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I just got back from the North Dakota Mission: Lifeline STEMI and Acute Stroke Conference in Bismark, ND. I had a great time and I learned a lot.
I often get asked to speak in various venues about acute STEMI and 12-lead ECG interpretation, but for this conference they wanted me to talk mostly about stroke. That turned out to be a good thing because it forced me to read the 2013 AHA / ASA Guildelines for the Early Management of Patients With Acute Ischemic Stroke to make sure I was asking intelligent questions during the panel discussion (which I moderated) and also giving accurate information for the class I taught about stroke recognition and treatment.
I also turned to a new source of information about acute ischemic stroke and that is the #FOAMed community on Twitter. If you're not familiar with FOAM or FOAMed it stands for "Free Open-Source Medical Education". I was surprised to learn that giving reteplase (Activase) or rtPA for acute ischemic stroke is somewhat controversial, at least in the emergency medicine blogosphere. That may explain why some of our emergency physicians locally are hesitent to give rtPA for acute ischemic stroke, especially for mild or rapidly improving strokes.
To help explain why rtPA is controversial for acute ischemic stroke I will refer you to a blog post entitled Schrödinger’s Fence at the Life in the Fast Lane blog.
This created some cognitive dissonance for me as I certainly didn't want to come across as a bomb thrower while moderating a panel discussion about acute ischemic stroke. In the end, it turned out that my concerns were completely unfounded because the panelists were happy to acknowledge that the therapy is controversial but well supported in the guidelines and give their reasons why they believed that rtPA is both indicated and underutilized for acute ischemic stroke. The panel discussion was video taped and I will update this blog post as soon as the video is available online.
What I really want to tell you about is a story of survival. But it's more than that. It's a story about love, and caring, and decision making, and even customer service.
As host of the Code STEMI Web Series as First Responders Network I have been priviledged to meet many STEMI and sudden cardiac arrest survivors, including the EMTs, paramedics, nurses, and physicians who worked together as a team to save their lives. I have always imagined that the holy grail of survivor stories would involve therapeutic hypothermia, and actually being there at the bed side when the patient opens his or her eyes for the first time in the presence of their loved ones.
At no time did I imagine how powerful a stroke survivor story could be. It simply never crossed my mind. So I was unprepared and deeply moved by a stroke survivor story that was presented on Wednesday.
The patient's name is Scott Onstine and his wife's name is Diane. Scott is a diabetic and the stroke affected the left temporal lobe of his brain. This area is involved in the rention of visual memories, processing sensory input, comprehending language, storing new memories, emotion, and deriving meaning. Scott sensed something was wrong so he contacted his wife by cell phone. This is critically important because as I learned this week, a huge number of stroke patients don't recognize their symptoms as stroke (perhaps because stroke does not cause pain) and it's not uncommon for stroke patients to "lie down" in attempt to "sleep off" the symptoms. This is a huge problem because time-to-treatment is extremely important for acute ischemic stroke and once stroke patients lie down, they usually don't get back up. Once they are found by a loved one it's usually either impossible to establish a timeline or it's too late to treat the stroke with rtPA.
Fortunately for Scott, his wife came home, thinking that perhaps his blood sugar was low. She tried to give him some orange juice but he threw it up. Then he knocked over the glass. She went up stairs and was shocked to see the bedroom completely trashed. Scott had been trying to use the phone, and because of his stroke symptoms, he couldn't figure out how to do it. Diane was getting scared, especially after she measured Scott's blood sugar and found out it was only 130. She contacted 9-1-1 with a certain amount of anxiety because she had called 9-1-1 once before thinking that Scott was having a stroke. On that occasion it turned out to be low blood sugar.
Diane got an awesome dispatcher. She rapidly determined that Scott was probably suffering a stroke due to his difficulty in forming speech. She actually had Diane perform a FAST (Face, Arms, Speech, Time) exam on Scott while waiting for the ambulance.
The test results revealed expressive aphasia. Diane spoke about how much this dispatcher meant to her, how she acted as a "life line" on the other end of the phone, keeping her calm and staying with her until help arrived. She spoke about a paramedic named Gus (who I also met); how kind, caring, and competent he seemed. She spoke about the firefighters who showed up on scene to assist, how professional they were, how they moved the furniture to make room for the gurney, and how they moved the furniture back.
She spoke about how Gus advised her that it would be a good idea to bypass the closest hospital and go straight to a Primary Stroke Center. She talked about how everyone kept her informed about what was going on, at this time when her life was spinning out of control. She talked about hearing the overhead page — a Stroke Alert in the Emergency Department — and how she knew it was for Scott, and how that reassured her that Scott was in the right place.
By this time Scott had taken a turn for the worse. He was barely responsive. A pastor showed up at the hospital and they prayed together at the beside. At the end of the prayer the pastor said "Amen" and they were both surprised to hear Scott say "Amen". She leaned over to him and said, "I love you!" He said, "I love you." Something deep in his soul knew that he was being prayed for, and that he loved his wife. He was receiving rtPA but they were simultaneously preparing him for an endovascular procedure due to the location and nature of the blockage in one of his cerebral arteries.
