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39 year old male CC: “Sick”

Here’s another great case courtesy of Mike from Massachusetts.

EMS is dispatched to a large health clinic affiliated with a local university, for the “sick male.” Initial dispatch is an ALS ambulance, ALS rescue company, and BLS engine company. Rescue company and engine company are canceled on ambulance’s arrival.

Upon arriving on scene, we find a 39-year-old male patient seated upright on an examination bench. He is alert and oriented x4, with slightly moist and warm skin, otherwise appearing free of distress.

He describes coming to the doctor’s today to be seen for a “malaise” and mild fever he had been experiencing over the past two weeks (100.2 F, taken at the office).

While being interviewed by the physician, he casually mentioned that he had been experiencing occasional episodes of “sharp” pain in his chest, the last episode a week ago and when he laid down for bed. A 12-lead ECG was obtained by the physician, and she reports having concern about “near global ST elevation.” This prompted EMS activation.

Patient has no significant past medical history, takes no medications, and has no medication allergies. He denies any recent history of trauma or infectious exposures that he can recall.

The cardiac monitor is applied, showing sinus rhythm @ 54 bpm. Patient is placed on oxygen by nasal cannula. Vital signs are obtained:

Blood pressure: 136 / 64
Heart rate: 58 bpm
Respiratory rate: 16
Temperature (oral): 100.2 F

While assessing lung sounds, patient takes a deep breath, noticably flinches and states, “There it is again.” He describes the sharp pain (localized in the sub-sternum) that he previously reported to the physician, which resolves shortly after. His lung sounds are clear and equal bilaterally, and this is reproducable with subsequent deep breaths.

IV access and a 12-lead ECG are obtained.

Patient is assisted onto stretcher without incident, moved to ambulance. Patient is transported to the hospital of the university’s preference, which is also a level 1 trauma center (< 10 minute transport time).

What do you think of the ECG?

Posted by Tom Bouthillet on February 27, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

Conclusion to “Run of the Mill” – Feb 2011 EMS 12-Lead column at EMS1.com

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The conclusion to “Run of the Mill” has been posted at EMS1.com.

Run of the mill: Patient follow-up

Apparently not everyone is happy with my treatment plan. Head on over and feel free to share your thoughts in the comments section!

Posted by Tom Bouthillet on February 26, 2011 • Filed under: ems-topics, patient-management • Tagged: case study, EMS, EMS 12-Lead, EMS1.com, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

55 year old male CC: Chest pain? – Conclusion

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Here’s the conclusion to 55 year old male CC: Chest pain?

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

This is a real challenge because it meets the voltage criteria for left ventricular hypertrophy in the limb leads and the lateral leads have the general appearance of “strain pattern” (or secondary depolarization abnormality).

However, leads V2-V4 just don’t look right. Unlike the limb leads, the precordial leads do not meet the voltage criteria for left ventricular hypertrophy (we would expect deeper S-waves in leads V2 and V3).

In fact, these are not S-waves at all, but rather Q-waves (absent R-wave progression). In addition, the amplitude of the T-wave in lead V4 does not seem proportional to the size of the QRS complex.

This is a very suspicious ECG, in spite of the fact that the patient was apparently asymptomatic at the time of EMS evaluation.

The 12-lead ECG was transmitted to the emergency department.

The ED physician was able to determine that the patient had received a negative stress test several years prior after a routine exam showed an abnormal ECG.

Here is the old ECG (please forgive the quality as it was faxed and then scanned).

Here was the patient’s ECG on admission to the emergency department.

Based on the patient’s hypertension and ST-elevation in leads V1-V3, the ED physician consulted cardiology.

The patient was prescribed Lopressor 5 mg IV (a total of 3 doses) and Norvasc 5 mg po which was effective in lowering the patient’s blood pressure.

Chest x-ray was negative for acute cardiopulmonary disease.

Cardiac biomarkers came back positive.

