Skip to content

Archives for

See all posts in the network tagged with

66 year old female CC: Chest pressure – Conclusion

1 comment

This is the conclusion to 66 year old female CC: Chest pressure.

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

Let’s break this down 3 leads at a time starting with leads I, II and III.

When you have artifact in a particular cardiac cycle you need to make a conscious effort not to let it influence your interpretation. So let’s look at this again with the second cardiac cycle removed.

Now we can see that ST-elevation is present in leads I, II and III. This would be unusual, but not impossible, for acute STEMI. However, pericarditis has to be a part of our differential diagnosis.

I’m always suspicious of pericarditis when I see ST-elevation in leads I and II. In addition, there is a “notched” J-point in lead I. However, the ST-segment is straight (non-concave) in leads II and III.

Now let’s look at leads aVR, aVL and aVF.

Again we need to make a decision as to which cardiac cycle we “trust”. I’m using the second cardiac cycle in my analysis.

There is a notched J-point in lead aVL but no ST-elevation (and it must be said, no reciprocal change in lead aVL which is almost always present with acute inferior STEMI). Lead III shows non-concave ST-elevation which favors acute STEMI.

Now let’s examine the right precordial leads V1, V2 and V3.

If you take nothing else away from this post, commit this ECG pattern to memory! This is highly suspicious for the reciprocal changes of acute posterior STEMI! The R/S ratio is > 1 in lead V2 (increased R-wave amplitude) and we have > 1 mm ST-depression in leads V1-V3.

Garcia and Holtz call these “carousel ponies”. Imagine the R-wave is a pole and the ST-depression is the saddle. This is an important 12-lead ECG finding and one that must be taken seriously.

If this was the ONLY abnormal finding on this ECG I would call it a STEMI (assuming clinical correlation). But, I would capture modified posterior leads V7-V9 just to have an ECG in my hand that showed the STEMI. Otherwise, there is a chance the patient’s reperfusion would be delayed by a well-meaning clinician who decided it was NSTEMI and not STEMI.

Finally, let’s look at the left precordial leads V4, V5 and V6.

The poor data quality here is unfortunate, because leads V5 and V6 probably show > 1 mm of ST-elevation here (which meet the conventional STEMI criteria). It can’t be stressed often enough. It’s critically important to obtain a clean tracing on a chest pain patient.

In this case, it all worked out well. The paramedics and the emergency physician agreed that it was an acute STEMI and the cardiac cath lab was activated.

Angiography revealed 100% occlusion of the obtuse marginal (major branch of the left circumflex). The lesion was crossed with a wire, the balloon was inflated, and a stent was successfully placed with successful reperfusion.

This ECG reminded me a little bit of the second ECG from 66 year old male CC: Chest pain (at least in the precordial leads).

Posted by on March 31, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

66 year old female CC: Chest pressure

17 comments

EMS is called to the residence of a 66 year old female who was awoken from sleep with substernal chest pressure.

On EMS arrival the patient is found sitting on the edge of the bed.

She appears anxious and exhausted. Skin is pale and clammy.

Past medical history: Breast CA x5 years ago. Additionally, she has recently experienced the death of a spouse and has been suffering from anxiety and insomnia.

Medications: Paxil, Ambien

Onset: 20 minutes prior to 9-1-1 call
Provoke: Nothing makes the pain better or worse
Quality: Pressure also described as a “heaviness”
Radiate: The pain does not radiate
Severity: 6/10
Time: No previous episodes

Vital signs are assessed.

Pulse: 64
RR: 18
NIBP: 138/79
SpO2: 98 on RA

Breath sounds: clear bilaterally

No JVD or pitting edema.

A 12-lead ECG is captured.

The ECG is transmitted to the emergency department.

Should they activate the cardiac cath lab?

See also:

66 year old female CC: Chest pressure – Conclusion

Posted by on March 29, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

71 year old male CC: Chest pain – Conclusion

4 comments

This is the conclusion to 71 year old male CC: Chest pain.

Thanks for all the great comments!

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

This 12-lead ECG shows acute anterior ST-elevation myocardial infarction.

Significant ST-elevation is present in leads V2-V5, I and aVL with reciprocal ST-depression in leads III and aVF.

A “STEMI Alert” was called from the field and the ECG was transmitted to the emergency department.

The patient was treated with MONA and the following 12-lead ECGs were recorded en route to the hospital.

The T-waves remain hyperacute but there is significant regression of ST-elevation. Remember, hyperacute T-waves are the best indicator of viable myocardium at risk!

When the paramedics (and their patient) arrived at the hospital the cath team was waiting.

