12 lead and oxygen

[tniuqs]

Perhaps Professor Wade you missed this post and seeing as you lecture on this topic and are an expert on EMS world wide Ground and Air you would kindly provide your in sight / clarifications as these prior statements:

Jwade, on 30 November 2009 - 07:40 PM, said:

I agree completely....In the OP original scenario, I would not blast anyone with O2 until 12 lead was done.

If you have a blocked vessel causing injury or ischemia to the heart, then blasting O2 will not do much....

(And please spare me the lecture on diffusing into the plasma again).

The ENTIRE GOAL of treating, pre-hospital chest pain is to decrease MVo2 demand.

It has been my experience most people who are truly having a cardiac event will get more anxious( read: claustrophobic) when sticking a NRB at 15l on them right off the bat....I will usually start with a NC at 4-6 and titrate along with other meds to relieve MVo2 demand.

In closing: parturient montes, nascetur ridiculus mus

Edited December 2, 2009 by tniuqs

[VentMedic]

Vent,

Yes, I have made blanket statements, I have the experience and education to make those statements, and while I certainly agree with your above statements about ALS et al.....I think you might be a tad biased based on your experience in Florida and California. Each of us see things through different filters, and therefore express opinions based on those filters instead of looking at the bigger picture. I have spent way too much time in marital counseling to learn all that stuff, so I try to put forth majority opinions based on what I know to be factual. One cannot argue the fact that I spent 11 years in Europe and have done countless flights to Europe and Middle East, Japan, Australia, Israel, to have a big picture perspective at what is going on in world medicine.

For your age, that would mean you have not actally spent much time working in the U.S. We do know that other countries have different EMS systems than the U.S. Are you comparing how they do things differently or just trying to impress us? Some on ths forum are also from other countries and some have more experience in EMS than you have been alive. Some also know the EMS systems in the U.S. well enough to know that blanket statements can not work in a country that has over 50 different EMS levels each working under different scopes and their own medical directors.

If you knew much about the history of EMS you would realize that Florida has been doing 12 lead ECGs probably for well over 2 decades and was also one of the first states to do thrombolytics. However, we also have the ability to transmit thus the ED doctor or caridiologist can actually be the one to have the final say on if the cath lab gets activated. Does that mean they don't trust the Paramedic? No. It just means they may also have more education or will be going by the hx of the patient for determining if the cath lab is the best option for that patient at that time. Also, when some EDs at hospital with cath labs get over 100 EMS trucks in a few hours, some traffic control is necessary and that ambulance may need to be diverted by someone who has existisg knowledge of all the cath labs.

I will be in New Hampshire visiting my best friend this weekend, I will get a copy of his protocols and post them for you when I get back. I will also dig out my protocols from Detroit, and send a few other emails out requesting hard copies.

Stats from NH:

Numbers of EMS services: Fire department (paid), 46; fire department (volunteer), 123; volunteer squads, 61; commercial, 24; hospital-based, 5; funeral home, 2; police department, 11; other, 18.

Again, I answered the OP based on his limited info scenario, in which I would not arbitrarily stick a NRB @ 15l on that person. I have done this many times throughout my career, and not once has any ER, Cardiac Surgeon, or Medical Director ever questioned me on the process.

You state progressive EMS but you must use a 15 L/M NRBM? Below is the OP and I do not see anything mentioned about a 15 L/M NRBM

Question for all of you. ..... You have a pt c/o chest pain. pt denies sob and there is no evidence of an increased work of breathing. pt speaks in full sentences. My question is: if the pt is not in any obvious respiratory distress, do you wait to put the pt on oxygen until the 12 lead is finished. Why or why not?

Thanks.

I realize that every patient is different, but, I have been fortunate to work in some progressive EMS( minus ARIZONA), HEMS companies and forward thinking hospitals, which has influenced my decision making process. To each their own however....

Respectfully,

Jw

HEMS is a little different. We also don't advise ground EMS to sit at scene for an hour with a chest pain patient waiting a helicopter. We are not dispatched simultaneously with ground EMS for chest pain as we can be for trauma. Is your helicopter service dispatched to every chest pain call with ground EMS? That patient may also be much better in a hospital ED who has a rapid transport IFT agreement for STEMI but can also initiate treatment rather than waiting in some field for a helicopter provided the hospital is closer. Chances are a few eyes have seen that patient's ECG before calling a helicopter. However, if you are flying in with a helicopter for IFT, I bet there were doctor to doctor communications for the referral for them to clear a path to the cath lab for you.

