Using 12 Lead to Rule Out MI: A bad move?

[Scaramedic]

Positively and Absolutely I whole Heartedly DISAGREE !

Pulse oximetry is a Vital Sign..... everywhere ! If one looks to the studies it is abundantly clear (ps these studies were done in the US btw!) and by experianced flight Medics and RNS, yes clinical judgement is clearly a guideline when Dyspnea or SOB c/o but when the flyboys/girls and can't identify Cyanosis until those that are truely hypoxic and cyanosed until they are a life threatning < 77%. Its a proven fact JACK, the reliability factor is wholy based on perfusion and the complete understanding of the device, its only as good and reliable as the practitioner that is using it ! say JUST like the 12 lead EKG .....

But this TOO is a side bar and excuse me for getting off track, the topic is 12 leads ! sheesh.

I disagree with you.

I have only had a handful of patients that were less than 80%. Most dyspnea patients fall in the low 90' to upper to mid 80's and I can identify them when I walk into the room. If your Fly boys can't detect them until their into the 70's I would be concerned. Also I didn't say NOT to use it. I said that you shouldn't use it as to rule out using an NRB. I only use NRB's on patients in obvious distress. Yes I consult my SPO2, but I do not rely on it. There are too many variables that can affect the readings. Unlike, say a BP, if you get a funky reading you take it on the other arm. Too many people including Flight Medics and Flight Nurses tend to take the reading they get as gold and treat that reading. Hell, a partner of mine got a piece of paper to read 87% on a pulse ox. Yeah we were really bored that day.

Also like Rid pointed out my system is also is all about the ETCO[sup:0ca48bb131]2[/sup:0ca48bb131] waveform. Our Doc considers a waveform as the only true way to assess a patients respiratory and circulatory status. Even our tubes are not considered verified until we get a waveform. He does not accept auscultation anymore. No waveform and your ass is grass. I'm not a big fan of that idea either. I like listening for my tubes not trusting a damn machine. Maybe I've just seen too many Terminator movies.

Also I like your attitude that Flight Medics are better Medics than ground Medics. Please. I've known several mediocre Medics than are Flight Medics. I have also known several excellent Paramedics that went flight and then they came back because once the thrill of flying got old they found the job boring. Let's get on scene pick up a patient who is already packaged and fly him 8 minutes. How exciting. OK now let me work in the ED for two hours and then pick up a NICU. No thanks.

[tniuqs]

I agree with some of what you say, too many people (whatever thier mode of transport) do not understand the readings, there are many variables in fact, as I have mentioned prior, hypoperfusion states, (number one on the hit parade) dyes, a few meds, motion and sunlight contamination. But anecdotal notations are just a very poor point in during an intelegent rational debate, and in passing the evidence based medical findings and the value of pulse oximetry "in the early days" this study was done in the US, therefore not my Fly Boys,(& Girls too!) oh btw they are your Brothers and Sisters, generally speaking they have more education, training, but then again I may be more influenced by that silly literature I read from the National Flight Paramedics Association Magazine, ie the N.F.P.A. and in by in large this group has been involved with more evidence based research than ground.

I am a huge fan of Arnie the Govenenator and he makes Chuck Norris look like a wimp, but how did we get into ETCO2, I will never know ? ps get at least 4 breaths on your Capnography AND document post intubation, as Manuel Resusitation with OPA or sans OPA may inadvertantly have had exhaled CO2 enter the oesophagus, hence giving a premature and a false positive finding, I think I like your Medical Director he is covering his arse and yours, btw, in a oesophageal intubation ETCO2 is by far more rapid indicator of a screw up than pulse oximetry. One can breath around an ETT when its in the cats **** hole, unless you are using sux.

NO SIR you have drawn that conclusion on your own, the personell here in Kanukistan work there way up the ladder, and the vast majority are proven Paras with at least 3 years on the street minumum, (not that much fling wing here, mostlt stiff wing and this long distance thang is not a quick hop in most cases) That said many land loving Paramedics are most excellent practioners, without any doubt, but many of that group either suffer from motion sickness or are too physically um "PORTLY " PC term ? to be wt./ flight effective, many fling wing craft are challenged with excessive payload and fuel. ie BK 105/ long jetbox.

cheers

[Scaramedic]

I agree with some of what you say, too many people (whatever thier mode of transport) do not understand the readings, there are many variables in fact, as I have mentioned prior, hypoperfusion states, (number one on the hit parade) dyes, a few meds, motion and sunlight contamination. But anecdotal notations are just a very poor point in during an intelegent rational debate, and in passing the evidence based medical findings and the value of pulse oximetry "in the early days" this study was done in the US, therefore not my Fly Boys,(& Girls too!) oh btw they are your Brothers and Sisters, generally speaking they have more education, training, but then again I may be more influenced by that silly literature I read from the National Flight Paramedics Association Magazine, ie the N.F.P.A. and in by in large this group has been involved with more evidence based research than ground.