Angiography revealed a 99% occlusion of the LAD. The lesion was crossed with a wire, the balloon inflated, and a stent was successfully placed with TIMI 3 flow restored (successful reperfusion).

After a short stay at the hospital the patient was discharged home.

Discharge diagnosis: ST-elevation myocardial infarction

Posted by on March 28, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , , , ,

71 year old male CC: Chest pain

27 comments

EMS is called to the residence of a 71 year old male with a chief complaint of chest discomfort.

On arrival patient is found standing at the front door.

He appears anxious and acutely ill.

Skin is cool, pale and diaphoretic.

Onset: “Fairly sudden” 30 minutes prior to 9-1-1 call
Provoke: Nothing makes the pain better or worse
Quality: Pressure in the center of the chest
Radiate: When asked if the pain radiates the patient states “I don’t know”
Severity: 10/10
Time: Less severe episode yesterday lasting approx 15-30 minutes

Past medical history: Dyslipidemia, mild HTN

Meds: Zocor, Norvasc

Vital signs are assessed.

RR: 20
Pulse: 64 R
NIBP: 131/85
SpO2: 98 on RA

Patient admits to mild dyspnea but breath sounds are clear bilaterally.

No JVD or pitting edema.

Oxygen is applied via NRB mask @ 15 LPM.

The cardiac monitor is attached.

A 12-lead ECG is captured.

The patient is loaded for transport and another 12-lead ECG is captured.

What is your impression of these ECGs?

What is your treatment plan?

See also:

71 year old male CC: Chest pain – Conclusion

Posted by on March 26, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

Found on the LIFENET 03/2011

11 comments

Let’s presume the chief complaint is chest discomfort.

What do you think?

Posted by on March 24, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

LIFEPAK 12 Li-ion battery and REDI-CHARGE battery charger now available

1 comment

I occasionally receive press releases of one kind or another in my inbox.

If I think they may be of interest to my readers (or if I really like the product) I will post them but I do my best to cut through the marketing language and get to the nuts and bolts of the device or product being offered.

Just prior to EMS Today 2011 I had received a press release from Physio-Control about their new lithium-ion batteries.

The press release makes this claim:

The new Li-ion battery offers up to 12 hours of monitoring (actual run times may vary depending on device configurations, environmental conditions and monitoring parameters used) on two batteries, offering EMS and hospital teams enough power for a 12-hour shift. Additionally, the new batteries require no conditioning or calibration.

The battery was developed with a cell technology specifically designed and approved for medical devices. Vital safety features such as over-voltage and over-temperature protection circuitry were then incorporated, creating the foundation for a high-quality, reliable battery. It carries an IP44 rating for solid and liquid ingress, making the battery the most durable yet for the LIFEPAK 12. And unlike some third party batteries, the battery is tested and validated with LIFEPAK devices by Physio-Control and recognized by Underwriters Laboratories Inc. (UL).

The new REDI-CHARGE charger offers support for both the LIFEPAK 12 defibrillator/monitor and LIFEPAK 15 monitor/defibrillator batteries, making it an ideal charging solution for organizations with mixed fleets. It features a rapid charge turnaround, returning batteries to full capacity in just over 4 hours.

I’m always a bit skeptical when I see qualifiers (e.g., language that essentially means “your mileage may vary”) so I went to the Physio-Control website and found a product data sheet that showed this chart:

This still didn’t help me figure out exactly how much longer these batteries would last than the batteries we use right now (especially since in my experience NIBP is a serious battery drain and that is not on the chart) so I contacted Erik Denny from Physio-Control with a simple question.

Can we compare and contrast the rechargeable lithium-ion battery with the batteries currently in use?

Here’s the reply I got.

Physio-Control’s highest capacity battery for the LIFEPAK 12 was the 1.6 Ah NiCd. This new 7.2 Ah Li-ion therefore has 4.5 times more capacity and will last 450% longer. So without know any specifics on how a particular device is used (NIBP, 12-Lead monitoring, a lot of printing, etc.) we are limited to say it lasts 4.5 times longer than the 1.6 Ah NiCd battery. Physio’s verification testing demonstrated nearly 12-hours of continuous 12-Lead ECG monitoring.

That’s a much simpler way to understand it! These batteries last 4.5 times longer.

I followed up with questions about the REDI-CHARGE battery system.

Specifically I asked:

1.) How about a cost analysis? How much were the NiCd batteries and how much are the Li-ion?

2.) I’m also confused by the “adapter tray” because on Hilton Head Island our charges don’t look like that. We use the “Battery Support System 2″.