CPK: 256 (24-195)
CKMB: 8.45 (< 6.73)
TROP T: 0.020 (< 0.010)

Bedside 2D echocardiogram showed left anterior and apical akinesis with an EF < 35%.

Based on these findings the patient was sent emergently to the cardiac cath lab.

The LAD was totally occluded just after the first septal perforator before the first significant diagonal branch. Left-to-left and right-to-left collaterals fill the mid and distal vessel.

Attempts at crossing the area of occlusion in the proximal LAD were unsuccessful and balloon dilatation was not performed.

Conclusions:

1. Two-vessel coronary artery disease with 100% chronic occlusion of the proximal left anterior descending with 50% narrowing in the ramus intermedius branch and 50% proximal left circumflex narrowing in a right dominant system.

2. Severely reduced left ventricular systolic function, left ventricular ejection fraction of 35% with a large area of anterolateral and apical wall motion abnormality.

3. Mildly elevated left ventricular filling pressures.

4. Unsuccessful attempt at crossing the chronically occluded proximal left anterior descending, despite attempts with 3 different guidewires.

Patient will be treated medically. He will have an evaluation for viability of the anterior wall and apex. If this is scar he will be treated medically. If there is a large area of viable muscle consideration will be given for CABG surgery.

Discharge diagnosis: Coronary atherosclerosis, Hypertension, Hyperlipidemia

Posted by Tom Bouthillet on February 25, 2011 • Filed under: ems-topics, patient-management • Tagged: angiograms, case study, EMS, EMS 12-Lead, ems12lead.com, left ventricular hypertrophy, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

91 year old female CC: Seizure (A strange situation) – Discussion

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I’ve been receiving some emails from readers who would like to know what happened with the 91 year old female (DNR patient) who went into PEA as she was loaded into the ambulance.

Here is the 12-lead ECG that was captured just as she went into cardiac arrest.

Here’s another that you haven’t seen.

She died. The paramedics did not interfere.

I posted the case because as long as I’ve been a paramedic, I’ve never had to deal with this situation.

It would be very difficult for me (and I suspect most paramedics) to stand by and do nothing while someone dies, even though we can rationalize that it respects the patient’s wishes.

When I discussed this case with my girlfriend (an advanced practice nurse) it became clear to me that DNRs are not always cut and dry.

We’ve all heard the saying “DNR does not mean Do Not Treat.”

But what does it mean? Exactly?

Does it mean we treat conditions that might be reversible?

What is a “heroic” measure?

I was discussing end of life wishes with my parents several years ago (a very difficult thing to do) and neither one wanted to be on life support.

But when I changed the question to something like, “What if you were only life support for a few days and then recovered?” or “What if you were on life support just long enough to see whether or not you would recover?” the response changed to “That sounds reasonable.”

DNRs, by their very nature, simplify things that are complicated.

The subject of DNRs warrants a lot more discussion than paramedic students are getting in school.

It warrants more discussion with the people who sign DNRs, too.

Before I receive any hate mail, I am not suggesting that the paramedics did anything wrong in this case, and I am not suggesting that this woman’s ribs should have been crushed.

I’m saying that the paramedic curriculum should spend more time on health care ethics.

I’m also suggesting that EMS protocols that say “DNR patients don’t go on the monitor” might be problematic because the ECG can be helpful in diagnosing a lot of reversible conditions.

There are shades of gray in the field of ethics and I’ve noticed that paramedics often demonstrate an intolerance of ambiguity.

As Einstein said, “Things should be made as simple as possible — but not simpler.”

Posted by Tom Bouthillet on February 24, 2011 • Filed under: ems-topics, patient-management • Tagged: cardiac arrest, Do Not Resuscitate, EMS, EMS 12-Lead, health care ethics, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

Atrial flutter can cause false-positive ACUTE MI SUSPECTED interpretive statements

4 comments

I first heard about this issue a couple of years ago in a webinar at the D2B Alliance website. Since then I have seen it several times in my own EMS system.

