Old dude can`t breathe

[systemet]

Systemet, don't think I was trying to pick on you.

Sorry; i realised after that I might have been a little sensitive. I'm trying to crawl my wait out from under a pile of spreadsheets and stats, with an awesome 'flu and some pretty fun back pain. I'm a little grumpy today!

There are a lot of times in EMS when you see a pt with X pathology but never know about it because you are unable to get followup.

I would agree that this was one of my biggest frustrations when I worked the road. We often didn't get the opportunity to know if we had treated appropriately in a given situation, and I think a lot of valuable learning experiences were missed.

Diagnostic uncertainty isn't typically well taught in most paramedic / EMT programs. Most of us don't tend to come away with a good understanding of sensitivity and specificity. There's also a definite tendency to take relatively insensitive or nonspecific indicators, like the S1Q3T3 pattern and turn them into absolutes, i.e. the patient with a PE will have this finding, or because this finding is present it will be a PE. This is a failing in the educational systems that I hope can be improved one day.

You usually are able to get followup on the sickest cases so you start to develop a biased view of a disease process based on your experience. We even do it as doctors, that is why cases like the ones I posted above are humbling. The difference is that in the hospital we get to know the dx and can be humbled. I don't remember if either one of them were brought in by EMS but if they were I can guarantee you that the crew never thought about them again. Had I not know about the PEs, I probably would never have thought about them again either.

I realise you've worked EMS as well, and while my anecdotal experiences might be quite meaningless, I can agree with those sentiments. A pulmonary embolus is something you suspect in the ambulance from time to time, based on the patient's history, you get that occasional 40 year old female on birth control, smoker, pain between the shoulder blades presentation, that starts you thinking in that direction, but we really don't have any tools to identify which of these patients really do have emboli.

I doubt any of us in EMS truely appreciate how many of our cardiac arrest patients potentially have had massive PEs.

As for the TNK (or any other lytic), it's not indicated in this case. I won't get into the interpretation of the EKG in case someone else wants to do that, but I will say there is no STEMI, so lytics are not indicated.

Yeah, that was what I was suspecting. I enjoy reading and learning more about ECG interpretation, (I've been working through the Mattu books, and doing a little bit of teaching), but I've always been aware that it's one thing for me to look at an ECG and say, hey that's BER, or there's borderline voltage criteria for LVH, so this ST elevation is likely secondary / spurious, but I've tried to have a low threshold for calling the clot-docs, in case I'm wrong. It's one thing for me, with 3 years of education and a paramedic licence, to say there's no STEMI here, despite the presence of ST elevation, and another thing for a board-certified EM or cardiology physician to make that call.