Here’s the reply I got:

1.) NiCd list price is $209 and has a 1.6 Ah rating. Li-ion list price is $395 and has a 7.2 Ah rating. (Though service contract customers can get them for $295 for the next 6 months). The Li-ion is less expensive and higher performance than any other battery for the LIFEPAK 12 in terms of dollars per amp-hour.

2.) As far as the charger goes, the Li-ion battery can only be charged in the new REDI-CHARGE charger. The BSS2 cannot be used to charge this newer technology. Similarly, the REDI-CHARGE charger can be used to charge, but not condition existing NiCd batteries. The REDI-CHARGE charger can charge either LIFEPAK 12 or LIFEPAK 15 Li-ion batteries by simply changing the adapter tray.

It could be old age but I found this to still be a bit confusing so I followed up with more questions.

1.) How much does the REDI-CHARGE charger cost?

2.) Does the adapter tray get used for the old batteries or the new batteries?

3.) Right now our LP12 can plug into a little charger/conditioner pack and it will charge the batteries that are currently installed in the LP12. Am I correct in assuming that will not work with the new batteries?

Here’s the answer I got.

1.) REDI-CHARGE Charger List Price is $1,537 with a LIFEPAK 12 Adapter tray. An additional LIFEPAK 15 Adapter Tray can be purchased for $175.

2.) There is a LIFEPAK 12 Adapter Tray that works for the new Li-ion batteries. It can also charge but not condition legacy LIFEPAK 12 batteries. The second adapter tray allows users to transition easily to the LIFEPAK 15 without requiring a new charger.

3.) Correct. The AC power adapter that charges batteries while they are in the device is not compatible with the new Li-ion battery. Due to the high capacity of the Li-ion batteries, there are currently no plans to upgrade the AC power adapter with this capability.

So there you have it! Everything you ever wanted to know about Physio-Control’s lithium-ion batteries and charging system but were afraid to ask.

I had just about forgotten about this correspondence with Physio-Control when Erik Denny contacted me yesterday with this promotion.

A free REDI-CHARGE battery charger when you buy 4 lithium-ion batteries for $295 actually seems like a really good deal to me.

Your mileage may vary!

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

Posted by on March 23, 2011 • Filed under: ems-topics • Tagged: , , , , , , , ,

79 year old female CC: Chest pain – Conclusion

10 comments

This is the conclusion to 79 year old female CC: Chest pain.

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

The treating paramedic immediately (and correctly) identified this as an acute inferior STEMI.

But is it also a right ventricular infarction?

Several of you indicated that you would capture a right-sided 12-lead ECG (or at least modified lead V4R).

The treating paramedic did in fact capture a right-sided 12-lead ECG.

So now that we’ve performed this test we need to interpret it! Is this positive for right ventricular infarction?

Let’s take a look at modified lead V4R.

This doesn’t look particularly impressive but we must remember the rule of proportionality! The smaller the QRS complex the lower the threshold for ST-elevation.

The QRS complexes in modified leads V3R-V6R tend to be small (as they are here) so it’s debatable as to whether or not we need a full 1 mm of ST-elevation to be positive for right ventricular infarction.

Let’s take lead V4R and “stretch” it vertically while preserving the ST/QRS ratio.

To me this is borderline. The higher up in the RCA the occlusion (i.e., the more of the right ventricle that is involved) the more ST-elevation we can expect in lead V4R.

You may recall this graphic from previous posts on right ventricular infarction.

Based on this diagram it seems to me that the occlusion is likely to be in the mid-RCA meaning that the majority of the right ventricle has been spared.

Indeed, the heart rate of 80 and blood pressure of 152/84 bear that out.

It’s still an acute inferior STEMI so I would use NTG and morphine cautiously but I would use them as needed. If you’re concerned you can always obtain IV access first!

As a final thought for the original 12-lead ECG you will note that the ST-elevation in lead III is about the same amplitude as the ST-elevation in lead II.

With a true right ventricular infarction you can expect to see ST-elevation in lead III greater than ST-elevation in lead II.

This patient was delivered straight to a PCI center with prehospital activation of the cardiac cath lab with a presumed diagnosis is acute inferior ST-elevation myocardial infarction.

Posted by on March 22, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , ,

The AHA’s Public Safety team is now on Facebook

1 comment

You can “like” them on Facebook HERE.

You can follow them on Twitter HERE.

You may recall that I had the privilege of giving a presentation to the AHA’s Public Safety team at EMS Today 2011.

Looks like they’re wasting no time engaging the EMS 2.0 community!

Posted by on March 20, 2011 • Filed under: ems-topics • Tagged: , ,

79 year old female CC: Chest pain

26 comments

Here’s a cool case from a faithful reader named Mike M.

EMS is called to evaluate a 79 year old female with a chief complaint of chest pain.

