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58 year old male CC: Chest pain

19 comments

Here’s an interesting case sent in by a faithful reader who wishes to remain anonymous.

EMS is called to the residence of a 58 year old male complaining of chest discomfort.

On arrival the patient is found sitting on the edge of the bed. He is anxious but alert and oriented to person, place, time, and event.

He was awakened from sleep by chest discomfort.

Onset: 30 minutes ago while sleeping
Provoke: Nothing makes the pain feel better or worse
Quality: Severe pressure or “ache”
Radiate: The pain does not radiate
Severity: 10/10
Time: He has had chest pain before but “not this bad”

Past medical history: HTN, dyslipidemia

Medications: Lipitor, Norvasc, ASA

Vital signs are assessed.

RR: 24
Pulse: 136
NIBP: 160/98
SpO2: 94 on RA

Breath sounds: basilar rales

The patient admits to mild dyspnea. He states that he has “gained a little weight” recently and his doctor was getting ready to put him “on a water pill.”

Temp: 99.1
BGL: 138

The cardiac monitor is attached.

A 12-lead ECG is captured.

The patient is given 324 mg of aspirin, 0.4 mg NTG SL spray and placed on CPAP.

Another 12-lead ECG is captured.

The patient is loaded for transport and another rhythm strip is captured.

What do think is going on with this patient’s heart rhythm?

What do you think is wrong with this patient?

You are 15 minutes away from the local non-PCI hospital and 60 minutes away from a STEMI receiving center.

Where would you transport this patient and why?

*** UPDATE ***

This 12-lead ECG was captured en route to the hospital.

And finally this rhythm strip.

Does this shed any light on the mechanism behind the wide complexes?

Rhythm Challenge #5 – Answer

4 comments

Here is the solution to Rhythm Challenge #5.

The rhythm is paced and here’s why.

As I explained in Evaluating the Pacemaker Patient – Part I, most modern pacemakers are DDD pacemakers according to the NBG pacemaker code.



Essentially that means that most pacemakers will “track” P-waves and deliver a paced QRS complex (when no native QRS complex appears) after a prescribed PR interval to take advantage of the “atrial kick” and the associated improved hemodynamics.

However, there is a limit. As you might expect, cardiologists don’t want the device to track P-waves and supply paced QRS complexes when the atrial rate goes up to 300 as it does during atrial flutter. That would not be in the patient’s best interest. So there’s an upper rate limit.

Let’s say the cardiologist wants a pacemaker to track a patient’s P-waves but he doesn’t want the paced rhythm to exceed 136 BPM. How can this be achieved? By a parameter called the PVARP or Post-Ventricular Atrial Refractory Period. That means that a pacemaker will “close its eyes” for a prescribed interval after each QRS complex, whether it’s a native QRS complex or a paced QRS complex. In other words, it will ignore P-waves during that period of time.

All of the ECGs in Rhythm Challenge #5 can be explained by a PVARP set for approximately 440 ms or 11 small blocks, which is a heart rate of about 136.

Let’s look at a graphic to see how this played out from the pacemaker’s point of view.

As you can see, when a P-wave falls outside of the PVARP the device waits for a prescribed PR interval and then creates a paced QRS complex if a native QRS complex does not appear first. P-waves that fall inside the PVARP are ignored by the pacemaker.

In other words, this is normal pacemaker behavior! Having said that, the only way to know for sure is to identify the exact type of pacemaker (the manufacturer and model), the indication for the pacemaker, how the pacemaker is programmed, and to read the report after the device is interrogated.

Rhythm Challenge #5

16 comments

@S_Cook_EMTP contacted me on Twitter with regard to a 77 year old male with an interesting heart rhythm.

He subsequently took a picture of the ECG and emailed it to me with this description:

77 yo male with history of COPD, CHF. Initial 4-lead EKG reveals A-Flutter with variable response: 2:1, 3:1, 4:1, and 5:1 is what I saw. Patient would have runs of both bi and trigeminal PVCs then settle back to A-Flutter in the 80s/90s. Then patient developed 20-30 second runs of the attached that ran from ~100BPM to 225BPM.

Best I can think is this is a run of V-Tach. Patient does have an implanted pacer/defib, but relates he hasn’t felt it fire.

Up to about 130 to 140, electrical rate and radial rates were equal.