Actually you can go to PubMed and find dozens of studies both ways. From field to OR to ICU. It has been covered pro and con many times. I tend to read EMS magazine and RN magazine since we have subscriptions to both. Oh and just for the record most of the experienced medics working flight in Oregon are not degreed like those newbies coming out of the schools now.

One can breath around an ETT when its in the cats **** hole, unless you are using sux

The cat comment goes over my head. But yes we are using sux for initial intubation and Vec for long term paralysis. Our Doc is also very aggressive when it comes to airway and gives us a lot of latitude for RSI.

NO SIR you have drawn that conclusion on your own, the personell here in Kanukistan work there way up the ladder, and the vast majority are proven Paras with at least 3 years on the street minumum, (not that much fling wing here, mostlt stiff wing and this long distance thang is not a quick hop in most cases) That said many land loving Paramedics are most excellent practioners, without any doubt, but many of that group either suffer from motion sickness or are too physically um "PORTLY " PC term ? to be wt./ flight effective, many fling wing craft are challenged with excessive payload and fuel. ie BK 105/ long jetbox.

cheers

Or some of us just hate to fly. Not to mention in little planes or egg beaters with no wings. If we could get Mag Lev trains I would never set foot on a plane again. :wink:

It's not different here you have to work your way up. But some people really don't like it when they get there. Personally I'll be happy to finish my BSN and sit in a nice quiet and grounded ICU somewhere.

[tniuqs]

"Ridryder 911"]I suggest everyone should read the article "Relying on your H & P; Are we losing the art of clinical medicine technology" in this months JEMS.

Have you got a link, PLEASE , cause I do not make the big bucks like AK / Dust to afford this JEMS thing

Basically addresses that we place too much emphasis on what the numbers are versus to good interviewing and assessment techniques, thus having good diagnostic skills. I do believe that an ECG is a lot different than using a pulse ox. Is there going to be any change in treatment from the pulse oximetry finding? No. In that regards do you use & monitor EtCO2 on patients? It is much more accurate on the respiratory system.

Don't you mean good observational and clinical skills ?

Yes, agreed we have established clearly that relying on an EKG for dx of MI stemi or non, this can be a late finding, serial labs are the gold standard.

That said:

Oxygenation Evaluation = The diagnostic tool "Pulse Ox" presently available to determine Hypoxia.

vs

Ventilation = ETCO2 which is the tool for an indirect and "somewhat controversial" acid base imbalances and often complicated by V/Q mismatch.

Nuff said these are clearly distinct diagnostic evaluations.

So I ask a polite Question:

What is the first (correctable) cause of an possible imminent arrest .... Hypoxia or Acidosis ?

BTW there are many ways to improve oxygenation in the ventilated and spontaneously breathing patients.

Now in regards to the ECG monitor.. yes. (edit out) You should have known they were already hypoxic, but again one may not realized they had a bifasicular block with that AMI.

Already KNOWN or assumed, sorry ? Once again You are the master of evidence based medical studies, did you throw that philosophy aside on this one or are you just teasing me? :twisted:

It takes an additional 45 seconds to perform a right side, to be able to determine the extent and location. Will this change my (edit) treatment modality... you bet. If they are borderline hypotension no NTG, no morphine but an alternative medication. Will this change the receiving hospitals plan .. yes. This is a cath lab patient, and if possible avoidance of thrombolytics. Thus when I notify ER, they can prepare for such and delay can be reduced.

Much more reduced time, than me sitting and getting a right & posterior ECG. Again I believe many place ER treatment way above the field setting, when in reality there maybe no to little difference. :shock: (edit confused)

Ok 45 seconds is this the average time? or your time, man it takes me way longer to do a 12 and R sided than that, and I think I can do it faster with a 4 lead EKG, to obtain a working DX.

Now lets be reasonable this is simply bunkola, with the proviso being that a serious relationship has already been established with the attending Cardiologist and the Paramedic, in most situations they have never met, come on R/r this is not reality here.

Yes even the Fly boy, as most Cardiac patients prior to an arrival to ER are dang lucky just having a Fellow or Chief resident saunter down to ER to take a gander before the attending is even called in and the team is gloved up and ready to blast !

Thing is that my system it may be very different, I would tend to believe in most situations I suspect the ER doc calls in the troops not the Paraidiot. We are not THAT well generally accepted just yet, hey, maybe some day down the road. 8)

Again, there are times to utilize our equipment as "tools" to aide us. Knowing when and how much is the key.

zactly !

[VentMedic]

Don't you mean good observational and clinical skills ?

Yes, agreed we have established clearly that relying on an EKG for dx of MI stemi or non, this can be a late finding, serial labs are the gold standard.

