleep at night.

Any type of "I can do ____ better than the ER physician" mentality is dangerous.

Chase, I agree with you 100%. In fact, I thought it was provocative enough, that an ER physician (not me) had that theory, to bring it up to the forum. Fair enough? I get terrible sleep no matter what's on my mind anyways.

And yeah I guess it makes sense that if paramedics deal with chest pain often, and they only have to look at one patient, with less liability than a doctor, then they can be come forward with a diagnosis quicker. That intuitive sense that mycrofft is talking about.

Like I said: I'm a new student without any hospital clinical experience yet, so it's cool to hear yall's background reasoning on this topic. I'm definitely going to bring this up with that doctor next time I see him and post back what he says.

 

[MSDeltaFlt]

Our interventions are riskier as well. We're not going to throw every chest pain patient on heparin or run them to the cath lab just because they have chest pain. Seriously, what's the worse you're going to do with a little aspirin and nitro?

That's not what I'm referring. You guys are most definitely more thorough and far more accurate. What I am referring is the speed only. And the speed is merely dye to the logistics.

 

[Epi-do]

Interesting! Still I wonder where that theory is coming from then.
It's interesting how technology is relied so heavily upon these days. It might be cool to see how these issues will be handled when the lights go out!

But, can't I still use my monitor? It does have batteries, after all.

 

[KellyBracket]

And 12-leading is cheating if we are just talking assessments and recognition of associated symptoms only...

Getting a 12-lead is "cheating?!" If using a quick, painless, effective, and cheap test is cheating, what is the game we're playing?

(Mostly kidding. Mostly.)

 

[Masenko]

Getting a 12-lead is "cheating?!" If using a quick, painless, effective, and cheap test is cheating, what is the game we're playing?

(Mostly kidding. Mostly.)

Well I was just talking about associated symptoms recognition...if there is one thing I've learned from this thread it's that 12 leads >

 

[mycrofft]

"Cardiac Associated Symptoms"

An ER doctor I spoke with the other day has a theory that generally, paramedics can spot associated symptoms of cardiac issues, and therefore start treatment for cardiac emergencies quicker, than ER doctors can. Even in the ER.

My take (as a new paramedic student) is that paramedics 12-lead very often anyway, and that is why they can start earlier.
But now that I think about it that's more of a factor outside rather than inside the ER. And 12-leading is cheating if we are just talking assessments and recognition of associated symptoms only... but I'm getting off track

I mentioned this but he still thinks it has to do with the way paramedics think through assessments for various reasons.

Any thoughts? It seems like this would be difficult to study.

Remember that the presenting symptom in about 70% of extensive MI's is sudden clinical death.
THERE'S your "signs".

I'd say paramedics and other prehospital providers including some docs are quicker to rule out MI's based on length and reported severity of symptoms, tenderness to palpation, absence or failure-to-progress of classic signs or exhibition of odd ones (e.g., "diaphoresis" only on the anterior face and when the hands are wet), vital signs and auscultation. Sometimes a trial of antacid. BUT it always ends in "GO SEE YOUR DOCTOR!".

 

[Masenko]

I promised an update

I talked with the same physician again. I relayed some of the points I got from this forum, and it turns out my original post was so very wrong! Doh!

Turns out his hypothesis was more along the lines of: Paramedics recognize associated signs/symptoms of cardiac issues quicker, and are better at knowing when to put on 12-leads... :rofl:

The idea is based off of his observations of both his own mistakes and the mistakes of other ER physicians. When I asked for an example, he gave me a pretty long story with lots of detail that I wasn't able to document well enough to his story much justice. Maybe that's good for hipaa reasons anyway.

But it starts with him working at an urgent care type place with a lady complaining of chest pain when out doors, but not inside. She just wanted some allergy medication. There was other weird stuff (real clinical and scientific I know), but overall she was clear to get her medicine and leave. A couple days later he's working in the ER and the same lady comes in. She's complaining of a similar chest pain that gets better when the car is vibrating, and the nurse cracks a joke about vibrator therapy. That's when he realizes that she needs a 12. There were a bunch of other details from the story both before and after the lady visited the hospital and got 12 leaded (I don't remember the diagnosis either :/ ) that would probably strengthen his argument/story, but unfortunately I also have to cram pharmacology in this brain. Main point being, he claimed that if a paramedic had assessed her there would've been a 12 on immediately, and the patient would have received better care sooner.

I know that's very different from what I originally posted. I also know that the hypothesis I'm relaying (don't kill the messenger! h34r may make me seem pretty presumptuous. Especially as a paramedic student. Lastly, I know that the theory is based off of anecdotal evidence, (more than the story I just posted I might add!) but still that is part of the reason I wanted to take it here

Based off some of the responses I got to the OP, the second hypothesis seems to match up a little better. It seems like most everyone on this forum likes to put on that 12 lead ASAP.