Otherwise, patient was hemodynamically stable, BPs in the 120s/70s, A&O X 4, with some difficulty breathing.

Patient was recieveing an A&A neb treatment. Initial SaO2 was 75, increasing to 98 during treatment. Heavy smoker. Denies any and all pain and relates he “just feels like $%^*”

Here’s the picture of the ECG in question.

What do you think this heart rhythm is showing?

After I gave my answer, @S_Cook_EMTP shared the following ECGs from the same case, indicating that the treating emergency physician did not agree with my assessment.

However, I still think I’m right!

Of course, I could be wrong (we’ll discuss that a little bit more later).

So, for the sake of Rhythm Challenge #5, to what do you attribute this wide complex tachycardia and why?

See also:

Rhythm Challenge #5 – Answer

Previous “rhythm challenges” can be found here:

What’s the heart rhythm?

Rhythm challenge #1

Rhythm challenge #2

Rhythm challenge #3

Rhythm challenge #4

Rhythm challenge #4 – Discussion

Early bird gets the worm

No comments

As Ambulance Driver would say, “For all you EMS types, my latest column is up at EMS1.com.”

Early bird gets the worm

Enjoy!

Cardiac Arrest – Anatomy of a System Failure

6 comments


Dave Statter (STATter911.com) recently posted a story about a cardiac arrest that occurred in Ocean City, MD. It’s a sad story with an unhappy ending. In fact, there’s only one redeeming quality about this story. It’s a perfect example of a system failure.

  • The dispatcher who answered the 9-1-1 call “froze” and was unable to effectively process the call.
  • There was an unacceptable delay in dispatching the call: approximately 4 minutes and 26 seconds.
  • Total response time for the first responder from call received (17:21:38) to patient’s side (17:27:50) was documented as 6 minutes and 12 seconds on the run sheet, even though the news story suggests that a fire station was only a mile and a half away.
  • Even this documentation is suspect considering that a Critical Incident Report from the Ocean City Department of EMS indicates that 7 minutes and 10 seconds into the call they switched dispatchers to handle CPR instruction. If first responders were at the patient’s side in 6 minutes and 12 seconds, why would they need to give CPR instructions?
  • Internal documents discussing the case attempt to gloss over the issue by suggesting that there’s no evidence based standard for call processing or response time intervals.
  • The dispatcher was unable to distinguish between agonal respirations and effective breathing, even though the caller stressed that the breathing was abnormal.
  • The dispatcher asked the caller to take the patient out of the boat prior to starting CPR.
  • The pre-arrival instructions, when they were finally given, were antiquated (mouth-to-mouth rescue breathing as opposed to “hands only” CPR for untrained lay rescuers).
  • The dispatcher sounds annoyed with the caller (stating “she’s screamin’ in my ear!”) as if the caller wasn’t completely justified in becoming impatient.
  • Internal documents refer to the caller as “panic stricken” in an apparent effort to stigmatize the caller and avoid responsibility.
  • Once paramedics arrived, the automatic CPR device malfunctioned.
  • The manufacturer of the automatic CPR device was able to determine that the equipment had not been properly maintained.
  • The EMS Incident Report is poorly written (I tried to figure out when or if the patient was shocked but I gave up) and suggests there was a problem with the patient’s airway en route to the hospital (tracheal tube replaced with a King).


In reading (and listening) to this story one is left with the sick feeling that the chain-of-survival is horribly broken in Ocean City, MD. Worse than that, one senses that officials in Ocean City, MD are oblivious to their duty to protect the public.

Imagine that your wife, husband, mother, father, sister, brother, daughter, or son will experience a sudden cardiac arrest in your jurisdiction sometime in the next 365 days. Then design a system to save their life.

Spare the bereaved families of the dead your lame excuses. They pay your salary and they deserve a heck of a lot better than that. I don’t think they expect perfection. Just an honest effort.

At the very least, the surviving spouse in this case deserves what she tearfully asks for in her interview with the news media: acknowledgement.

See also:

Left waiting: Alexandria man in cardiac arrest waits for EMTs in Ocean City

Conclusion to 43 year old female CC: Chest pain – Angiograms

4 comments

Here is the conclusion to 43 year old female CC: Chest pain.

Let’s take another look at her 12-lead ECG.

This patient experienced cardiac arrest on arrival in the emergency department.