I also mentioned it when I commented on:

Review of Factors Associated With False-Positive Emergency Medical Services Triage for Percutaneous Coronary Intervention

According to that study the most common factors associated with false positives statements were:

A specific brand of one of three monitors used in the system
Sinus tachycardia
Missing lead recording on 12-lead printout
Atrial fibrillation
Female gender
Poor ECG baseline
A discussion ensues during

The authors make this important statement:

“Poor ECG baseline and failure to record all 12 leads for machine algorithm interpretation are false-positive associated variables that can be addressed by improved quality in field acquisition of 12-leads.”

It can’t be said often enough! That’s why I’m always harping on achieving excellent data quality!

The authors continue:

“Variables more difficult to address are sinus tachycardia and atrial fibrillation, which had a tendency to be wrongly interpreted by machine algorithm as acute MI.”

In response to that statement I made this comment:

“It would be interesting to know if they are including atrial flutter in with atrial fibrillation. Either way the message is clear. The specificity of the computerized interpretive algorithms is highest when a tachycardia is not present.”

The reason I questioned whether or not atrial flutter was included with atrial fibrillation is simple. Many times I have seen atrial flutter trigger a false-positive ***ACUTE MI SUSPECTED*** message on the LP12 but I can’t think of a time atrial fibrillation cause a false-positive statement (when poor data quality was not present).

Consider these cases that occurred in the past week.

Case #1

In this case the paramedic immediately realized the ***ACUTE MI SUSPECTED*** message was being caused by underlying atrial flutter. A “STEMI Alert” was not called from the field and the patient was not sent to the cath lab.

Case #2

This case was a little more difficult because 2:1 atrial flutter more difficult to recognize than 4:1 atrial flutter. It also must be said that this patient was “sicker” and presented very much like ACS. A “STEMI Alert” was called from the field and the patient ended up in the cath lab. No significant lesions were noted with angiography.

The point isn’t to blame the paramedic from the second case. A board certified emergency physician and a cardiologist both had to agree that this patient needed emergent angiography.

It’s easy to criticize individual paramedics especially when they’re from other EMS systems. What’s hard is to create quality improvement feedback mechanisms so that every call can be a learning opportunity.

There are two kinds of EMS systems in this world: those that make mistakes and those that have no idea whether or not they make mistakes (unless they receive a complaint).

Strive to be the former because anyone can be the latter.

Posted by Tom Bouthillet on February 24, 2011 • Filed under: ems-topics, patient-management • Tagged: atrial flutter, atrial flutter and false positive cardiac cath lab activation, EMS, EMS 12-Lead, ems12lead.com, false positive cardiac cath lab activation, GE-Marquette 12SL interpretive algorithm, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

56 year old female with a “cardiac disorder”

14 comments

Here’s an interesting case submitted by Mike from Massachusetts.

Here’s the story in Mike’s own words:

EMS is contacted by a local rehabilitation facility for a female patient with a cardiac disorder. Initial dispatch is an ALS ambulance, ALS squad, and a BLS engine company.

Approximately 20 minutes prior to EMS arrival, patient began experiencing palpitations (“fluttering”) and reported this to staff. Oxygen has been applied by non-rebreather mask @ 15 L/minute. An initial set of vital signs and an ECG tracing were obtained.

Vital signs as follows:

Heart Rate (on monitor): 214 (Wide-complex)
Pulse: 40
Blood pressure: 114 / 94
Respiratory rate: 22

The ALS ambulance crew arrives first (my parther and I) and finds a morbidly obese (> 180 kg) 56-year-old female patient resting semi-fowlers in bed. Patient is undergoing inpatient rehabilitation following pneumonia. Patient is pleasant, alert and oriented x4 and does not appear to be in acute distress. Patient is conversing appropriately with staff, continues to complain of palpitations, but denies other symptoms.

EMS’ LifePak 15 is applied, paddles only, showing the following rhythm.

While in the process of obtaining vascular access and applying the 12-Lead, the patient becomes unresponsive and apneic. Her cardiac rhythm is noted to deteriorate to a wide-complex rhythm with an electrical rate at over 300 bpm. The LP15 is charged and the patient is defibrillated at 200 J within 15 seconds of the arrest.

