fiznat

I think this is a bit of a mis characterization of my post. What I said is that he is missing the forest for the trees. That is an accurate point, and I stand by the need to say it. The original post is a collection of copy and pasted Wikipedia article entries, which focus much more on esoteric detail than the greater picture. The OP can dive right into neurotransmitters if he wants, but I don't believe that starting at the microscopic level is really the most effective way to learn this lesson. Keep in mind the original question was about a clinical symptom, not a biological process. The gap between those two perspectives can be extremely broad, and I think it was prudent to establish some groundwork before delving into a neurology lesson on an internet forum.

What about all of these together in one ECG? I understand that individually they can't be used to exclude VT, but if they are all present I would imagine VT is increasingly less likely....?

First, if you are going to cut and paste from Wikipedia articles you should cite them at the very least. The way your post reads now, its as if you are passing that stuff off as your own. I'm sure that wasn't your intention... Second, I think you're getting way ahead of yourself here. The relationship between diaphoresis and the degree of an illness is not linear. It is an extremely complicated process that integrates a number of biological processes which, frankly, require far more knowledge about neurology than most people have here (myself included). When you start rattling off stuff about pre and post ganglionic neurons I think you're missing the forest for the trees. What you need to know about diaphoresis is that it is a clinical sign, one of many, that needs to be integrated into a comprehensive patient assessment. "X" amount of sweating doesn't translate into "Y" amount of illness. There are plenty of sick people who sweat, and plenty of healthy people who sweat. The only well to tell the difference is to thoroughly assess.

Okay, here it is. (big breath) I gave Cardizem to this patient, and it was a big mistake. I was convinced, incorrectly it seems, that this was 1:1 a-flutter with an abbarency. I came to that conclusion based on the flutter waves that I thought I saw with the trial of adenosine. In addition, I did not believe I was looking at VT as the axis is leftward (VT should be extreme rightward), there is no precordial concordance (as seen in VT), the morphology looks asymmetrical and abbarant (not VT), the rate is awful high for VT, and the patient was somewhat young. I think, although I wasn't consciously recognizing it at the time, that the auto interpretation on the 12 lead pushed me towards this decision as well. I try not to let that happen but in retrospect, if I'm honest, I think it played a role. I started with 15 mg Cardizem, which did nothing. Next I transmitted the 12 lead to the ED and consulted with a physician. I recognized the rhythm was wide and that our standing order is Amiodorone for this scenario (if its not flutter), but I wanted to discuss with the physician- especially since the first Cardizem didn't work (I was hesitant to give a 2nd dose). I was ordered to follow up with another 10 mg of Cardizem (??). That didn't do anything either. In the ED they gave mag and amiodorone with no effect. Cardiology consult eventually decided to cardiovert, which worked immediately. The post cardioversion rhythm had delta waves, and a pattern (not an expert on this part at all) that the cardiologist identified as an orthodromic reentry mechanism/WPW. For those who are unfamiliar, giving Cardizem (calcium channel blocker) to patients with WPW is absolutely contraindicated and quite dangerous. The patient turned out to be fine, but the cardiologist said that I "really dodged a bullet," and "got really freaking lucky." Turns out I was right that there was an atrial origin, but dangerously wrong about the rest. I consider a big lesson learned for me. There is no reason I should have been messing around trying to identify an atrial origin/abbarency. Wide + fast should have just been amiodorone (or procanimide), and that should have been that. I stand by my decision not to cardiovert immediately, but I recognize that I made a pretty big error in my drug choice. Anyways, there it is. I've been a medic for 5 years now, I've done lots and lots of bad calls, but I'm still making mistakes and learning hard lessons every now and then. I thought I'd pass it on so hopefully people can give these things some thought before this happens to someone else! Thanks for playing!

This isn't something that I can quote directly, just a perspective that I take from the entirety of the ACLS algorithm. ACLS tells us that if a patient is unstable, we must cardiovert immediately. If not, however, it is preferable to further analyze the rhythm and administer medication. To me, that says that the *right* medication is less dangerous and invasive than cardioversion. If that weren't the case, why wouldn't we just forget about meds entirely and cardiovert everyone?? That whole idea gets messed up if you give the wrong med, of course... A bit from ACLS: My impression of this patient is that he fits the definition of stable/symptomatic, NOT unstable. If we agree on that and we want to stay within the boundaries of ACLS, we need to talk about drugs. Yeah this patient was something of a wake-up call for me. You'll see..