Onset: Sudden while watching TV
Provoke: Nothing makes the pain better or worse
Quality: “Heavy”
Radiate: The pain does not radiate
Severity: 7/10
Time: About 30 minutes prior to 9-1-1 call

On EMS arrival the patient is alert and oriented to person, place and time, speaking in full sentences.

Skin is cool, pale and diaphoretic.

Past medical history: Breast CA, Parkinsons
Medications: Unknown
No known drug or environmental allergies.

Vital signs are assessed.

RR: 20
Pulse: 72
BP: 152/84
SpO2: 98 on RA

Breath sounds are clear bilaterally.

No JVD or pitting edema.

The cardiac monitor is attached.

A 12-lead ECG is captured.

What do you think is going on?

How would you treat the patient and why?

See also:

79 year old female CC: Chest pain – Conclusion

Posted by on March 19, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

Impedance threshold device and active compression/decompression CPR on the Standing Orders podcast

2 comments

I was recently a guest on the Standing Orders podcast discussing the Impedance Threshold Device (ITD) or ResQPOD and active compression/decompression CPR (ACD CPR) with the ResQPump.

Specifically, we reviewed the recent Lancet article:

Standard cardiopulmonary resuscitation versus active compression-decompression cardiopulmonary resuscitation with augmentation of negative intrathoracic pressure for out-of-hospital cardiac arrest: a randomised trial. Aufderheide, TP et al. (2011) Lancet 377(9762): 301-311.

You may recall that I had previously interviewed Keith Lurie, M.D. about the ResQPOD after the ROC PRIMED trial.

One of the more interesting things about the new trial from Lancet is the difference between the statement Tom Aufderheide M.D. made when the National Institute of Health announced that the ROC PRIMED trial was stopping enrollment:

“While the ITD is based on sound physiologic principle, in this study it did not appear to improve survival rates for adults in cardiac arrest outside the hospital.”

and this statement Tom Aufderheide M.D. made following the Lancet article (which appeared in a press release I received via email).

“The goal of resuscitation during cardiac arrest is long-term survival with preservation of brain function. This new, effective intervention achieves that goal and is potentially the most significant advancement in the treatment of cardiac arrest since defibrillation.”

Potentially the most significant advancement in the treatment of cardiac arrest since defibrillation!

How about that sports fans?

You can listen to this episode of the Standing Orders podcast here:

Episode 4: Making Sense of Confusion

Special thanks to Mr. Matt Fults, Dr. Chris Russi, and Mr. J.D. Graziano for inviting me on the show! I think I mentioned before that, in my opinion, the Standing Orders podcast is the best new medical podcast of 2011.

Be sure to check out the other great episodes!

You can also find the Standing Orders podcast on Facebook HERE and on Twitter HERE.

Incidentally, during the show I promised I’d ask Keith Lurie, M.D. why it’s not a good idea to hold a mask with an ITD over the patient’s face and perform continuous chest compressions without ventilations.

Here’s the answer:

“If you do not ventilate but perform CPR with the ITD in place, then air is pushed out of the lungs and not allowed to get back in. The lungs become atelectatic, probably faster than if there was not ITD in place (though never studied), and then it is harder to move blood through the lungs from the right heart to the left heart. Even without the ITD, the lungs will become atelectatic without positive pressure ventilations during CPR: this is a bad thing as pulmonary vascular resistance goes up and blood does not circulate. That is one of the reasons I stress the need to ventilate.”

Order recommended:

  • Standard Chest compressions right away
  • Apply ITD with 2-handed face mask technique – hold firm all the time (see figure)
  • Ventilate 30:2 until intubated

See also:

Interview with Keith Lurie, M.D. discussing the ResQPOD and the ROC PRIMED Trial

Posted by on March 17, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , , ,

Is this a mimic or the real thing? – Discussion

8 comments

This is the follow-up discussion to:

Tweet about ECG leads to mystery – is this a mimic or the real thing?

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

This is a very suspicious ECG and must be considered acute inferior STEMI until proven otherwise.

This was my initial gut feeling about this ECG and I confirmed it with one of the smartest electrocardiographers I know (Stephen Smith, M.D. from Dr. Smith’s ECG Blog).

In fact, he discussed this exact type of ECG in his recent appearance on the EMCrit podcast.

EMCrit Podcast 42: A phD in EKG with Steve Smith

Let’s take another look at the ECG marked up so I can point out the key features that make this ECG so suspicious.

In the first place, the ST-elevation is limited to a particular set of contiguous leads (the inferior leads).

When a patient is experiencing acute inferior ST-elevation myocardial infarction, there is almost ALWAYS some type of reciprocal finding (ST depression, T-wave inversion, or both) in lead aVL.