There is near-immediate return of spontaneous circulation and patient quickly regains consciousness. Patient does not recall the event, but otherwise remains alert and oriented.

Vital signs as follows:

Heart rate: 90 bpm (Sinus rhythm with occasional multi-focal PVCs)
Blood pressure: 125 / 74
Respiratory rate: 18
SpO2: 100% (100% FiO2)

Intravenous access is obtained. Lidocaine, 180 mg IV bolus is administered and a Lidocaine infusion @ 2 mg / minute is initiated.

A 12-lead ECG is obtained.

Transport time to nearest facility (non-PCI) is less than three minutes.

What do you think of the initial rhythm and arrest rhythm?

Do you see anything to worry about on the 12-lead ECG?

Why or why not?

Posted by Tom Bouthillet on February 23, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, cardiac arrest, case study, defibrillation, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

EMS EduCast Episode 91: Cardiac arrest (and skill retention)

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Thanks to the EMS EduCast for inviting me back on the show last Wednesday night!

We had a spirited and interesting discussion about cardiac arrest.

You can listen to (or download) the episode here:

Skill Performance Reinforcement and More: Episode 91

The Facebook page is HERE. The Twitter profile is HERE.

See also our previous discussion about 12-Lead Education here:

12 Lead ECG Education: Episode 56

Posted by Tom Bouthillet on February 21, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-lead ECG education, cardiac arrest, CPR retention, EMS, EMS 12-Lead, EMS EduCast, Prehospital 12-Lead ECG blog, Tom Bouthillet

55 year old male CC: Chest pain?

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EMS is called to a local urgent care center for a 55 year old male with chest pain.

On arrival, a patient care technician states that the patient is experiencing a hypertensive crisis.

He has already received SL NTG x3 but his BP is still 180/118.

The physician states that he is also worried about changes on the patient’s ECG and he has “already talked to the ED physician”.

The patient is placed on the gurney and he is removed to the back of the ambulance.

He appears to be in no distress.

In fact, he denies having chest pain. He states, “I came in for a sinus infection but I started coughing and when I coughed I grabbed my chest so the doctor thought I was having chest pain.”

The paramedic says, “So you’re not having any chest pain at all?”

The patient answers, “Well, I had some pain in the right side of my chest last night and also along the inside of my right arm, but it went away. But that’s not why I came to see the doctor today.”

Past medical history: HTN
Meds: Lisinopril, Diovan HCT

Vital signs are assessed.

RR: 18
Pulse: 80
NIBP: 188/120
SpO2: 100 on RA

Skin is pink, warm, and dry.

Breath sounds are clear bilaterally.

The cardiac monitor is attached.

A 12-lead ECG is captured.

Much ado about nothing?

Or a very astute urgent care physician?

Posted by Tom Bouthillet on February 21, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

76 year old female CC: Diminished LOC – Discussion

27 comments

Here’s the follow-up to 76 year old female CC: Diminished LOC.

Be sure to check out all the awesome comments on the case!

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

There’s something very unusual about this heart rhythm.

It’s slow, there are no P-waves, and the QRS complexes are extremely wide (> 200 ms).

Could this be a ventricular rhythm?

Sure. It’s possible. But this is wide even for a ventricular rhythm.

The morphology is consistent with a nonspecific intraventricular conduction defect.

Whenever I see an ECG like this I immediately think, “Hyperkalemia!”

Other possibilities include:

Tricyclic anti-depressant overdose (note the tall R-wave in lead aVR)
Other sodium channel blockers (Class 1a antiarrhythmics, tramadol, diphenhydramine, etc.)
The effects of prolonged myocardial ischemia (end stage of big MI, PE, or respiratory arrest)

Special thanks to Dr. Smith from Dr. Smith’s ECG Blog for helping me refine this list of differentials.

Another interesting feature of this case is the multiple ecchymotic areas on the body and the pulseless R foot. This could suggest a coagulopathy or renal failure.

