This is the discussion for 13 year old female CC: Syncope.
You may wish to go back and familiarize yourself with the details.
The short of it is that on a very hot and humid day a 13 year old female passed out after looking at her sister's scraped knee. She had passed out at the sight of blood before.
The parents were not the ones who contacted 9-1-1 and they were not interested in having the patient transported to the hospital by ambulance.
However, the family history was very concerning as the father's brother died (many years ago) at age 16 from a "seizure disorder."
Prudently, the treating paramedics obtained consent for an exam and obtained a 12-lead ECG.
I had posed the following questions:
- Why did the paramedics ask questions about the family history?
- Why did the paramedics perform a 12-lead ECG?
- Do you see anything that would suggest this patient is at-risk of anything life-threatening?
- Is it okay for the parents to refuse transport to the emergency department?
Paramedics asked about the family history because early, unexplained deaths in the family could suggest some kind of inhereted disorder like Prolonged QT Syndrome, Wolff Parkinson White Syndrome, Brugada Syndrome or Hypertrophic Cardiomyopathy.
The fact that the father's brother died at age 16 is important (and would be even if the patient hadn't experienced a syncopal eposide).
Paramedics performed a 12-lead ECG because they knew the parents did not want their daughter transported to the hospital but they saw it as an opportunity to screen the patient for these disorders.
Now, some of you may think this kind of screening is dangerous or poses liability to the paramedics or EMS system because the paramedics haven't been formally trained in how to detect these abnormalities.
However, there's one easy rule you can follow to make sure you always do the right thing in EMS.
Treat every patient like a member of your own family.
A member that you like (preferrably).
I think we all understand (or at least I hope we all understand) that paramedics are not board certified emergency physicians, let alone pediatric cardiologists or electrophysiologists.
So, part of the risk of refusing care for any patient is that a paramedic's assessment is not equivalent to a qualified physician's assessment (complete with all the diagnostic tests they have at their disposal).
Let's break down these abnormalities one at a time.
- Is the QT/QTc prolonged? No.
- Are there delta waves suggestive of WPW? No.
- Is there a Brugada pattern? No.
- Is it suspicious for HOCM? It's close to meeting the voltage criteria for LVH (for adults) in the precordial leads. But no.
If you saw the recent case on Burned-Out Medic's blog then you know the most difficult ECG-diagnosis in all of medicine is "Normal ECG"!
However, one of the really cool things about Web 2.0 and blogging is "peer sourcing" and I do my best to make sure I'm giving out correct information.
So, I had this ECG reviewed by two people I respect a whole heck of a lot.
The first is Stephen Smith, M.D. from Dr. Smith's ECG Blog. Here's what he had to say.
It looks pretty normal to me. I get a QTc of 460 at most, not dangerous. Also, the history strongly suggests vasovagal.
Then, when specifically questioned about the voltage in the precordial leads:
I did notice that there is more voltage than usual, and thought about HOCM, but it is certainly not highly suggestive of it. And the patient was not exercising when this happened, and she had a classic vasovagal from looking at blood. I wouldn’t worry about it. On the other hand, if you sent her to the right ED (like ours) we would do a bedside ultrasound to look for LVH and septal hypertrophy. If you sent her to one that doesn’t do that, she would be sent home without any further workup (most likely) or possibly be admitted, and possibly get a formal echo at some point. It’s just playing the odds, and the odds of this kid having something bad are not zero, but they are very low.
I also had the case reviewed by Mark P. of the Electrophysiology Fellow blog. Here's what he had to say.
The ECG is normal. History is classic for vasovagal. The dead 16 year old necessitates followup for the extended family in any case (ECG as a first procedure). But there is no danger in this young girl not going to hospital. Reading the comments, almost all of the ECG changes noted by people are related to her age.
As a closing thought, some paramedics are quick to say that ECG transmission means that an EMS system doesn't trust its paramedics, and over and over again I've suggested that simply isn't true. There is nothing wrong with getting a second (or third) set of critical eyes on a 12-lead ECG, especially when the stakes are high (as they are for a possible STEMI patient).
There's no shame in transmitting an ECG like this to the hospital to get a second opinion (or even a first opinion if, like so many other paramedics, you have never been trained to look for prolonged QT, WPW, Brugada or HOCM). Discussing this case with Medical Control (as suggested by Ken Grauer, M.D. in the comments) is a great idea!
If you had a 13 year old daughter, sister or niece, how would you want the case to be handled by EMS?