If this is a mimic of acute STEMI, it’s one of the best I’ve ever seen, because of the inverted T-wave. In fact, I’m certain that’s why the computerized interpretive statement is calling this a STEMI.

In addition, the R/S ratio in lead V1 makes me suspicious (although it would be more suspicious in an older adult).

I’m also not pleased with the appearance of the Q-waves in lead III. Granted, lead III is a bit “quirky” but as you can see, these little coincidences are adding up and as Tomas Garcia M.D. is fond of saying, one must “consider the company” any ECG abnormality keeps.

This case demonstrates why a good story is very important when screening people for acute STEMI.

As Dr. Smith indicated in regard to this case, a lower pre-test probability changes things and makes some type of localized pericarditis much more likely (remember the patient has a low-grade fever).

However, it does not eliminate the possibility of acute inferior STEMI, and an ECG abnormality like this cannot be blown off. The way to handle it is a stat bedside echocardiogram to look for wall motion abnormalities that would indicate acute STEMI.

(Editor’s note: this ECG is not typical for benign early repolarization in spite of the fact that the patient is a young African American male).

Posted by on March 16, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

March 2011 EMS 12-Lead column at EMS1.com – Mirror on the Wall

2 comments

The March 2011 EMS 12-Lead column is up at EMS1.com.

Mirror on the wall

You won’t want to miss this one!

Posted by on March 16, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , ,

Tweet about ECG leads to mystery – is this a mimic or the real thing?

33 comments

One of the best things about EMS 2.0 is the ability to network and learn from EMS professionals all over the World.

Since I’m interested in ECGs and STEMI care I occasionally use the search engine at Twitter to see what folks are talking about when it comes to emergency cardiac care.

During one of those searches I came across this tweet by @in_the_city.

EKG geek? I’m your Huckleberry!

This piqued my curiosity so I answered @in_the_city.

Note: this was from my personal Twitter account @tbouthillet. The EMS 12-Lead blog is also on Twitter @EMS12Lead.

To be honest I was expecting one of the obvious mimics of acute STEMI.

Here’s the story in @in_the_city’s own words (with minor edits).

“EMS is dispatched to an area nursing home that specializes in pediatric patients with special needs and other wards of the state. The patient is a 19 year old ventilator-dependant black male with a chief complaint of a low grade fever 99.8 F taken tympanically.

The patients physician has been consulted and while the patient is responding to Tylenol he wants the patient taken to the ER for rehydration and the probable insertion of a PICC line.

PMH: Cerebral Palsy, Hypertension, Diabetes, Asthma, Respiratory Failure
Allergies: NKDA
Meds: Not recorded

The patient presents as follows:

NonVerbal. GCS=4-2-4 This is normal for this particular patient.

Airway is patent, with a number 6 portex tracheotomy tube in place and connected to the facilities ventilator.

Breathing is being assisted by the ventilator, with the patient taking an occasional spontaneous breath over the programed rate.

Circulation is apparently being maintained, with a normal steady radial pulse and good distal pulses in the feet.

Vitals signs:

BP 110/70
P 72
RR 20
SpO2 100%
EtCO2 35-40
Blood sugar 118

PERRL pupils, clear bilateral breath sounds.

Skin parameters are all normal.

Taking our time we attach the patient to the transport vent with the following settings:

Assist Control Tidal Volume 500 RR 14 FiO2 40% Peep 5.

As per system policy, this patients is considered an ALS patient due to being on a vent so we attach our monitor leads and print a 6 second strip to put with the chart.

At that point, we felt like we were being punked by someone. The elevation was evident to the both of us, in our nonverbal no complaint having vent patient! But neither of us wanted to be less than thorough so we hooked up the 12 lead.

So, since I saw ST elevation, my partner saw ST elevation, and the stupid computer in our Zoll E series saw ST elevation we had no choice but to suspect that our nonverbal complaintless patient was having an inferior wall STEMI.

When we arrived everyone pounced on our patient… at least until my partner showed the physician our 12 lead and she informed us that we had “wasted her time”

She didn’t elaborate. We felt bad. Then found out that benign repolarization effects about 1% the population and is common in young black males. The way to tell the difference (apparently) is that the ST segments, while elevated are scooped.

It really threw me that the repolarization isn’t seen globally, and is localized in those dang inferior leads. But live and learn.”

So what do you think?

I’ll share my thoughts once you’ve had a chance to weigh in.

See also:

Is this a mimic or the real thing? – Discussion

Other great case studies can be found HERE.

Posted by on March 14, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

Life-threatening hyperkalemia: do you recognize the ECG signs?