Additionally, I liked David’s theory about rhabdomyolysis contributing to hyperkalemia.

Would I have given this patient calcium? Absolutely!

It couldn’t hurt and it might help.

We often have to make decisions in the field based on incomplete information.

It’s the “fog of war”.

As Carl von Clausewitz wrote:

“The great uncertainty of all data in war is a peculiar difficulty, because all action must, to a certain extent, be planned in a mere twilight, which in addition not infrequently — like the effect of a fog or moonshine — gives to things exaggerated dimensions and unnatural appearance.”

So what was the outcome?

This patient went into cardiac arrest at the emergency department and was not successfully resuscitated.

~~If we find out the exact cause of death we’ll let you know.~~

*** UPDATE ***

The patient’s potassium level was 8.3 (Critical High).

Here’s the raw data.

Thanks again to Randy for the great case!

Posted by Tom Bouthillet on February 18, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, ems12lead.com, hyperkalemia, Paramedic, Prehospital 12-Lead ECG blog, slow and wide rhythm, Tom Bouthillet

76 year old female CC: Diminished LOC

46 comments

Here’s an interesting case study from a faithful reader named “Randy”.

EMS is called to evaluate a 76 year old female with a diminished level of consciousness.

On arrival the patient is found lying supine in bed moaning.

She is conscious but lethargic. She is oriented to person only.

She appears cyanotic around the mouth.

Past medical history: IDDM, CVA, MI
Meds: ASA, Baclofen, Atenolol

Breath sounds: diminished bilaterally

Vital signs are assessed.

RR: 24
Pulse: 48
NIBP: 99/33
SpO2: 78 on RA > 92 with O2 via NRB @ 15 LPM

Multiple ecchymotic areas are noted around the body. Discoloration is noted from the calf to the toes on the R side. No pedal pulse on R foot. L sided paralysis from previous CVA.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What do you think is wrong?

Posted by Tom Bouthillet on February 14, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

A strange situation (91 year old female CC: Seizure)

37 comments

Here’s an unusual case submitted by Linuss from Confessions of a Baby Medic.

EMS is dispatched for a local nursing home for a seizure.

On arrival, the patient is found awake in bed in no apparent distress. She is able to converse, answers questions appropriately, and doesn’t appear to be post-ictal.

The nurse states she walked in to find the pt shaking for a short time.

The patient denies chest pain or discomfort, denies nausea, denies shortness of breath, denies weakness… denies everything.

Vital signs are assessed.

RR: 20
Pulse: 80 and irregular
BP: 98/68
SpO2: 100 on RA

A 12-lead ECG is captured.

The patient is moved to cot and covered with blankets.

The patient quickly kicks the blankets off. When asked if she’s uncomfortable she replies, “I don’t know”.

Suddenly the patient’s head angles to left, eyes still open, breaths rapidly and shallow at a rate of 40, shakes for about 3 seconds, and after the shaking, mumbles when trying to speak, with slight facial droop, and doesn’t follow commands.

The episode lasts about 20 seconds, she goes back to normal mentation, and the facial droop resolves.

The patient is rolled outside to the ambulance. The patient comments that it’s chilly (ambient temperature is 40F).

Suddenly, the patient stops breathing. She is a DNR.

A change is noted on the monitor and an additional 12-lead ECG is obtained.

A carotid pulse is absent.

What would you do?

Posted by Tom Bouthillet on February 12, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Seizure, Tom Bouthillet

Feb 2011 EMS 12-Lead column “Run of the Mill” at EMS1.com

9 comments

The February 2011 EMS 12-Lead column at EMS1.com has been posted.

Run of the Mill

Submit your interpretation and treatment plan for a chance at a T-shirt and bottle opener.

Good luck!

Posted by Tom Bouthillet on February 11, 2011 • Filed under: ems-topics, patient-management • Tagged: case study, EMS, EMS 12-Lead, EMS1.com, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

An unusual case of right bundle branch block – Discussion

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Here is the conclusion to an unusual case of right bundle branch block.

