V-Tach or Not?

[Just Plain Ruff]

no one said we were perfect. Most of us were asking why you didn't get a 12 lead as they dont' take that much time to do.

Don't get so bent out of shape when we question why you did what you did. We were just wondering why you didn't get a 12 lead.

[medic001918]

The reason I asked is this cardiologist took one look at the patient and a 2 second glance at the monitor strip and said "your wrong" and walked out of the room. He didn't have any patient history, vitals or nothing else but he was able to make the determination. I posted this strip to see if I had missed something, wide complex, bizaar, unifocal tachycardia.......yeah maybe I should have done a 12-lead but I didn't have time. I suppose that some of you are perfect but me.....I make mistakes and have oversights on occasion.

You were looking for input on the EKG and why this is or isn't V-tach, and also what else it could have been. One of the best ways to determine what else this might have been is with a 12-lead. Myself, I'm not convinced that it's V-tach either. Seeing what the rest of the heart is doing would be most helpful and that's why we keep going back to the 12-lead that's missing. This call merely presents a teaching point that you can tuck away for future refrence. Don't underestimate the importance of a 12-lead in a tachycardic patient complaining of shortness of breath. That 12-lead just might help you to determine the underlying cause of the patients shortness of breath (respiratory vs. cardiac etiology).

We were trying to help you...not bash you. Remember that anytime you post a case on a public forum, you open yourself to questions, comments and even criticism. If you dont' want everything that goes with it, well...that's a decision you have to make for yourself. Don't take an internet forum so seriously. This is a place of learning for most of us. We all try to learn from each other. And part of that learning process is making mistakes and recognizing them. Most people won't be harsh over a mistake, only when the mistake is repeated. There's things that all of us do now in our practice because of mistakes we've made in the past getting where we are. You can choose to take this constructively...or not. That's a decision for you to make. If it were me, I'd try to find a way to make myself a better clinician for the future. Noone's saying you're a bad medic, but we ALL have room for improvement.

Shane

NREMT-P

[ncmedic309]

I would love to see a 12-Lead on this patient - it's definitely a wide-complex tachycardia - possibly VTACH. I'm not trying to bust any balls, but in situations like this with these type rhythms, it should be a high priority to obtain a 12-Lead EKG if you have the ability to do so. I wouldn't be too quick to form a treatment modality based on this EKG, we need more information - we can determine much more from a 12-Lead. Just looking at the 3-Lead we can tell that we have left axis deviation along with a likely LAHB or quite possibly a complete LBBB. This might be causing the wide-complex that we're seeing...

EDIT: Sorry about the continuing 12-Lead rant, I just noticed that they had been hammering it home in the last few posts, I didn't read it all before responding...

[scottymedic]

It's also down to the scene as well and time from hospital and was the patient symptomatic to warrent a 12 lead, they are hardly done here, yes something I am not pleased with as they are great diagnositic tools, but its a judgement call at the time. I am wondering though if AZCEP is a rep for physio control lol seeing as he is continually going on about lifepak 12 etc. What deal can you cut me on one.

The post was on the initial strip posted, not on a potential 12 lead, it is what do you think it is, looking at that strip, as I said before, I think it was Vtach, there, my uneducated opinion :)

Scotty

[Medic26]

The post was on the initial strip posted, not on a potential 12 lead, it is what do you think it is, looking at that strip, as I said before, I think it was Vtach, there, my uneducated opinion

Scotty

This was the kinda thing I was looking for, I knew before the run was over that I should have done a 12-lead. I have never done a 12-lead on a shortness of breath patient until now. You can bet that I will be doing them from now on. My frustration was with the Cardiologist, how from a 2 second glance and no history did he know/think this wasn't V-T? Yeah my measly paramedic degree is no match for his royal education, but he could have been far less arrogant and made this a teaching moment!! :x

[chbare]

Scottymedic, why do you think this is ventricular tachycardia? This is not a challenge; however, I am curious to see how you arrive at this conclusion. As stated earlier, right shoulder axis deviation is characteristic for ventricular tachycardia. Upon completing a 3 lead axis assessment, I do not think there is right shoulder deviation. This does not definitively disprove the ventricular tachycardia hypothesis; however, it leads me to question the actual origin of the tachycardia.