11 comments

I received a couple of interesting 12-lead ECGs from a semi-regular contributor who still wishes to remain anonymous (which is perfectly fine with me).

It was a transport from the emergency department to a tertiary care center for emergent dialysis.

Here are the 12-lead ECGs captured en route.

Potassium was 8.1.

Congratulations to this paramedic for using this transport as a learning opportunity!

Here are some ECGs from a recent case 76 year old female CC: Diminished LOC.

Potassium was 8.3.

Here are some ECGs from “Rhythm Challenge #2“.

I don’t remember the exact potassium level but it was above 8.0.

From 58 year old male CC: Unconscious.

I don’t think we ever got a potassium level on this poor fellow but he died.

Life-threatening hyperkalemia is something you can expect to see in the course of your career and it’s treatable!

It’s one of the few conditions (like D50 for insulin shock) that we can treat with IV meds (calcium gluconate or calcium chloride) and have an immediate therapeutic effect.

Take a close look at these ECGs and learn what to look for.

  • Undetermined rhythm (absent P-waves)
  • Non-specific intraventricular conduction defect
  • QRS duration > 180 ms
  • So-called “sine wave” or “Z-fold” appearance (merging together of S-wave and T-wave)

Throw in a history of renal insufficiency or renal failure, a missed dialysis appointment, use of potassium sparing diuretics, potassium supplements, etc., and you should be able to clinch the diagnosis.

Posted by on March 13, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

EMS Today 2011 in review

25 comments

I’m home sick today convalescing from some crud that I picked up in Baltimore. So, I’m watching the Matrix trilogy and getting caught up on some emails.

So much happened in Baltimore that I’m not sure where to begin. Whether I write about the specifics or not, I accomplished all of my goals. I caught up with some old friends and I made a lot of new ones. I didn’t sign up for any classes this year. I just came to Baltimore to have fun and network.

I flew up on Tuesday, March 1 and checked into the Hilton Garden Inn at the Inner Harbour and met Dave Hiltz for some drinks at the James Joyce Irish Pub. Dave and I have know each other online for several months now, so it was a real pleasure to meet him in “real life”. Somehow we never have a shortage of things to talk about and it was even better over some Black & Tans (in Dave’s case with a sidecar).

On Wednesday, March 2 I met with the Public Safety Team of the American Heart Association (follow them on Twitter @ahapublicsafety). We discussed EMS 2.0 and the intersection of EMS and social media. As I mentioned before, they really impressed me as a group of top-notch professionals ready to re-engage the EMS market. Special thanks to Craig Day, Dave Hiltz, and Lindsey Sandoval for their help setting up the meeting.

Dave Hiltz and Tom Bouthillet at EMS 10 Awards

I also met with the EMS Section of the International Association of Fire Chiefs (follow them on Facebook). Again, the topic was social media and the power of Web 2.0. It was a pleasure to sit down with these gentlemen who I hadn’t seen since Fire-Rescue Med 2010. I’m pleased to see fire-based EMS under such competent leadership and I think we can expect even more from the EMS Section of the IAFC in the not-too-distant future.

I attended the EMS 10 Awards (congratulations to Dave Hiltz of HEARTSafe Community, Greg Friese of EMS EduCast, and Chris Montera of EMS Garage). Also special thanks to Erik Denny of Physio-Control for being kind enough to extend me an invitation for this exclusive event. It was a privilege and I had a great time!

Immediately following the EMS 10 Awards we headed on over to the ZOLL Pre-Conference Blogger Bash at the Pratt Street Ale House. What an awesome time! If you weren’t there, you missed an awesome party. Many have already seen the video of me drooling on myself at the end of the night. Thank you Ted Setla (@FRNtv)!

Natalie Quebodeaux, Meris Shuwarger and April Sailing at the ZOLL Blogger Bash

The next morning I slept in as long as possible and then packed up my things and moved over to the Hilton Baltimore attached to the Convention Center. I attended the HeartRescue Project “lunch and learn” (I will be writing about that in the near future because it’s awesome). Then I walked over to the Physio-Control booth and made some new friends, including Dana Yost from King County Medic One. Of course I also said hello to my good friend Tim Phalen.

That night was the Fire/EMS Blogger meet-up at the Uno Chicago Grill. This year we had the entire place to ourselves. At first I thought that was pretty cool. Unfortunately, it meant that everyone had plenty of room to spread out and sit at different tables.

Ted Setla and Justin Schorr (not visible in frame) doing what they do best at the JEMS FireEMSBlogs.com meet-up sponsored by Physio-Control

So, while it wasn’t as crowded as last year, there was a lot less “mingling” and it just didn’t feel quite the same. It’s just as well because I knew I was podcasting the following day. Last year I appeared with a blistering hangover on the MedicCast and I was determined not to repeat the error!