She was defibrillated while still on the EMS gurney, stabilized, and then transferred to the cardiac catheterization lab.

Here we see a proximal occlusion of the right coronary artery (RCA). Those of you who suspected right ventricular infarction in addition to acute inferior STEMI were exactly correct.

Here we see the wire crossing the lesion.

Balloon inflation.

More balloon inflation.

Blood flow restored.

The patient was admitted to the ICU and discharged three days later.

Diagnosis: ST-elevation myocardial infarction

Another soccer player experiences sudden cardiac arrest on camera

1 comment

h/t Dr. Wes

You might recall a previous post that showed Belgian soccer player Anthony Van Loo collapsing on camera and receiving a shock from his ICD.

In this video Salamanca soccer player Miguel Garcia experiences a sudden cardiac arrest on camera.

Electrophysiology Fellow makes the point that sudden syncope is almost always cardiac! You will note that the victim makes no effort to protect his face when he falls.

See also:

Miguel Garcia ‘continues to improve’ after suffering heart-attack during Spanish league game

Incredible video of soccer player saved by ICD (VIDEO)

Scientist shocked by ICD at Copenhagen Summit (VIDEO)

Cardiac arrest – are you ready to save one of our own? (VIDEO)

Physio-Control announces LIFENET System 5.0, partnership with AirStrip Technologies

3 comments

Today at the American Heart Association’s Scientific Sessions 2010, Physio-Control announced the release of LIFENET 5.0 and a new partnership with AirStrip Technologies.

New features available in LIFENET 5.0 include:

  • LIFENET Consult – iPhone application allows physicians to perform rapid consults and provides decision support remotely to EMS and hospital care teams. The LIFENET Consult app is available for download from the iPhone App Store.
  • LIFENET OnePush – Automated protocol activation, notifies necessary caregivers and allows hospital teams more time to prepare for incoming patients.
  • LIFENET ePCR Delivery – Enables efficient and secure remote delivery of electronic patient care records (ePCR) to hospital printers or electronic medical record systems.
  • LIFENET Asset –Provides LIFEPAK device overview and management across entire fleet including automated alerts on device status, usage information, management of setup options and software updates.
  • Enhanced data integration – Enables EMS and hospitals to capture more patient data and combine it for a more-complete view of the patient.

If you’re not familiar with AirStrip Technologies some of their mobile wireless solutions were featured in this TED Med talk in October 2009: Eric Topol: The wireless future of medicine.


Here’s another video featuring Cameron Powell, M.D.

AirStrip CRITICAL CARE from MacKorisnik on Vimeo.

This post was derived in part from a press release sent by Physio-Control with whom Tom Bouthillet has no conflict of interest.

60 year old male CC: Syncope

18 comments

Here is yet another awesome case courtesy of Christopher Watford who writes the My Variables Only Have 6 Letters blog.

One of these days Christopher is going to say (in his best Darth Vader voice), “Once you were the teacher but now I am the master!” and it will be completely justified.

EMS is called to evaluate a 60 year old male patient who experienced a syncopal episode.

On arrival the patient is found sitting in the front seat of his car. He is ashen gray and cold to the touch.

He is in moderate respiratory distress.

Past medical history: Brochitis
Medications: None

Breath sounds: clear bilaterally

Vital signs are assessed.

RR: 30
Pulse: 118 (weak and rapid)
BP: 108/64
SpO2: 88 on RA (increases to 94 on oxygen via NC @ 4 LPM)

BGL: 79

The patient states that he “can’t afford to go to the hospital.”

The cardiac monitor is attached.

A 12-lead ECG is captured.

What do you think is wrong with this guy?

*** Update 12/10/2010 ***

This gentleman was diagnosed with bilateral pulmonary emboli. He was admitted to the hospital on Lovenox (enoxaparin). After almost signing out AHA he was persuaded to stay by a doctor and nurse who informed him in no uncertain terms that he would die if he left.

The most suggestive ECG findings were:

  • Sinus tachycardia
  • S1Q3T3 (S-wave in lead I, Q-wave in lead III, inverted T-wave in lead III)
  • Possible beginnings of an acute right ventricular strain pattern in the right precordial leads

It’s important to note that the most common ECG abnormality associated with PE is sinus tachycardia.

