fiznat

Speaking of experience... Anyone have any good examples of AMI in the setting of LBBB with positive concordance? I'd like to see what it looks like, and maybe we can discuss it a little bit.

I like to do a lot of that stuff with 12 leads. As others have mentioned, mean axis is really one of the most useful "extra" things to know, as this can be extremely helpful in diagnosing rhythm origin, as well as possible strain/hypertrophy patterns that could be useful as well. Ischemia/infarct really goes without saying, while chamber enlargement is something I usually notice later on when I review the ECG. Bundle branches I watch out for, as they can confound ST elevation findings and screw up axis readings, but beyond that I dont use them all that much as far as identifying pathology. One of the things I am really trying to get better at is evaluating all of these characteristics more quickly. I know what to look for by now, but it takes me much longer than I'd like. I want to be able to look at an ECG quickly in the middle of a call and be able to rapidly identify subtle yet key changes. I can find injury patterns fairly quickly, but sometimes I find myself needing to think a little bit longer when assimilating all the axis, rotation, hypertrophy, etc information. With time and practice, I suppose.

A very, very good read. They are all excellent writers, and it is an interesting idea to put together a story like that. I read AD's blog fairly often, but thank you for the reminder.

Info on Sgarbossa. I admit I had to look it up too. It seems a little too academic to be useful for our purposes. Information like this is nice and all, but I think that in the ED very few docs are truly going to care THAT much about the exact "constellation of ST elevations" and extremely detailed evaluations of morphology when other, more direct assessments are available. Especially in the light of research like what AZCEP posted. Nothing against you specifically at all, but I feel like a lot of people who use stuff like this are more trying to show off rather than do good for their patient.

I agree with you that the nurse needs to back off. ...But about this inflammatory process, I would like to clarify. Correct me if I am wrong of course, but I didnt think that wheezing in CHF is related to an inflammatory process. I was sure that the so-called "cardiac wheeze" is different from other wheezes in that it comes from partial fluid obstructions rather than bronchospasm and inflammation. Assuming that this was CHF (which may or may not be true), then wouldn't it be advisable to allow routine CHF treatments to work before we go after an inflammatory pathology? Solu-Medrol takes quite a while to work in the body IIRC, while nitrates, loop diuretics, CPAP, broncodialators, etc work fairly quickly. Why not give them a shot first and see...

haha hey man dont worry about it at all. I've taken my fair share of grilling here as well-- I understand how ya feel. As long as in the end we all learn something and nobody's feathers get *too* ruffled. :wink:

Okay, just to make a few points. I'm not criticizing you, just commenting on the call and offering another opinion-- which is why I assume you posted in the first place. -JVD and distal edema are not ALWAYS present. Their absence does not rule out CHF -Sleeping with extra pillows is suggestive of orthopnea, even if the guy didnt specifically say it -CHF does not depend on a history of any kind of pulmonary disease -A lack of stated heart history does not mean that there wasn't some underline borderline failure going on. He does not need to be actually diagnosed with cardiac insufficiency before CHF becomes a possibility that you need to consider. I would ALWAYS consider CHF, "heart history" or not. Especially with this presentation. -The color of sputum isn't very valuable, in my opinion, for diagnosis between CHF and pneumonia. ...And even still, you said yourself that he had a hx of bronchitis. What if the sputum is still some of that, while the primary problem remains CHF? -Your recent experience with "the last few" patients who had pulmonary edema isnt very valuable, either, as far as to the worthiness of CHF treatments. This is a terrible argument. Nitro and CPAP work awesome for pulmonary edema in general. ...Just because it didnt work for your last few patients doesn't mean you shouldn't try it now. -History isn't everything. It is true that CHF arises out of a backdrop of cardiac failure, but just because this guy hasnt actually gone to the doctor and received a diagnosis doesn't mean that it is impossible for the condition to still exist. There are plenty of people who have undiagnosed cardiac insufficiency, people who dont go to the doctor often or simply havn't gone recently. You need to go by your assessment, not by the previous assessments of other doctors. In the face of the rest of this guy's presentation, a lack of history is not enough to rule out CHF. Just some things to think about. Like I said, I didn't see the patient though.

To be honest, I would be highly suspicious about possible CHF with this patient as well. I have seen lots of CHFers present with lungs FULL of fluid but lacking in clinical findings like JVD and distal edema. The two do not necessarily always show up together. -Hypertension is another warning sign for CHF, as well as "full" sounding lungs with wheezing at the top. That is very common. Rhonchi and rales are notoriously difficult to tell apart and lots of people - even doctors - get this part wrong with amazing consistency. -Sleeping on extra pillows at night is another finding typical for CHFers, as it minimizes areas of the lung obstructed by fluid. At the same time, this would be atypical for pneumonia patients, as mucus is more viscous and will generally remain where it is regardless of body position. -The SOB sounds like it was more of a rapid onset. This seems to suggest CHF more than pneumonia, as lungs can fill up quickly, but pulmonary infections take some time to build up. -The patient's skin was cool. I know it is not an exact thing, but pneumonia sufferers are often hyperthermic. The cough may have been a red herring, but who knows. Perhaps he had a little bit of both going on. This is a tough one. It really is hard to second guess something like this without seeing the patient, hearing the lung sounds, looking at the 12 lead, etc (do you have the 12 by the way?). Like I said though, I would be VERY suspicious about failure in this patient with all of the findings you've listed above. It seems - just from what you've written - that there may be more "pro CHF" stuff than "pro pneumonia" stuff. I dont think you did anything wrong, but I'd be interested to hear a little more of your defense as to why the seemingly CHF-sounding factors didn't sway you from your pneumonia diagnosis.