One nice thing about Baltimore is that it’s easy to catch a taxi cab. I headed straight back to the hotel and hit the rack. At least, I tried. Even from 11 stories up the City of Baltimore was rocking! Eventually sleep came.

Next thing I knew it was Friday, March 4. It’s amazing how fast these conferences fly by! I grabbed my prerequisite cup of coffee and I was off to the conference. They almost didn’t let me in because I didn’t have an exhibitor pass. But, I was able to convince the guard I was a podcaster and he allowed me though.

MedicCast with Tim Noonan, Dana Yost, Tom Bouthillet and Jamie Davis

I showed up at the ProMed Network podcasting booth about 10 minutes early at 9:50 a.m.. The schedule was running slightly behind (but only slightly) and the MedicCast kicked off with the EMS “Yeti” Tim Noonan (Rogue Medic), Dana Yost from King County Medic One, me and the ’podmedic’ Jamie Davis (always a gentleman). You won’t want to miss this episode! I’ll let you know as soon as it’s released.

After that it was off to lunch with my good friends Charlotte Norton and Jon Cloutier from ZOLL. It’s even remotely possible that I had a shot of tequila with one of them but I’m not telling which one. Then it was back to podcasting area because the EMS Research podcast was set to kick off at 2:00 p.m. and I had to make sure our guests were lined up or I knew Anne Robinson would kill me! I say that with love, Anne.

EMS Research podcast with Lynn White, Dave Hiltz, Tim Noonan and Tom Bouthillet

Thankfully, it all worked out in the end. Special thanks to Harry Mueller who allowed me the opportunity to host our special episode of the EMS Research podcast. I was honored to invite my good friend Dave Hiltz (hopefully you’ll be seeing a lot more of him because I’m going to do my best to talk him into becoming a blogger) and a new friend, Lynn White (HeartRescue Project Education Director) to be our special guests, and of course, the illustrious scallywag and EMS “Yeti” Tim Noonan.

After that, I “laid low” with Tim Noonan, Russell Stine (@HybridMedic) and David Baumrind at the Diamond Tavern. Special thanks to Chris Montera (@geekymedic) for finding my computer at the podcasting booth, figuring out it was mine, and contacting me via Twitter. We met up with them briefly at the Orioles Grille before I turned in for the night.

They were on the way to Max’s Taphouse (karaoke night which was obviously going to be epic) but I was just partied out. I was subsequently disowned by Carissa O’Brien (@CarissaO) but I’m hoping she’ll eventually forgive me.

All in all, a heck of a good time. I was sorry to come home! Of course, my trip home was uneventful compared to that of Ambulance Driver and Too Old To Work Too Young To Retire!

Speaking of Kelly Grayson (Ambulance Driver) consider these observations he made about EMS Today 2011 and EMS 2.0.

What is different this time is the social media revolution.

EMS bloggers like Justin Schorr, Chris Kaiser, and others, filmmakers like Ted Setla, and EMS podcasters like Jamie Davis, Chris Montera, Greg Friese, and Ron Davis have recognized the power of social media, and they’ve harnessed it to empower the rank-and-file EMS provider in the process.

The days when the professional committee members could shape EMS policy without input from street providers are becoming a thing of the past. We have a voice now, and its a powerful one.

Thanks to all for a wonderful time! Hopefully I’ll see you at EMS Expo 2011.

Posted by on March 9, 2011 • Filed under: ems-topics • Tagged:

39 year old male CC: “Sick” – Discussion (Pericarditis)

15 comments

Here’s the conclusion to 39 year old male CC: “Sick”

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

Several findings in this case point toward pericarditis.

In the first place, the patient is feeling unwell and has a temperature of 100.2 F, the chest pain is “sharp” in quality and is reproducible with deep inspiration so it’s atypical for coronary ischemia.

Secondly, the constellation of ST-elevation (or at least J-point elevation) is unusual. For example, you can see J-point elevation in lead I and also leads II and aVF which are reciprocal leads.

It’s not impossible for a STEMI to have ST-elevation in leads I and II (see this case from Dr. Smith’s ECG Blog) but you will notice that the computer incorrectly reads the ECG as pericarditis!

Here are the last few tips to help you identify pericarditis. In the above image which shows a single cardiac cycle in lead II, you can see (A.) PR-segment depression, (B.) a “notched” J-point, and (C.) upwardly concave ST-segment elevation (if in fact the ST-segment is really elevated in comparison to the TP segment).