Synchronized cardioversion without sedation – Part II

4 comments

Rogue Medic responds to my recent post here:

On the relative wisdom of synchronized cardioversion without sedation – Part I

And here:

On the relative wisdom of synchronized cardioversion without sedation – Part II

In Part II, Scallywag Rogue Medic writes:

“We are discussing the awake and alert patient with severe signs and symptoms related to a suspected arrhythmia (eg, acute altered mental status, ischemic chest discomfort, acute heart failure, hypotension, or other signs of shock).

Why do we presume that acute altered mental status automatically accompanies all of the other acute conditions?

What if the patient with ventricular tachycardia at a rate of 170 has severe crushing chest pain (ischemic chest discomfort), but is an awake and alert patient?

Is this a stable patient?

What if the patient with a sudden onset of crackles half way up and severe air hunger (what appears to be acute heart failure) also happens to have a ventricular tachycardia at a rate of 170 and further happens to be anawake and alert patient?

Is this a stable patient?

What if the patient with ventricular tachycardia at a rate of 170 has a blood pressure of 74/52 (hypotension) still manages to be an awake and alert patient?

Is this a stable patient?

What if the patient with ventricular tachycardia at a rate of 170 is extremely, drenched with sweat, and feels ice cold (other signs of shock), but is an awake and alert patient?

Is this a stable patient?

Accepting the fact that patients can be “unstable” for a multitude of reasons, let’s contend with the awake and alert patient who is showing sign shock related to a wide complex tachycardia at 170 BPM.

The fact remains that drugs like morphine or midazolam can further impair the patient’s hemodynamic status. In other words, they can cause harm.

We have competing goals here. One is to provide comfort and the other is to provide life-saving therapy.

Both are laudable goals but they are in conflict when the patient is hemodynamically unstable. To pretend that this tension does not exist is not helpful in answering the question, “What should a paramedic do?”

What are the possible outcomes?

Sedate the patient > cardioversion is successful > hemodynamics are improved > patient lives

Sedate the patient > cardioversion is unsuccessful > hemodynamics are further impaired > patient may die

Cardiovert without sedation > cardioversion is successful > hemodynamics improve > patient is traumatized but alive (happens all the time with ICD shocks)

Cardiovert without sedation > cardioversion is unsuccessful > hemodynamics do not improve but at least they do not get worse > patient is traumatized but alive

Reasonable people can disagree about how this situation should best be handled, but I would not call cardioversion without sedation a “sentinel event” requiring some type of inquiry or formal explanation.

Unless of course the patient begged not to be shocked and the paramedic shocked the patient anyway.

That’s a different kind of malpractice.

I’ll give Rogue Medic the last word.

78 year old female CC: Headache

28 comments

Here’s a case submitted by a faithful reader by the name of Nick Mercer.

EMS is dispatched to “possible heart attack” in rural Montana.

On arrival they find a 78 year old female lying on the couch where her friends found her in the morning.

The patient is awake and oriented but not alert. Speech is clear and appropriate but sluggish. She states that she has been lying on the couch for less than 1 hour.

The paramedics determine that she is complaining of a headache.

From bystanders they learn the patient as a past medical history of CVA, CHF, and MI.

The patient is cool, pale and diaphoretic.

During a neuro exam paramedics discover right-sided facial palsy and left-sided arm drift.

The patient starts to vomit.

Because they are 50 minutes from the hospital, the paramedics call for aeromedical transport.

The patient’s head appears to be atraumatic. She denies recent falls. She denies chest pain or shortness of breath.

Vital signs are assessed.

RR: 24
Pulse: 90
BP: 216/134
SpO2: 98 on oxygen via NRB @ 15 LPM

BGL: 168

A 12-lead ECG is captured.

The patient is more lethargic by the time aeromedical transport arrives although the other neurological symptoms have resolved. She still looks acutely ill.

The patient has vomited a total of six times but stops after being treated with IV Zofran.

Repeat vital signs are assessed.

RR: 20
Pulse: 88
BP: 164/110
SpO2: 99 on oxygen via NRB @ 15 LPM

An additional 12-lead ECG is captured.

What is your impression of this patient?

On the relative wisdom of synchronized cardioversion without sedation

5 comments

Rogue Medic and I don’t always agree, but we agree more than we disagree.

When we disagree, it’s usually because I think RM is being deliberately controversial. He is the Rogue Medic, after all.

Let’s look at how the Princeton University WordNet defines “rogue“.