I agree completely. If I were to be asked "do I calculate MAP on all of my trauma patients" the answer would be no. If I were instead asked "do I think about MAP and it's implications for systemic perfusion," the answer would be yes. It isn't a number as much as it is an important concept that should help direct your care through (patho)physiological understanding.

Electrical tape would clean up nicer, although it is harder to pull apart if (for some reason) you needed to quickly untape the leads. I'm going on a field trip to a hardware store tomorrow, maybe I can find a clip that will work.

I don't know how you could possibly be so sure about this. Since the 12 lead doesn't capture the rhythm in question, we are really comparing opinions based on a 3 lead view only which, to be honest, really doesn't allow us to make diagnoses with such certainty. It is a regular, wide complex tachycardia of unknown origin. I agree. I'm not sure I would have done ASA and NTG, but I think we are all in agreement that this patient was more or less stable, and probably didn't require overly aggressive treatment. The fun of this though is to imagine if the patient were perhaps a *little* less stable and presenting with the same rhythms. Then you would need to make a decision...

We have both plastic perforated tape as well as the cloth stuff. I usually use the plastic tape because it rips really easy if I needed to take the leads apart. Bread twist ties might work, although sometimes the paper comes off and the ends are kinda sharp. ...Might poke someone? I donno...

It's a thing of mine: I have to tape the 4 wires of the 3 lead ECG together at the beginning of every shift. I tape the black and white together, and then the red and green together. I feel it makes it much easier to organize on scene, and the tape prevents the leads from getting really tangled together. Other people at work, including the medic who relieves me, are very much against it. They say the tape is unsanitary and promotes cross-contamination between patients from various nasties that "stick to the tape." I'm skeptical about this to begin with, but I would like to find another solution if possible. I heard from someone else that LifePak actually sells plastic clips for this purpose? I looked on their website though and couldn't find anything like that. Any suggestions? EDIT: Things I've thought of: -Zip ties might work, but they can ruin the leads if they need to be taken off -Electronic stores have various cable clips, but often they are too big/bulky and would defeat the point -Velcro straps might work but they might be tough to clean

Its a tough situation because your issues with him are not major problems in the moment they occur, but rather they become an issue when they pile up one after another into the larger picture. It isn't helpful, I don't think, to immediately confront a guy over something like not reaching for the BP cuff himself-- but I think it would be appropriate to discuss at the end of the day how you feel about him in summary. He needs to show a little more interest in being part of a team. We work together on the rig, and unless he can show an interest and respect the rest of the crew, he is going to have a big problem here. It doesn't matter how long you guys have been in EMS. He is the preceptee and you are the preceptor. He will listen to what you have to say or he will not pass. ...And as far as sitting in the dialysis chairs while you guys stand like you should be, that is unacceptable. He should be told right then and there not to get so comfortable. It is disrespectful to the dialysis facility, to his new job, and to you.

An impostor? What do you mean? I see a left axis deviation and predominately negative complexes (the wide ones) in V6: both suggest a ventricular origin.

Huh? Maybe I'm not getting what you're trying to say here. I am measuring peak of S wave to peak of S wave. I had to stagger the lines so they would be readable. Some of the S waves are deeper than others, but the horizontal (as in, time) point-to-point regularity is pretty consistent. Someone back me up here...

Ah I gotta disagree with ya there dude. That rhythm is regular. No question about it. Here, I'll demonstrate. All of the (S-S) red lines are of the exact same length (cut and paste elements in photoshop)

This is probably it, and to be honest, I don't think there is anything wrong with that. Medicine - even at the physician level - teaches us to look for signs and symptoms, to calculate odds based on history and published probability. These are subjective observations though, even in the case of the EKG and the supposed finality of cardiologist-level knowledge. Medicine's ties to science require that we all remain a bit skeptical till we've seen it for ourselves, clear as day on the angiograph. I agree with him. The potential consequences are too great to make a decision with such limited, subjective information. It deserves a direct look.

This one?