Again, I am not trying to bust anybody. I love great conversation and I love to see how people arrive at their conclusions.

Any follow up would be helpful. Any way to obtain a copy of the 12 lead performed at the receiving facility?

Take care,

chbare.

[medic001918]

This was the kinda thing I was looking for, I knew before the run was over that I should have done a 12-lead. I have never done a 12-lead on a shortness of breath patient until now. You can bet that I will be doing them from now on. My frustration was with the Cardiologist, how from a 2 second glance and no history did he know/think this wasn't V-T? Yeah my measly paramedic degree is no match for his royal education, but he could have been far less arrogant and made this a teaching moment!! :x

I'm confused, I thought you wanted to know how we arrived at our determination of what we believed it to be. He just said it's VT without any explanation and you're okay with it? Just kind of confusing from where you were earlier in the thread in the information you desired.

I'm surprised that you had never done a 12-lead on a shortness of breath patient. Where we practice, it's a standard of care and it's enough to have you pulled into the office of the medical director for having not done one when it was indicated. In this case, with the heart rate I would say a 12-lead is more important than an IV. As soon as the patient is put on the monitor and I see that it's wide complex (as long as the patient has a pulse) my next step is to do a 12-lead. I guess ultimately it comes down to what your protocols dictate and what your medical director expects. If a 12-lead is not in your protocol for shortness of breath patients, then use this case as a way to change your own practice and better the care you provide for the patients you come into contact with. Again, it's not meant as a bash as much as it is a means of education for everyone who reads this thread. So please, don't take it negatively even though we keep coming back to the 12-lead. It's an example of importance.

As far as the cardiologists attitude, unfortunately some doctor's are just like that and there's nothing else you can do about it. You could always take the strip and talk to your medical control or another doctor that you're comfortable approaching and getting their thoughts on the matter. Any pro-EMS physician should be willing to take a minute and talk to you.

It's also down to the scene as well and time from hospital and was the patient symptomatic to warrent a 12 lead

Distance or not, a 12-lead should generally take less than one minute to perform from set up to capture. As far as if the patient was symptomatic or not, he called due to being short of breath from my understanding. So I would take a patient with shortness of breath, that's tachycardic with a wide complex to be symptomatic. I'm glad that you agree that one should have been performed in this case. But I'd also still like to know how you arrived at your determination that this patient was in V-Tach from the three lead?

Shane

NREMT-P

[AZCEP]

No, scotty, I can't get you a deal on anything from Physiocontrol. The LP12 is just the equipment I'm most familiar with. I'd probably discuss the benefits of the Zoll, or Phillips, if I had anything more than passing information about them. Now, if you'd like to buy a bridge... :wink:

For the benefits of your future patients, to no one in particular, take the time to pick the brains of every physician you come into contact with. Each will have more information, and significantly differing opinions of how to manage a given situation. You will learn more in a few minutes, with an open mind and a willingness to ask intelligent questions, than you did all through your EMS education.

Many enjoy showing you what they know. Occasionally you will even be able to use the information.

[medic001918]

Might I suggest downloading and reading this from Bob Page's download page. It's a power point titled "Advanced Dysrhythmia Course" and is loaded with great information that might shed some light on the subject.

Shane

NREMT-P

[Medic26]

I'm confused, I thought you wanted to know how we arrived at our determination of what we believed it to be. He just said it's VT without any explanation and you're okay with it? Just kind of confusing from where you were earlier in the thread in the information you desired.

I would prefer it explained but since he didn't armchair it, I'll take a short humble opinion. As far as 12-leads on SOB patients, unless they have cardiac complaints we are not required nor is it even referenced in our protocols. The only time we are required/asked to perform them is chest pain/ACS patients. You can bet your posterior that it won't happen agian.

I respect your opinion but just because someone didn't treat a patient the way you would have treated a patient does not mean they were wrong. I have worked a few different regions/states in several different services, every place puts emphasis on different things but the care is generally the same. Something you find as a major delinquency in your area may be nothing but provider discretion in another, BUT IT DOESN'T make it any more right or wrong.