Noun

(n) rogue, knave, rascal, rapscallion, scalawag, scallywag, varlet (a deceitful and unreliable scoundrel)

A deceitful and unreliable scoundrel.

Now that’s just funny and I don’t care who you are!

So now we come to Rogue Medic’s recent post Cardioversion – 2010 ACLS – Part III.

Before we go further (or is it farther?) it needs to be said that you shouldn’t start what you can’t finish. I’m filled with those awful presentiments that a commander must feel when he orders the first shots fired in an action that will certainly provoke an immediate and disproportionate response.

If you can’t tell, Tim Noonan and I are friends, although we’ve never met in “real life”. Somehow I missed him at EMS Today which was disappointing.

In this post, Rogue Medic amends his statement from Part II to read:

In what way is the electrocution cardioversion or defibrillation of an awake patient not a sentinel event that requires the medical director to justify the abuse of this patient to the state medical board?

The drama!

Here’s the problem I have with what Rogue Medic is saying (beyond the fact that it’s inflammatory).

A conscious but hemodynamically unstable patient in non-sinus tachycardia (where the signs and symptoms are thought to be caused by the tachycardia) is in a precarious position and it’s not given to us to know ahead of time whether or not synchonized cardioversion is going to work.

Let’s pause for a moment and acknowledge that there are degrees of stability/instability.

I’m talking about the peri-arrest patient.

If the patient cares that much about whether or not you are shocking them, I have questions about how “unstable” they really are.

Rogue Medic shares a comment from a reader who states, “I begged the worker not to shock me.”

If the patient begs you not to shock, you probably shouldn’t shock!

A far more egregious act than shocking without sedation is shocking against the expressed wishes of your patient, who I presume possessed decisional capacity!

Once you give a drug you can’t take it out. So if you push drugs that can negatively effect a patient’s hemodynamics and those hemodynamics are already compromised you are taking a risk.

What is the benefit?

Many things in EMS (and Fire) are risk/benefit.

I can conceive of circumstances within which I would shock a hemodynamically unstable patient who was not unconscious. I can conceive of circumstances within which that would be the best thing for the patient. I can conceive of circumstances within which that would be life-saving.

Like so many things in medicine, this is not a black and white issue.

Help for a FireEMSBlogs.com blogger!

5 comments

In case you didn’t know, Matt McDowell is the author of the S.A.F.E. Firefighter blog here at FireEMSBlogs.com. He’s a lieutenant with Bluffton Township Fire District (BTFD) which is just over the bridge from Hilton Head Island.

While I don’t know “Jeebs” as well as I would like, we have many mutual friends and I can tell you that he’s a class act and well respected by his peers.

A friend of mine forwarded an email to me yesterday. I’m cutting and pasting it here with Captain Dollahan’s permission.

~~~~~~~~~~~~~~~~~~~~

Good morning everyone,

If you haven’t heard by now, Matt and Elizabeth McDowell are expecting a little girl by the name of Juliann McDowell. With the joy of Juliann’s arrival coming soon (Dec 28), there will be some major expenses due to the heart defect that they have already found in the multiple ultrasounds. Baby Juliann will require numerous open-heart surgeries, just after birth, in order to correct this heart defect. I have listed a link about the nature of the defect HERE.

In an effort to help McDowell (Jeebs) and Elizabeth, we are doing a 50/50 raffle to offset the major expenses coming their way. We will draw the winner of the Raffle on November 20.

I need your help to get this raffle information out… I attached the sheet with the raffle information so you can forward onto friends and family, even people you don’t know… It’s time for us to help one of our own brothers!

THANK YOU… In advance

Please don’t hesitate to call or email me with any questions!!!

Richard Dollahan
Captain Shift 3 Engine 325
Bluffton Township Fire District
357 Fording Island Rd.
Bluffton, S.C. 29909
work (843)757-2800
cell (843)247-4606
captain.dollahan@blufftonfd.com

He’s Not Heavy!
He’s My Brother!

~~~~~~~~~~~~~~~~~~~~

Here is a copy of the flyer.

It has been brought to my attention that the area codes are missing from the flyer. The area code is 843.

You can download a copy of the flyer HERE.

I’m pledging $50.00 and I hope you will do the same (although any amount will be appreciated).