We could also get into some of the HEMS issues in AZ as well as some their EMS companies but that can be another thread. Few states are perfect and every hospital and every EMS system performing to the highest possible level without some issues. We could or have already had discussions about Michigan and that state's outspoken reluctance to have its EMS education programs accredited. Again, the states you listed earlier, you can not overlook the fact that many of their services are BLS volunteer only. Thus, it is difficult to toss around a stat like >90% activate the cath lab if there are only a few ALS EMS agencies in the state.

[crotchitymedic1986]

No, I'm dead serious.

Yes I would and routinely do. You (and others) are making assumptions, I said withold the treatment (O2) until a baseline 12 lead is established and proven to be clear and readable (no artifact, intererence, etc). Once that is done, continue on with standard of care. O2 as appropriate, IV, ASA, Nitro, Morphine, etc.

The diagnostic test is the standard of care in nearly our whole Province as is early physician intervention (consultation) to triage to either PTCI (proimity, availability of cath lab, which cath lab, etc) or prehospital thrombolysis (tNk) , if warranted. This followed with Plavix and Enoxaparin (low molecular weight heparin).

I'm sorry, but this is one of the few definitive times where you do actually treat the monitor (12 lead/15 lead) with more importance than the patient.

And tniuqs, the Wellens discussion comes from a Cardiologist and 2 residents at UAH. Not specifically O2 alone, but our global treatment for cardiac ischemia (MONA if you will) has evidenced many occasions resolution of 12 lead indicators but our early 12 lead establishes evidence of the pathology. Hence why Cardiology loves EMS 12 leads.

I know there are semantics and generalities in your statement, but you should always treat the patient before you treat the equipment. When I started out, we did not have glucometers, pulse oximeters, or 12 Lead, and it amazes me to see how many Paramedics trust the equipment over patient presentation, history, and signs and symptoms. The first thing I did for any new Paramedic on my truck was to take all of that equipment away, so that he had to assess the patient first.

[VentMedic]

I say the 12 lead prehospitally is of benefit by allowing diversion to PCI capable facilities, prehospital thrombolysis and identification of things you just can't get with Lead II like bundle branch and fasicular blocks, LVH etc

Can also allow for more appropriate triage - you roll up to ED with a little old lady who was complaining of chest pain but now has none thanks to the GTN and morphine as well as no ECG changes so she'll probably end up in the hallway, have a cardiac arrest an hour later and croak out; but, if I whip out a 12 lead showing bad-ass ST changes, well, maybe she'll go for an angiogram straight away.

Transmission technology now used by some in EMS in the U.S.

http://content.onlinejacc.org/cgi/content/full/50/6/509

The ECG is tranmitted and prehospital treatment can be continued without fear of the hospital missing ST segment changes or waiting until you get to the hospital.

This study from Los Angeles none the less supports lower door to needle time in PCI; .... in Los Angeles for frick sake, where Paramedics rely on machine interpretation of 12 lead ECG to active STEMI facilities; ..... gah!

It is amazing that for an area with the size and wealth of LA that the 12-lead ECG is just now getting started. But again, there are many areas in the U.S. that can not do 12 lead ECG and many areas that are only BLS. Michigan just announced their first 12-lead ECG about 5 years ago.

Here's an article from September 2009 about Chicago. Believe it or not Chicago FD EMS does have a decent reputation.

http://www.chicagobreakingnews.com/2009/09/chicago-behind-the-times-in-heart-attack-response.html

None of the Chicago Fire Department's 75 ambulances carries equipment that can identify "widow maker" heart attacks, or STEMIs,

Here's another area in California:

San Luis Obispo County

http://www.sloemsa.org/

http://www.sloemsa.org/policy/pdf/619.pdf

Edited December 2, 2009 by VentMedic

[Jwade]

Transmission technology now used by some in EMS in the U.S.

http://content.onlinejacc.org/cgi/content/full/50/6/509

The ECG is tranmitted and prehospital treatment can be continued without fear of the hospital missing ST segment changes or waiting until you get to the hospital.

It is amazing that for an area with the size and wealth of LA that the 12-lead ECG is just now getting started. But again, there are many areas in the U.S. that can not do 12 lead ECG and many areas that are only BLS. Michigan just announced their first 12-lead ECG about 5 years ago.