That said:

Oxygenation Evaluation = The diagnostic tool "Pulse Ox" presently available to determine Hypoxia.

vs

Ventilation = ETCO2 which is the tool for an indirect and "somewhat controversial" acid base imbalances and often complicated by V/Q mismatch.

Nuff said these are clearly distinct diagnostic evaluations.

So I ask a polite Question:

What is the first (correctable) cause of an possible imminent arrest .... Hypoxia or Acidosis ?

BTW there are many ways to improve oxygenation in the ventilated and spontaneously breathing patients.

zactly !

As Tniuqs already made reference to, ETCO2 and SpO2 are just simple tools that may help guide you with treatment for your working diagnosis from the whole clinical picture the pt is presenting to you with other signs and symptoms. This is off topic but I just want to demonstrate that the intended use or capabilities of the Pulse Oximeter and ETCO2 monitor may not be fully understood by some.

ETCO2 monitors are excellent if it is a respiratory event and waveform analysis is used to narrow down some possibilities. If one does not know the PetCO2 : PaCO2 gradient for a V/Q mismatch or perfusion abnomalities you may be misled. If the ETCO2 respiratory status is in the face of a metabolic abnormality where you do not know the anion gap of the patient, again, you may be guessing in another direction. Remember there are metabolic, respiratory and mixed acidosis. These all come in varying degrees of compensation.

The same goes for pulse oximetry. One may have 100% SpO2 but may have an A-a gradient of almost 400 mmHg (sea level). The oxyhemoglobin curve is also not understood by many Paramedics or EMTs. A shift in it, significant V/Q mismatch and various perfusion problems give you a train about to derail and with an SpO2 of 94 - 100%. Hb and HCT values also influence the validity SpO2 and CaO2 especially if the H & H is low.

When running a sepsis protocol in the ICU, we will not allow the SpO2 to drop below 97% if possible by the creative use of ventilators and pressors, using the measured SaO2 and PaO2, for the first 12 - 24 hours if the lactate is staying at 4 mmol/L or above. Most of our O2 titration and BP pressure support treatment will come from the SvO2, CVP and MAP. Once the sepsis is stabilized, hopefully the PaO2 will be adequate to where O2 can be weaned enough to get off the O2 clock and still keep a PaO2 of 55 mmHg. That may still give a high A-a gradient if the FiO2 is at 0.60.

Even for many cardiac patients, not all MIs are straight forward and have other underlying causes or disease processes which must also be taken into consideration at some point. Some may need to be addressed before cath lab intervention. There is not enough differential diagnostic equipment, time or knowledge available to the Paramedic to adequately rule out or rule in the many disease processes.

Flight Paramedics come with various backgrounds and knowledge. Since flight medicine has increased in the number of companies, many trying to stay alive financially, standards have changed. Even by reading some of the posts on the specialty forums, one can tell the education and mentorship is not that great in some of services. There are some areas that I (myself) would prefer an hour ground transport with very knowledgeable and skilled ground paramedics or EMTs to a haphazard 10 minute flight with some of the teams whose company is utilizing the warm body or cowboy mentality.

[Dustdevil]

You're all missing the point, which is that any system that is sending Basics out to make these decisions in the first place is a system that sucks. Can't blame that on the providers.

[Scaramedic]

Yes Dust, I agree but this is the first topic in a long while that has given ALS providers something to debate. I love it.

[tniuqs]

Yes Dust, I agree but this is the first topic in a long while that has given ALS providers something to debate. I love it.

:arrow: AGREED

Scara I know this is off topic but I simply LOVE your new look, let me think it its so umm .... SCAREE ! :shock:

Its a very intimidating tactic ... but It will not WORK :twisted:

LMAO

[Scaramedic]

That's Big Daddy Mars from the movie Ghost's of Mars. I highly suggest it, a great movie from John Carpenter.

I was going to post your pic Tniuqs but I didn't want to scare the kiddies.

Alas now I must go down and entertain. The annual family get together for Easter. About 100 people will be here soon for food and an egg hunt. I am getting too old for this crap. Takes two weeks to set up for. :evil:

[Jinketsu]

ok you know what all you people out there who think that bls cant handle a cardiac have to be from some far out state where you still use mast pants and cant get to a hospital in less than an hour because you dont know how to move an ambulance.here in the real world its bls BEFORE als. ...and where i work we are sent to help out the medis because they cant do everything themselves.now heres my thing i have worked side by side with some of the best medics in this country and it takes a medic TWICE as long to do thier assesment as it does for us to do ours and you know what it doesnt matter if you have two medics working at the same time it still takes a while.....it would take a medic the same amount of time to start an ekg,run a line and push meds then check for vitals than it wuld for me to put in a notification,get to the hospital and let somone who is better trained find out if someone is having an MI.unless someone falls under the contra indication for asprin then giving them 81mg isnt going to kill them and it may make them feel better....so all you medics get off your damn high horses and remember your bls traning and if you think you can survive a day in a REAL city you are welcome to try