An easy way to remember the difference between “upwardly concave” and “upwardly convex” (or non-concave in the case of a straight ST-segment which is also bad) is that and “upwardly concave” ST-segment looks like a smiley face (good) and “upwardly convex” looks like a frowny face (bad).

It’s important to remember that acute STEMI can, and often does, present with upwardly concave ST-segments, so the mere fact that the ST-segments are upwardly concave does not mean it’s not a STEMI.

It’s one piece of the puzzle.

So what happened to the patient? Here’s what Matt from Mass had to say.

“Follow-up with the ER nurse a week later revealed a diagnosis of pericarditis with an unremarkable clinical course after intravenous antibiotics. Etiology of the infection was not determined.

In addition, patient was referred for outpatient cardiologist evaluation for possible Wolff-Parkinson-White syndrome.”

One of the really cool things about Web 2.0 and social media is “peer sourcing”. Since I too thought that lead V3 looked very suspicious (meaning that it looks like a delta wave is present even though the PR interval is not short) I forwarded the ECG to Mark P. from the Electrophysiology Fellow blog.

He sometimes leaves comments on my case studies which I always appreciate very much!

Here’s what he had to say.

“It is very unlikely to be WPW:

  • the ‘deltas’ in in the mid praecordial leads, in the absence of deltas elsewhere, do not fit the usual patterns of preexcitation
  • the septal q waves in V5 and V6 suggest that conduction to the septum is first i.e. the normal pattern, rather than preexcitation of the ventricle elsewhere (see reference here)
  • it is not unusual to see a little slurring in some leads as appears in V3

On the other hand he has a number of interesting features:

  • ST depression in aVR, the most specific ECG marker for pericarditis
  • ‘early repolarisation’ in an infero-lateral pattern; once considered a normal finding, now known to be associated with SCD (although this is weak marker for sudden cardiac death; useful in populations, practically useless for predicting an individual’s risk)

This case did make we wonder about the differential diagnosis for a slurred beginning to the QRS in precordial leads. Obviously WPW and the other preexcitation syndromes, HCM (read recently about one lab’s experience with patients referred with HCM for suspected preexcitation – not a single patient had an accessory pathway), presumably LVH, and intramyocardial conduction delay of whatever cause, and electrolyte abnormalities.”

Pretty cool, huh? Thanks, Mark!

By the way, you can follow Mark the EP Fellow on Twitter here: @epfellow

You can also subscribe to the ECGs & Cardiology fan page on Facebook and we’ll keep you notified when Mark posts something new!

Posted by on March 8, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , , , ,

572-pound spokesman for the Heart Attack Grill dead at 29

11 comments

Let’s face it. Sex sells. I mean, who (other than most of our girlfriends) wouldn’t want to eat a hamburger here?

Photo credit: Outhouse Rag

Photo credit: examiner.com

But there’s a fine line between having a sexy nurse serve you a hamburger (or anything else for that matter) and glamorizing public health burdens like obesity or cardiovascular disease.

Photo credit: AP via Fox News

Blair River is dead (possibly from pneumonia according to news sources). That is unfortunate.

From the article at Fox News:

Jon Basso, the restaurant’s founder, teared up a bit Wednesday when he was asked about the 29-year-old’s sudden death.

“We all have a very, very brief time on this earth, and the measure of a man is how he leaves the world after he’s been here, and I can tell you Blair River was my friend,” Basso told MyFoxPhoenix.

Many criticize the eatery that offers meals in excess of 8,000 calories. They feature huge hamburgers, milkshakes and fry their fries in pig lard. A sign in front of the building reads, “Caution. This establishment is bad for your health.”

Basso says he expects the criticism, but the message beneath the outrageous menu is one of caution. Even some diners agree — it’s your choice to eat there or not to eat there.

“We are absolutely guilty for glorifying obesity, it’s what we do, but if you stop and think about why we glorify obesity and come into the Heart Attack Grill diet center I think you’ll get it,” Basso told the website.

What a ridiculous crock of bullshit. The Heart Attack Grill glorifies obesity to make money. There’s is no hidden altruistic meaning behind it.

Remember The Fat Boys?

The Human Beat Box (Darren Robinson) died at age 28 of a heart attack.

Sexy girls are awesome. Obesity and cardiovascular disease suck.

It’s not funny and it’s not something to glamorize under the banner of personal choice.

I will never set foot in a Heart Attack Grill. I hope none of you will either.

See also:

iPhonECG turns the iPhone 4 into a cardiac event monitor

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

Transcutaneous pacing (TCP) – The problem of false capture

Cardiac arrest – Are you ready to save one of your own?

Posted by on March 7, 2011 • Filed under: ems-health-safety, ems-topics • Tagged: ,