Here's an article from September 2009 about Chicago. Believe it or not Chicago FD EMS does have a decent reputation.

http://www.chicagobreakingnews.com/2009/09/chicago-behind-the-times-in-heart-attack-response.html

Here's another area in California:

San Luis Obispo County

http://www.sloemsa.org/

http://www.sloemsa.org/policy/pdf/619.pdf

Vent & Tniuqs

I don't have a lot of time to answer your previous questions at the moment but i will get to them promise.....Just a quick question about the above highlighted area. What does that mean " announced"?

I was doing 12 leads in Michigan back in 1999 when I was working, so not sure what exactly you are talking about.

Thanks

JW

Edited December 2, 2009 by Jwade

[VentMedic]

Vent & Tniuqs

I don't have a lot of time to answer your previous questions at the moment but i will get to them promise.....Just a quick question about the above highlighted area. What does that mean " announced"?

I was doing 12 leads in Michigan back in 1999 when I was working, so not sure what exactly you are talking about.

Thanks

JW

I didn't ask any questions that require an answer.

What service were you with? When the data was being collected for prehospital 12-lead usage, Michigan was stil looking to establishing theirs and only a could of agencies were considering it in the late 90s. A few years later a few more did consider the 12-lead and did impliment the programs. Thus 12-leads in Michigan seem to have come about later in the last 10 years rather than earlier. Detroit FD was attempting to get their program started around 2005 as they were still working on the technology side with the hospitals. That acutally was an interesting conversation on another forum and at one of the EMS conference to see them evolve while still plagued with other controversies.

Edited December 2, 2009 by VentMedic

[Jwade]

I didn't ask any questions that require an answer.

What service were you with? When the data was being collected for prehospital 12-lead usage, Michigan was stil looking to establishing theirs and only a could of agencies were considering it in the late 90s. A few years later a few more did consider the 12-lead and did impliment the programs. Thus 12-leads in Michigan seem to have come about later in the last 10 years rather than earlier. Detroit FD was attempting to get their program started around 2005 as they were still working on the technology side with the hospitals. That acutally was an interesting conversation on another forum and at one of the EMS conference to see them evolve while still plagued with other controversies.

VENT,

Medstar was one of the agencies I worked with that was using 12 leads, Lifepack 12, we did them all the time. One of my friends worked for HVA as a paramedic during his entire Medical School and Orthopaedic Surgery residency, and he was using them as well.

So, I can say with absolute certainty we were using 12 leads in Michigan before your recent 5 year mark. Hell, I have been in Arizona for 5 years now!

JW

Edited December 2, 2009 by Jwade

[VentMedic]

VENT,

Medstar was one of the agencies I worked with that was using 12 leads, Lifepack 12, we did them all the time. One of my friends worked for HVA as a paramedic during his entire Medical School and Orthopaedic Surgery residency, and he was using them as well.

HVA bought their 12-leads in 2001 and went live officially around 2002.

So, I can say with absolute certainty we were using 12 leads in Michigan before your recent 5 year mark. Hell, I have been in Arizona for 5 years now!

JW

Just how old are you since you also worked for 11 years in Europe?

[Jwade]

HVA bought their 12-leads in 2001 and went live officially around 2002.

Just how old are you since you also worked for 11 years in Europe?

Well, <55 & >35 on the age! I don't give out personal info on a public forum. OLD ENOUGH to know what the hell I am talking about!

2002 - 2010 That would equal 8 years +/- a month or two. > than the 5 years you quoted in your earlier post.

Germany to be exact, Are you familiar with Medicine at the University of Heidelberg? My link

Respectfully,

JW

[VentMedic]

Well, <55 & >35 on the age! I don't give out personal info on a public forum. OLD ENOUGH to know what the hell I am talking about!

2002 - 2010 That would equal 8 years +/- a month or two. > than the 5 years you quoted in your earlier post.

Germany to be exact, Are you familiar with Medicine at the University of Heidelberg? My link

Respectfully,

JW

My exact words were about 5 years. Okay so there are 2 services that got started between 5 - 10 years and a few that just recently got their 12-lead capability.

But, from what has been stated from Michigan's EMS officials, the state is largely volunteer which is why they are arguing against the CoAEMSP standards. From the 2008 survey is looks like almost 50% are volunteer and many of those are probably just BLS judging by the number of EMTs/FR vs Paramedics in the state. Thus, again when you throw a number like >90% can activate, that may mean little if only half of the state even has ALS and not all of the ALS providers have 12-lead capability.

Numbers of EMS services: Total EMS/ambulance services, 401; volunteer, 191; fire department (volunteer and paid combined), 102; air ambulance, 6.

Edited December 2, 2009 by VentMedic