ACLS considers cardioversion *more* invasive, which is why it is reserved for only the sickest of patients.

When watching coverage of the recent events in Tuscon, the media referred to all EMS on scene as "first responders." The president did it also in his address about the incident. It irked me.

Generally it means: 1. The patient has symptoms related to the tachycardia. 2. The patient is not in shock. There is definitely some flexibility here, but my opinion was that while this guy was surely in trouble, at the moment he was not "unstable" per-se. By the way, you can assume that the given BP is accurate, and is verified by multiple reassessments throughout the call. I got diaphoretic and tachycardic the other night when I ate some hot wings!! True, but that is a subjective evaluation. If I'm going to make this guy ride the lightning I feel I would need something objective as well. More than what I saw. That's my opinion anyways. I'm fully aware that other people would feel differently- that's part of the reason I posted this here!!

No change in presentation, or rhythm really. After that initial slowdown, the rate came right back up and it was as if I had never done anything. I didn't give a 2nd dose of 12 mg adenosine. I know that ACLS tells us to, but dammit it never ever ever has worked for me and I feel it isn't worth the time, effort, or patient's discomfort. Slap my wrist, but I didn't do it... You can assume for the rest of this case that we are doing the other basic stuff. Oxygen, IV access, pads in place, fluids wide open.... Cardizem. There's the tricky part. Are we sure enough about this flutter to give cardizem? Let's hear what people have to say about that....

Okay, I'll move this forward a little bit. 12 mg of adenosine barely touched the rhythm. There as a brief period (maybe 5 or 6 beats) where the space between each QRS widened and I could see what I thought were flutter waves. Could have been p-waves though, but they did seem to have that f-wave appearance to them. Unfortunately, though I printed this out, I never got this section back in the code summary when I printed later so I don't have a copy to show you. You'll have to just go with what I say haha. I also did notice: -The mean QRS axis is to the left. -The precordial leads are not concordant -The QRS morphology looked asymmetrical and aberrant to me -I feel I can see atrial activity (especially with the adenocard, but also on the original strips) Does this change anything?

I answered most of these questions in the original post... He hasn't had any previous episodes of this. Haha sounds good. Don't think anyone will argue with you as far as that stuff goes. What's next??? So I can take from this your vote is that he fits into the ACLS "symptomatic/stable" category?

Would you guys really call this patient unstable? BP 128/82 GCS 15 No pain Sweaty Pale Nervous Mild SOB (still speaking full sentences, no increased WOB) Remember the alternative isn't "stable" as in "everything is fine." We're talking about the ACLS definitions of unstable versus stable/symptomatic, which is a different animal alltogether. Some things we consider in this VT/Not VT decision: -QRS Axis -Precordial concordance -QRS morphology -Visible atrial activity -Rate -"Diagnostic" treatments What do we think? **I do have an opinion on this, and I do have an end result, but I'm biting my tongue on purpose because I think the discussion on this is more important than the actual answer.... Please feel free to chime in with what you think--- this could be your next patient!!!

Hmmmmmmmmmmm good questions Mobey! Why is (or isn't this) ventricular tachycardia?? What criteria do we have to evaluate the ECG?

Thanks for the kind words Dwayne. It's been a long time since I've written on that blog. I should pick it back up one of these days....

My initial impression was that the guy looked like crap! haha. He was pale, and profusely diaphoretic. His t-shirt was soaked through like he had been pushing boulders up mountains. Other than that though, he was alert and oriented, carrying on a normal conversation, sounding kindof scared and nervous. Pulse quality was good at the radial artery. Fast though. Not bad for someone with no cardiology training! The first question anyone must ask with these "fast and wide" rhythms is "is this VT?" I'm not going to give up the answer that easy though... haha

42 year old guy in good general health (albeit obese) complaining of an acute onset of weakness, diaphoresis, and shortness of breath while sitting at his desk at work. No pain or chest discomforts. BP is 128/82, he's pale and soaking wet. No medical history/meds/etc.... Have at it!