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

This 12-lead ECG shows acute anterior STEMI in the presence of right bundle branch block, but you really need a trained eye to see it.

We talk a lot about the “rule of appropriate T-wave discordance” with bundle branch blocks. What makes this case difficult is the fact that the T-waves are appropriately discordant.

However, the J-points are concordant in leads V1-V4!

If you look carefully you will see that the point at which the QRS complex turns into the ST-segment (the J-point or “junction” point) is elevated above the isoelectric line.

That’s abnormal for right bundle branch block. In fact, if the J-point isn’t isoelectric in the right precordial leads it should be slightly depressed (in the same direction as the T-waves).

Lead V4 looks the most abnormal.

If you’re still having doubts, consider that Q-waves are present in leads V1-V4.

That’s what Tomas Garcia, M.D. means when he says to “consider the company” that any ECG abnormality keeps.

Finally, let’s look at leads III and aVF.

We are forced to assume that these are reciprocal changes. Once again, it’s the sum of all these abnormalities that is significant. They are more than the sum of their parts.

This patient was in fact diagnosed with an acute anteroseptal ST-elevation myocardial infarction.

An unusual case of left bundle branch block – Discussion

Posted by Tom Bouthillet on February 9, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, identifying AMI in the presence of RBBB, identifying STEMI in the presence of RBBB, J-point elevation, Paramedic, Prehospital 12-Lead ECG blog, RBBB, right bundle branch block, Tom Bouthillet

Physio-Control and BeneChill enter strategic partnership to launch RhinoChill IntraNasal cooling system in Europe

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Physio‐Contro (@PhysioControl) and BeneChill (@RhinoChill) announced today a strategic partnership to launch the RhinoChill IntraNasal Cooling System in Europe. RhinoChill is a non‐invasive, portable system for transnasally cooling the head and lowering the body’s core temperature immediately following cardiac arrest, stroke or traumatic brain injury.

Initially, the partnership will focus on bringing the RhinoChill System to market in the United Kingdom, Germany, Austria, Switzerland, Belgium, Netherlands and Luxemburg during the first quarter of 2011, utilizing Physio‐Control’s extensive European distribution network. Additionally, as part of this strategic alliance, the two companies will work jointly to develop additional applications for BeneChill and work towards making the RhinoChill System available in the U.S.

The RhinoChill System uses a non‐invasive nasal catheter that sprays a rapidly evaporating, inert coolant liquid into the nasal cavity, a large area situated beneath the brain that acts as a heat exchanger. As the liquid evaporates, heat is directly removed from the base of the skull and surrounding tissues via conduction and indirectly through the blood via convection.

The system is battery‐powered, compact and does not require refrigeration, making it ideal for use in pre‐hospital settings. Each coolant bottle holds enough liquid to cool a patient for 30 minutes at nominal flow, and bottles can be easily exchanged to maintain the cooling process.

See a video at the company website HERE. The YouTube channel is HERE.

I’ve got to admit that this technology looks interesting. I’d like to see how it stacks up against iced saline and external cooling (which is pretty inexpensive).

This blog post derived in part from a press release by Physio-Control with whom Tom Bouthillet and the EMS 12-Lead blog have no conflict of interest.

Posted by Tom Bouthillet on February 9, 2011 • Filed under: ems-topics, patient-management • Tagged: BeneChill, cardiac arrest, EMS, EMS 12-Lead, ems12lead.com, induced hypothermia, Paramedic, Physio-Control, Prehospital 12-Lead ECG blog, RhinoChill, therapeutic hypothermia, Tom Bouthillet

Social media and health care

3 comments

As many of you know I pay close attention to social media and I’m especially interested in the intersection of health care and social media.

One person that I think does an extraordinary job is Kristen Hall with Barnes Jewish Hospital.

Facebook fan page here, Twitter account here, news blog here.

You may recall that I blogged previously about a video Barnes Jewish Hospital created to help market their STEMI system.

Note the outstanding production values!