Update: If you would like to make a donation using PayPal, please click HERE and then click the DONATE button. Your donation will benefit the McDowell family and the Rice family. David Rice is a firefighter with Bluffton Township Fire District who has recently been diagnosed with a rare tumor.

Thank you for your support!

69 year old male CC: Chest pain

28 comments

Christopher A. Watford from the My Variables Only Have 6 Letters blog has submitting a very interesting case study (actually he submitted two but you’ll have to wait for the other one).

EMS is called to the residence of a 69 year old male complaining of chest pain.

On arrival the patient is found sitting in a kitchen chair.

He appears acutely ill.

Skin is ashen, cool, and very diaphoretic.

Levine’s sign is present.

It is obvious that the patient is anxious and in severe pain.

Onset: Sudden onset approx 20 minutes before EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: Severe pressure
Radiate: The pain does not radiate
Severity: 10/10
Time: No previous episodes

Breath sounds are clear bilaterally.

Vital signs are assessed.

RR: 20
Pulse: 60 R
BP: 142/68
SpO2: 90 on RA (increases to 96 with oxygen via NRB @ 15 LPM)

BGL: 104

No known drug allergies.
Denies any significant medical history other than “indigestion”.

The cardiac monitor is attached.

A 12-lead ECG is captured.

Another 12-lead ECG is captured with modified chest leads V4R, V5R and V6R.

How would you treat this patient?

Is there anything about this case that surprises you?

*** Update 12/13/2010 ***

What Christopher and I both found unusual about this case is that the GE-Marquette 12SL interpretive algorithm was not giving the ***ACUTE MI SUSPECTED*** message, even though it was giving messages like “ST-elevation consider anterolateral or acute infarct” and “inferior injury pattern” which I had always thought automatically trigged an accompanying ***ACUTE MI SUSPECTED*** message.

This is especially important because some EMS systems require the ***ACUTE MI SUSPECTED*** message in order for paramedics to bypass the local non-PCI hospital for the STEMI Receiving Center!

So, I contacted a friend at Physio-Control who put me in touch with the person responsible for the computerized interpretive algorithm. He was also surprised that the ***ACUTE MI SUSPECTED*** message was not present on these 12-lead ECGs. So he turned to a “veteran 12SL designer”.

Together they figured out the problem.

Mystery solved! The 12SL expert said that the 12SL algorithm would definitely give the Acute MI statement for the first cse that you sent me. So I turned to the setup choices (LP12 Operating Instructions, chapter 9). One of the setup menu items is “ACUTE MI”. The description is “Print Acute MI message”. Further explanation says, “ON: Prints on the 12-lead reports when criteria are met.”

I think that the LP12 is set up with the ACUTE MI option turned off. I suggest that you get back to the customer and have them turn ACUTE MI on in the setup menu for this LP12 and any others that they have.

So, if you have a Lifepak 12 and you’re not receiving the ***ACUTE MI SUSPECTED*** message for obvious acute STEMIs, you might want to check this parameter.

LIFEPACK 12 Defibrillator/Monitor – Operating Instructions

How long does it take to transmit an ECG to the emergency department with a Lifepak 12 and In Motion Gateway?

13 comments

My fire department recently upgraded to the “new” LIFENET system by Physio-Control because the “old” LIFENET system used so-called “sunset” Circuit Data Switch technology as opposed to Internet Protocol. In other words, it was only a matter of time before it stopped working.

Setting aside the issue as to whether or not ECG transmission is a “million dollar solutions to a 5 cent problem” I thought it would be interesting to find out exactly how long it takes to transmit an ECG to the emergency department.

Because this can be configured so many ways, it’s important to understand exactly how our system is designed. We use a Lifepak 12 which connects with a In Motion Gateway via Bluetooth. This is not the modem that attaches to the side of the Lifepak 12.

So what did we find out?

1.) It takes exactly 30 seconds for a Lifepak 12 to acquire, analyze, and print a 12-lead ECG.

2.) There are 4 steps to transmitting a 12-lead ECG, not including prepping the patient, applying the electrodes, or interpreting the 12-lead ECG.

A. Pushing the 12-LEAD button.
B. Pushing the TRANSMIT button
C. Selecting DATA
D. Selecting the In Motion Gateway

Actually, this is generous, because using the LP12′s “selector” is a two-part process. You turn the knob to your selection and then you have to press it.