I am presenting this on behalf of a friend at work (who is also a member here), so please excuse anything that I may be missing.... I wasn't there. Pt Dispatched for chest pains, on arrival found 88y/o male at home complaining of chest pains that have since resolved. He is currently without any complaint whatsoever, but would like an evaluation at a local ED. Hx: A-Fib, HTN, IDDM Rx: Digoxin, Lopressor, ASA, Lantus NKDA VS HR: 90-120 variable BP: 160/90 RR: 20 SPO2: 94%-->100% with O2 EKG Unfortunately unable to capture much of the wide rhythm on 12 lead. Again, calling it transient wide complex tachycardia of unknown origin. ?P-VT. The wide rhythm came in and out every few seconds, lasting at a maximum of 7 seconds. The patient states he feels "fine" despite the changing rhythm. Tx Routine ALS. Pt was given 324mg PO ASA, 1 x 0.4mg SL NTG. Pt remained without complaint throughout, no significant BP/RR/Mental status changes, etc After administration of the NTG, the wide complex tachycardia ceased completely- leaving behind only a-fib at a rate of about 90. Discussion It is tough without much of the wide complex stuff on the 12 lead, but what would you call this rhythm? It is regular, wide, and of a consistent morphology, which definitely suggests paroxysmal ventricular tachycardia, although I know that aberrancies can really widen a rhythm when it suddenly speeds up like this. I recently had a similar patient in which that was the case. It would be easier with the aid of axis on a 12 lead, but the provider wasn't able to capture any of it in that mode. What do you think of the treatment? The patient had no complaints, but obviously had a profoundly irritable heart. We don't have a specific protocol for this kind of situation, but the obvious answers are amiodorone, lidocane, etc. ...Although the patient remained stable and without complaint throughout, so perhaps medication isn't indicated. What do you think about ASA + NTG in the absence of chest pain or ischemic changes? Discuss!

Thats a tough one. The global elevations (without reciprocal depressions) is a hallmark of pericarditis, and the young age of the patient would definitely make most of us skeptical about ACS to begin with, I'd think. It does worry, though, that the patient does in fact have a "cardiac history," and that the symptoms were brought on with exertion (I don't believe this is characteristic of pericarditis?). I remember reading that pericarditis pain is sometimes relieved/aggravated with changes of position. Did you notice this at all? What about history of infections, viral illnesses, etc? Not that we are able to in my area anyways, but I don't think I would directly activate the cath lab on this one. More likely I would try to present the patient as clearly as possible to on-line medical control, and put the decision on them. Its one of those cases that really could go either way, and I'll be dammed if someone were to try and blame me for under treating a potentially deadly condition. Pass the buck, my friend, pass the buck.

I agree with you Dustyn in that NO response to or from the hospital is worth risking injury to the crew or other drivers on the road. Priority one responses, all of them, should be very controlled, minimum-necessary types of drives. With that said, I will play devil's advocate a little bit here. How well are we equipped to absolutely diagnose etiology on a majority of our critical patients? I understand that there are a large number of cases where we are pretty damn sure what is going on, and fairly well versed on what it is that the hospital will have to offer that patient. Still though, I wonder if some of us might employ a bit of humility in this respect, and - in accordance with our level of education and equipment available - defer to the ED a little more often. I'm as realistic as the next guy, though. I understand that 5 or 10 minutes added to transport time will, for 95% of our patients, really make very little difference. Still though, it might be a little bit arrogant to assume that we, with our limited resources, will be able to clearly define the line between those for who it will matter and those for who it will not. If the rule is always to err on the side of the patient, why is it not the same in this case? ...Especially if we concede that "priority one" is always to be driven in a responsible manner. Types of presentations that I imagine might go priority one: Trauma CVA (with a reasonably recent onset) AMI Shock Refractory or unknown AMS Refractory SOB (asthma, anaphylaxis, etc) Non-narcotic, significant overdoses Newborn in distress Uncontrollable hemorrhages (internal or external) Failed airway Routine calls near shift change/lunch time etc

Huh, interesting. I'd never heard of it before this thread, so I read the wikipedia article on it: http://en.wikipedia.org/wiki/Salvia_divinorum Sounds like it is a (now) legal, natural hallucinogen with effects similar to LSD, although the drug is metabolized very quickly- in the area of 5 minutes or so if smoked, 30 minutes or more if chewed. Did you have a patient on this? Do tell...

Holy shit! I know that the siren call of EMS is often something that is hard to resist, and that the prospect of becoming a medic has both financial as well as non-financial draws, but are you sure this is the right thing to do?? You quit your job?? You remortgaged your house?? For medic school??? I'm sorry, and I hope I'm not being overly callous, but that sounds to me like some REALLY poor planning. Lost wages + a new mortgage + opportunity cost = WAY more than a (POTENTIAL, you're not hired yet) pay bump of 9k per year. Have you calculated how long it would take you to break even? ...To pay off a whole 2nd mortgage with a 9k pay raise? I cant imagine it is less than 5 years or more. You're willing to make that kind of sacrifice for a paramedic patch? And you have a kid to take care of by yourself? Jeez... I mean I love this and I dont think I could give it up, but the job doesn't pay THAT well.

I gotta say, it is one of the nice things about working in a city that there is almost always another ambulance nearby. I think it would be extremely tough to keep on driving if faced with a situation like Ruff's, where it is clear that another ambulance is not right around the corner. Extra ambulances nearby in the city makes this decision much easier for me. If the situation were such that I really thought it was life + death if I stopped for a 2nd patient, and I knew that there were no other available ambulances, and the patient in the back was not critical, I think I would probably stop. I think. The only think I can say with perfect clarity is that I hope it never happens to me.