Why is this important?

Because the traditional news media is in big trouble. They’re losing money. People get their news online and they get it from multiple sources. For free.

So the the traditional news media is continuing to cut staffing levels. They employ lots of interns. Fewer news organizations have dedicated health care reporters.

So what’s the end result? PR people spend time and money trying to get their message out and all-too-frequently the traditional news media “gets the story wrong.”

In walks social media.

Suddenly public relations and social media specialists have an opportunity to take control of their own message and deliver it directly to their customers.

Kristin Hall does an outstanding job helping Barnes Jewish Hospital deliver that message, which is why I follow Touching Base, the Barnes Jewish Hospital news blog on a regular basis.

Talk a look at this blog post to see what I’m talking about.

Kristin Hall takes something recent and relevant and creatively ties it back in to the services that Barnes Jewish Hospital has to offer in a way that doesn’t seem insincere or phony.

That’s how it’s done.

Posted by Tom Bouthillet on February 8, 2011 • Filed under: ems-topics, patient-management • Tagged: Barnes Jewish Hospital, EMS, EMS 12-Lead, ems12lead.com, health care and social media, Paramedic, Prehospital 12-Lead ECG blog, social media, Tom Bouthillet

Osborn waves (J-waves) of hypothermia

4 comments

Here is the conclusion to 68 year old female unresponsive on kitchen floor.

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

This ECG is classic for severe hypothermia.

The rhythm is atrial fibrillation
It’s bradycardic
The QT/QTc is prolonged
Osborn waves (J-waves) are present throughout

You can see how the Osborn waves (J-waves) can be a STEMI mimic, which is one of the reasons we need clinical correlation with any ECG.

The patient was transported to the hospital where the core temperature was measured at 76°F (24°C).

The patient went into cardiac arrest and was defibrillated x3.

CPR was continued for the next 2 hours as the patient was re-warmed.

Remember, in this particular special resuscitation situation “you’re not dead until you’re warm and dead.”

The patient was not successfully resuscitated.

To see how Osborn waves can regress during rewarming, see Giant Osborn Waves in Hypothermia (Images in Clinical Medicine Case in the New England Journal of Medicine).

Posted by Tom Bouthillet on February 8, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, hypothermia, hypothermic arrest, J-waves, Osborn waves, Paramedic, Prehospital 12-Lead ECG blog, special resuscitation situations, STEMI mimic, Tom Bouthillet

An unusual case of right bundle branch block

18 comments

Here’s a case submitted by Captain Jack Sparrow from the UK Ambulance Forum.

I’m presenting it here with minor modifications.

Turns out Mark Glencorse isn’t the only clever Brit! We Yankees can learn a lot from the way they do things across the pond.

EMS is called to the residence of a 69 year old male with a chief complaint of chest pain.

Onset: Gradual while driving
Provoke: Nothing makes the pain better or worse
Quality: Describes pain as pressure
Radiate: The pain does not radiate
Severity: 3/10
Time: Similar episode over the weekend while gardening

Past medical history: CVA x 13 years ago, AF
Past surgical history: None
Allergies: No know drug or environmental allergies
Medications: Warfarin, digoxin, others

On arrival the patient is found sitting in a chair.

Skin is pink, warm, and moist.

He appears ill.

Vital signs

RR: 16 regular
Pulse: 130 irregular
NIBP: 137/102
GCS: 15
BGL (BM): 146 (8.1)
SpO2: 99 on RA

Breath sounds: clear bilaterally with normal air entry

No obvious trauma or anything else out of the norm.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What’s wrong with this patient?

Posted by Tom Bouthillet on February 6, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, RBBB, right bundle branch block, Tom Bouthillet

68 year old female unresponsive on the kitchen floor

28 comments

Here’s a wonderful case submitted by a faithful reader who wishes to remain anonymous.

EMS is called to perform a “health and welfare” check on a year old 68 year old female who has not been seen by the neighbors for at least 24 hours.