In the testing we found that pushing it (and eliciting a sound) does not always mean the LP12 “recognizes” the selection. You have to watch the screen and watch for the brief “flash” of the selection for reassurance that the LP12 understood your intent.

If you get impatient and press it again, the transmission cancels, which wastes valuable time.

3.) The total elapsed time from pushing the PRINT button to “Transmission Complete” is approximately 2.5 minutes (a full minute of which is the transmission “stuck” at 99% which is the LIFENET verifying that the transmission was successful).

One of the “negatives” of our system design is that the patient has to be in the back of the ambulance to transmit an ECG with the In Motion Gateway.

So if our patient is on the 5th floor of a multi-family residential complex and we call the “STEMI Alert” it will be another 5 minutes (at least) before the patient is in the back of the ambulance, and then another 2 minutes (give or take 30 seconds) before the transmission can be completed.

We have not measured the time interval between “transmission complete” and an email actually showing up at the hospital.

You can watch one of the test videos here.

The forgotten history of fire suppression on Hilton Head Island

2 comments

Several months ago I did some research on the history of the fire service on Hilton Head Island. What I uncovered exceeded my expectations.

I had known that Hilton Head Island, located between Charleston and Savannah, was an important base of operations for the Union blockade of the Southern ports during the Civil War.

What I didn’t know was that a fire department thrived here. The first and oldest reference I found was from the Boston Herald in 1863. As far as I know, it’s the oldest known reference to “The Hilton Head Fire Department.”

THE HILTON HEAD FIRE DEPARTMENT

When this place was captured by the Federals, an old hand fire engine, which looks as if it might have been constructed to the order of Mr. Noah, for the purpose of extinguishing fires on his ark, was found here. Another was brought down from Beaufort, and two from New York. A chief engineer, tour foremen, and twenty-five men were detached from the N. Y. 47th Regiment, and detailed to handle these engines. Arrangements were also made for a big force in case of a fire. The suttlers [sic] are under orders, in case of an alarm, to report to one engine, and other details provided for from the Quartermaster’s and Commissary’s departments and other sources, to man all the other machines. Three are located on “Robber’s Row,” in a building provided for the purpose, and one near the Post Office. Cisterns have been made in convenient proximity to all valuable buildings. It is a singular fact that there has never been a fire here since the occupation of the post, and for the exemption from conflagrations we are probably indebted to martial law.

My next stop was the Coastal Discovery Museum.

With the assistance of the good folks there I discovered a photograph of an actual fire station in an out-of-print book called The Forgotten History, A Photographic Essay On Civil War Hilton Head Island.


Fire Engine House. The pump for this firehouse is visible in the foreground. The hoses and water supply were inside the building. The first two fire engines on the Island were purchased from New York by John A. Smith, who was the first chief of the fire brigade. The new engines were side-lever type, piano build and cost $800. A small dock enabled engines to take suction from Mud Creek. Cisterns held extra water reserves.



I found two additional news stories using Google’s historical news archive search.

The first is from the New York Times, published June 27, 1864.

A HOOK AND LADDER COMPANY

Is in the process of organization at Hilton Head. One or two meetings have been held, and the principal officers chosen. The number of members will be limited to about thirty. We have at the Head three fire engines which have, on three or four occasions, performed excellent service. The character and location of the buildings here are such that a fire would do immense damage unless speedily checked.

The last story is also from the New York Times, published February 16, 1865.

I didn’t think anything could top the “Noah’s Ark” comment from the story in the Boston Herald, but I was wrong!

SOUTH CAROLINA

A Narrow Escape from a Disaster at Hilton Head – Serious Fire

From Our Own Correspondent
Department of the South
Friday, Feb. 16, 1865.

