The Evolving Patient (ECGs!)

[p3medic]

I'm not saying that at all....look at the qrs complexes in v1 and v6, see? negative and wide in v1, positive and wide in v6....thats a LBBB "looking" complex. If this was a clear cut sinus rhytm with qrs complexes that looked like that, with the same progression you wouldn't say that appears to be a LBBB? This ekg could very well be V Tach, its the MOST LIKELY regular, wide complex tachycardia, but it doesn't make it a fact. I've made a valid arguement using well studied criteria why it "may" be something else....Lead placement would do nothing to change the precordial tracing.

[CBEMT]

I would have no option but to set myself up for a code, unless he can last about 20 minutes.

There's no treatment for this in my protocols without a med pump, which the chief can't get the money for from the town since they aren't mandatory. Obviously the town council knows best, right? :roll:

[jjones1418]

Ah but it's not a clear cut sinus rhythm. I do agree with you that, if it were at an appropriate rate, and had p waves, it would resemble a LBBB.

I'm just saying that it's VTach. Ectopic ventricular beats, then progressing to a wide complex tach resembling the ectopic foci.

And you did make a good argument about the LBBB. Your criteria was accurate.

[rdenman26]

Transport time can vary 5 mins to an hour. Of course planned transfers can be longer. We have paramedic thromolytic threapy in the vast majority of the UK, and I can fast track ACS patients to CCU. Some areas are taking patients to cath labs, but in my area we dont have enough cardiologists to set up a primary angioplasty servise at the moment.

[rdenman26]

May be because we give the drugs under our licence as paramedics, with out referecne to an MD, there is a reluctance to add drugs to our list at times. This may be because the UK has been behind educationally in EMS the wider medical community does not trust us with extra drugs. However UK paramedics are now far better trained and educated than only a few years ago. There seems to be a resitance to accept further medical oversight in UK EMS, which aint nesseserily good for the patients. For example, my service was one of two in the UK that decided to require (untill recently) paramedics to refer to a senior clinican before using tenectoplase. Because we did this we were able to treat far more AMI patients than other services that were working to a restrictive protocol.

we can have other drugs and procedure introduced at a local level through various standing orders etc. For example the helicoper people have extra protocols for ketamine, midazolam, flumazanil, surgical airways, thoracostomies and the PASG.

But mostly we are get excuses such as,

Cost, safetly, education, cost, evidence of benifit, cost, and did I mention cost.

To take the above dysrythmia as an example. At the moment we are told if the patient is stable then its safer to be treated in hospital. To change that and bring ambulance practice in line with national guidlines would mean investment in research and education in the use of the other drugs. Changes in legislation or development of protocols to allow us to use other anti-dysrythmics. As for the unstable patient, who ought to be cardioverted! We start getting into conscious sedation.

Actualy come to think of it the air ambulance guys use consious sedation at the moment and most of them are no more qualified than us ground staff. But then there are plently of people that I would not trust with a band aid.

Things are improving here. Critical Care Practicioners are being developed and will improves (we hope) gaps like this.

Anyway Im going on to much now so I had better go, becasue Im not sure what I wrote made any sense.