After several phone calls to the residence from dispatch and a discussion with the patient’s daughter, the fire department gains entry through a window in the back of the house.

The patient is found lying supine on the kitchen floor.

She is unresponsive with dried vomitus around the mouth.

Vital signs are assessed.

RR: 8 and shallow
Pulse: 46 and irregular
BP: 102/70

The cardiac monitor is attached.

SpO2: Initially does not register

Airway reflexes are absent.

The patient is intubated.

SpO2: 100 with oxygen via BVM

ETCO2: 20 mmHg

An IV is established.

BGL: 140

1 mg atropine and 2 mg naloxone are given with no effect.

Skin is pale and cold to the touch.

Physical exam reveals no head trauma.

A 12-lead ECG is captured.

You are 10 minutes from the local non-PCI hospital and 45 minutes from a STEMI Receiving Center.

What do you think is going on here?

See also:

Osborn waves (J-waves) of hypothermia

Posted by Tom Bouthillet on February 3, 2011 • Filed under: ems-topics, patient-management • Tagged: 12-Lead ECG, case study, ECG, EKG, EMS, EMS 12-Lead, ems12lead.com, Paramedic, Prehospital 12-Lead ECG blog, Tom Bouthillet

An unusual case of left bundle branch block – Discussion

6 comments

This is a follow-up discussion to an usual case of left bundle branch block (60 year old male CC: Shortness of breath).

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

It turns out this patient was experiencing a STEMI.

However, the 12-lead ECG doesn’t meet any of the typical criteria for acute STEMI in the presence of left bundle branch block (if indeed this is a left bundle branch block).

While it’s a supraventricular rhythm with a QRS duration > 120 ms and shows LBBB morphology in lead V1, there are S-waves in leads I and V6. Hence, you could argue that this is a nonspecific intraventricular conduction defect.

Having said that, there is something strange about the ST-segments in this ECG.

Normally when faced with a left bundle branch block I consider the “rule of T-wave discordance”.

With a left bundle branch block, that means that the T-wave (and ST-segment) should be deflected opposite the QRS complex.

But what about qR, rS or Rs complexes in the presence of left bundle branch block?

Should the ST/T-wave be deflected opposite the majority of the QRS complex or the terminal deflection?

Opinions are divided on this point but I use the terminal deflection.

Let’s look at lead aVR for this case.

You will note that the ST-segment and T-wave are deflected in the same direction as the terminal deflection of the QRS complex. That makes it concordant (bad).

Now let’s look at the inferior leads.

I would consider this to be concordant ST-depression.

How let’s look at leads V5 and V6.

Even though these are RS complexes and almost equiphasic, the ST-depression is in the same direction as the terminal deflection. Again, I would consider this to be concordant (bad).

So, we have ST-elevation in lead aVR and ST-depression in the inferior and lateral leads.

There also appears to be less ST-elevation than we would normally expect in the right precordial leads, but it’s hard to say definitively due to the wandering baseline and the fact that the S-waves are “cut off” in leads V2 and V3.

It reminds me a little bit of the previous case 63 year old male CC: Chest pain.

Let’s take a look at that 12-lead ECG.

Here the QRS duration is only 116 ms (not quite a bundle branch block) but there is ST-elevation in lead aVR and ST-depression in the inferior, lateral and anterior leads.

The patient was experiencing an acute left main coronary occlusion.

Again, this was a tough case, and I can’t say that it was diagnostic for acute STEMI, but it wasn’t “normal” looking either.

EMRAPTV Episode 68: aVR Gets No Respect!

Life in the Fast Lane … Another Widow Maker?

See also:

80 year old male CC: Chest pain

Excessive discordance as a marker of acute STEMI in LBBB

80 year old male CC: Chest pain – Conclusion

58 year old female CC: Chest pain

58 year old female CC: Chest pain (Sgarbossa’s criteria)

62 year old male CC: Chest pain (LBBB with ST-elevation > 0.2 the QRS complex)

Identifying AMI in the presence of LBBB – Sgarbossa’s Criteria Part I