A few mornings since the people at Hilton Head very narrowly escaped a disaster rivaling that which occurred in Savannah two weeks ago. At 3 o’clock A. M., on the 14th instant, the guard on the long pier discovered a bright light in a building situated in front of the Ordnance Yard, and used as an office by Capt. Pratt. The alarm was immediately given, and soon thereafter a large crowd of military and civilians were on the spot. Notwithstanding the efforts of the firemen of two engines, the flames spread through the entire building, and, in a short time, communicated to an adjoining building occupied as an office by Lieut. Arnold, of the Ordnance Department. The fire rapidly increased in intensity, and it absolutely became a matter of personal safety that every man in the vicinity should exert himself to the utmost to prevent the fire igniting the powder and ammunition which was stored in dangerous proximity. Major-Gen. Gilmore, who was on the ground in person, threw off his coat and worked with a will that must have astonished, and, at the same time, mortified a few persons who were disinclined to render active aid. On such an occasion, when the life of every person on Hilton Head was in great peril, it is difficult to conceive how any one able to assist in adverting the impending disastrous calamity could stand by as silent spectators. I believe, however, that with few exceptions, the party present took hold and worked with all their might and main to subdue the flames. At one time, during the progress of the fire, Gen. Gilmore ordered a fellow who was standing by, with his hands in his pockets, to go to work with the others. The fellow, not recognizing the General, refused to obey, whereupon he suddenly found himself knocked heels over head on the sand. A half hour later, the force of active laborers was increased by one. As good luck would have it, only the two buildings mentioned were destroyed. With them were burned nearly all of the private property of Capt. Pratt and Lieut. Arnold, also a considerable amount of Government property, consisting mostly of books and documents. The muster-rolls of the Ordnance Department were consumed. Five thousand dollars in greenbacks, which were placed in a safe in Capt. Peatt’s office, were scorched so as to be useless for payment, but they will doubtless be identified and exchanged at the Treasury Department. Brig.-Gen. M. S. Littlefield very wisely sent out to beyond the intrenchments for a force of three hundred laborers, who arrived at the scene in time to render very valuable service. At 5 o’clock the fire was nearly extinguished, but it was not until some hours later that the people at Hilton Head thoroughly comprehended the imminent danger that hung over them during the night. Had a single spark ever found its way into the mass of powder stored but a few yards from the burning buildings, the result would have been appalling in the extreme. Such an explosion, and such a flight of shot and shell would have ensued, that in all probability, not a house would have been left standing on the Head. I dare not even intimate of the loss of life that would have been involved. How the fire originated is a matter of conjecture. Parties who live near the building in which the flames were first discovered, are of the impression that the cause was a defective flue, while others assert that the fire was the work of rebel incendiarism. It is a fact that quite a number of rebel refugees and deserters are employed in the Quartermaster’s Department, but no evidence has yet been adduced sufficiently strong to make them responsible for what might have been a most terrific event.

Does this mean we can brag that Hilton Head Island Fire & Rescue is older than Charleston Fire Department? That would probably be disingenuous, since we’re not sure what happened to the fire department after the Civil War. But it’s fascinating to know that “Hilton Head Fire Department” was battling blazes on this Island 145 years ago!

Conclusion to EMS1.com case study “Changing Channels”

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Part II of my introductory column at EMS1.com has been posted. Enjoy!

Changing Channels: Patient follow-up.

43 year old female CC: Chest pain

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Don’t worry, I haven’t forgotten about the 73 year old female CC: Chest pain.

The conclusion will be posted as soon as it’s available. In the meantime, here’s another case for you to ponder.

EMS is called to the residence of a 43 year old female with a chief complaint of chest pain.

On arrival, the patient is found supine in bed.

She is alert and oriented to person, place, and time.

She is anxious and diaphoretic.

Past medical history: Hypertension
Surgical history: One kidney removed (unknown reason)
Medications: Azor

She denies shortness of breath and breath sounds are clear bilaterally.

Onset: 1 hour prior to EMS arrival
Provoke: Nothing makes the pain better or worse
Quality: Severe “pressure”
Radiate: The pain radiates down the left arm
Severity: 10/10
Time: No previous episodes of similar pain or pressure

Vital signs:

RR: 18
Pulse: 76
NIBP: 114/71
SpO2: 98 on RA

The cardiac monitor is attached.

A 12-lead ECG is captured.

How would you treat this patient and why?

See also:

Conclusion to 43 year old female CC: Chest pain – Angiograms

Tom Bouthillet and Jamie Davis discuss cardiac arrest and the chain-of-survival

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Part I – Jamie Davis and Tom Bouthillet discuss the 2010 AHA ECC Guidelines with Monica Kleinman, M.D., incoming Chair of the AHA’s ECC Committee.

Part II – Jamie Davis and Tom Bouthillet discuss the 2010 AHA ECC Guidelines with Monica Kleinman, M.D., incoming Chair of the AHA’s ECC Committee.

Part III – Jamie Davis and Tom Bouthillet discuss cardiac arrest and the chain-of-survival.