I very much disagree. If you are in a situation where you are giving a medication that you haven't given in a while, or a situation that is new to you, I think it is FAR preferable to look things up rather than rely on memory. I carry a small reference guide in my pocket, and I have absolutely no issue with looking something up if I am unsure. I care about getting it right, not showing off the depth of my memorization. The same goes for drip calculations. It is VERY easy to make simple calculation errors in the middle of a call. Write things down and use whatever resources you can. The patient is far more important than than your ego. And guess what, doctors and physicians do this too. I carry a miniaturized version of our protocols that I made at Kinkos, and also a ScutMonkey brand drug reference guide. When I made the protocol book at Kinkos I added some printouts of dripcharts that I made in excel. They have been lifesavers on a few calls.

Medical school. Been working towards this goal for a looooooong time now (almost 6 years after graduating college). Finally starting to see some results. Application season isn't over yet though so I'm just feeling out my options. Can anyone help me with AZ??

Can anyone give me a quick update about what EMS is like in and around Phoenix AZ? I may be moving there for school and would like to be able to work part-time in the area if it is at all possible. I am a NREMT registered paramedic with a good amount of experience, looking for solid 911 volume. I'm not a firefigher. Thanks guys!

Interesting.. This lung recruitment volume, is it clinically significant?

There would likely be a police report regarding the incident as well. Where I work, if we stumble upon something like this we would get the police, and possibly the fire department involved also. Usually in crashes like this, the car needs to be taken care of and a report made (Police), and fluids/debris on the road need to be cleaned up (Fire). So, there are two more written reports that would be generated from the incident in addition to the EMS paperwork.

I've done plenty. The fact of the matter is that we are supposed to be professionals, and the rules don't change just because someone "important" gets hurt. It is our job to make sure things don't "become a major cluster," and that includes keeping every tom/dick/harry voyeur out of the back of our ambulances. Especially on critical calls where there is work be done. When the police arrest celebrities do they allow family and friends in the cruiser? No they do not. When the patient gets to the hospital and goes into the trauma bays, do family members follow? Hell no. Be in charge of your ambulance. Just because a call is "high profile" doesn't mean other people start making decisions for you.

I would never let family or friends in the back of the ambulance on a call like this. Sorry, but we're busy and they only get in the way. My experience is that people respect the fact that we have a job to do and they need to give us space to do so. Family and friends are welcome to ride along if they want, but UP FRONT. Oh also BTW, there isn't anything "unique" about this from an EMS standpoint. Despite the circumstances, this is just another patient, and IMHO the job shouldn't change no matter who it is or how it happened.

I'll agree with what Mobey said: this is probably the most difficult job paramedics face in the field. It isn't rhythm analysis, or drip calculations, or assessment, it's making sense out of chaos and getting these scenes under control. It takes a LONG time to get good at this, and even then there will always be calls that throw you for a loop. It's part of what I think makes this job fresh and exciting. There isn't going to be a single set of advice that will tell you "how to do this," but some general pointers from my experience: 1. It's not your emergency. Stay calm and relaxed. I usually try to establish scene control by being the coolest head in the room. On scenes where everyone is freaking out, it's the guy who's not yelling that stands out. 2. Realize that you don't need to have all the answers in the first few minutes. It's easy to feel overwhelmed with everyone trying to give you tons of details and requests at once. None of that matters. The only things you should care about when you first arrive on scene is (1) whether the scene is safe, (2) how many patients there are, and (3) what other resources you will need. Thats it. 3. Utilize your resources as best you can. Clinician on the phone can go bye-bye, paramedic interfering on scene can be helpful or he's out. Use the police for crowd control, and your partner (EMT?) to get a head count/quick triage numbers. If the fire department is on scene, find their leadership (white hat?) and get on the same page with him. Try to leave yourself free to take in the scene and make sure big things don't get overlooked. It is not your job to treat or assess patients right away. 4. Talk about the call afterwards and discuss things that you could have done better. Find out if everyone else really was on the same page as you, and brainstorm about ways you could have better communicated. Don't expect everything to be perfect, because that never ever ever happens. Hope some of that helps.

Don't confuse "ALS" interfacility transports with "Critical Care" interfacility transports. Around here, truly unstable patients who require transport between facilities almost always go by helicopter or a ground critical care team that includes nursing staff. Regular paramedics who do "ALS interfacility transports" will generally be doing stuff like transferring stable patients who happen to require cardiac monitoring, have meds on pumps, or other basic ALS stuff like that. It may be different elsewhere, but around here you need to have your CCEMT-P cert if you are going to do the critical care stuff, and most rank and file medics don't have that.