It turned out that the rtPA had worked and that blood flow had been restored to Scott's brain. He was rapidly improving. Before long, and had recovered almost all of his neurological functioning. He was discharged from the hospital and given a Holter monitor that revealed periodic atrial fibrillation. He now takes Coumadin to help prevent another stroke.
The Interventional and Stroke Neurologist Dr. Ziad Darkhabani made this simple observation. "Stroke is treatable and stroke is preventable."
This was truly one of the most powerful survivor stories I have ever heard, perhaps because it was seen through the eyes of the survivor's spouse. At the beginning of her talk, Diane made one of the most poignant statements of the entire conference. She said, "Strokes happen to a patient but they also happen to a family."
I have often thought about how any case study — good or bad — can provide a lens through which we can analyze a system of care from the patient's perspective. In this case we can see the entire stroke chain-of-survival. Scott didn't lie down. He called his wife. She realized it wasn't low blood sugar and contacted 9-1-1. The dispatcher recognized the signs of stroke and stayed on the line to encourage and reassure Diane. The first responders took the problem seriously, treated the patient with caring and competence, and provided excellent customer service by respecting the patient's property and moving the furniture back. Gus has the presence of mind to bypass the closest hospital for a Primary Stroke Center. The overhead page told Diane that the hospital was prepared for patients like Scott. They kept her informed. She was allowed at the bedside. She was treated with dignity, compassion, and respect.
Stories like this remind me why I got into health care. We need to celebrate our "wins" to keep us focused as health care professionals. System building isn't easy. In fact it can be very difficult. Couples like Scott and Diane make me realize that in the end it's all worth it. Although many believe the "jury is still out" on rtPA for acute ischemic stroke, it certainly appears to me that stroke patients do better within systems of care, and in hospitals with highly coordinated expertise at every level of care — prevention, diagnosis, and treatment — and dedicated units with nurses who specialize in neuro care.
We in EMS need to do a much better job in educating patients how to recognize the symptoms of acute stroke, and to encourage them to contact 9-1-1.
Special thanks to Mindy Cook from North Dakota Mission: Lifeline for inviting me to be a part of the North Dakota Mission: Lifeline STEMI and Acute Stroke Conference! Also to Peggy Jones, Coordinator of the Illinois Critical Access Hospital Network (ICAHN), who sat next to me at the conference and taught me a lot about the problem of patient delay. She is also a stroke survivor and an inspiring woman in her own right.
Also, to the EMTs, paramedics, nurses, and even a physician or two who stuck around for the 6:30 p.m. class on stroke and the 7:30 p.m. class on STEMI and 12-lead ECG basics, thank you! You guys totally rock! North Dakota is blessed with a truly dedicated group of health care providers.
EMS 12-Lead podcast – Episode #11 – Are we harming patients with oxygen?
In this episode of the EMS 12-Lead podcast we're joined by Kelly Arashin, ACNP, CCNS and Mike McEvoy, PhD, RN, CCRN, REMT-P at EMS Today 2013 in Washington D.C. We discuss the benefits and dangers of oxygen administration.
Kelly is a dual boarded advanced practice nurse and Chair of the Hypothermia Steering Committee at Hilton Head Hospital in Hilton Head Island, SC.
Mike describes himself as a nurse, paramedic, firefighter, and medical college professor. He is also Chair of the Resuscitation Committee for University Teaching Hospital in Albany, NY.
*** Update ***
Thanks to Brooks Walsh, M.D. for bringing this article to our attention:
Tom Bouthillet, Kelly Arashin, Mike McEvoy at EMS Today 2013
Special thanks to Physio-Control, JEMS, PennWell, and the ProMed Network
You can also watch the video version.
Follow Kelly Arashin on Twitter at @BarefootNurse24
Visit Kelly's blog
Follow Mike McEvoy on Twitter at @McEvoyMike
Visit Mike's website
Ivan Rokos, M.D. has referred to primary PCI for acute STEMI as “the most complex, multi-disciplinary, and time-sensitive therapeutic intervention in the world of medicine.”
The emphasis on door-to-balloon times, and more recently, first medical contact or EMS-to-balloon times has transformed how acutely ill patients suffering heart attacks receive timely reperfusion in many communities, because as we’re so often told, “time is muscle.”
While some believe that the emphasis on door-to-balloon times has unintended consequences, in our opinion the real-life stories of the men and women who build these systems of care illustrate the very best of what modern medicine has to offer.
A single 9-1-1 call (9-9-9 in the UK) triggers an awe-inspiring series of highly coordinated events that clearly demonstrate that despite all of our arguments about health care and how it should be paid for, when a fellow human being is in danger, we will work together to save that person’s life.
We will exercise exceptional caring and competence, and then return that patient to their family. We give them another chance.
Many of us in EMS (and other areas of medicine) love survivor stories because it makes us feel good to know we’ve helped another human being. That’s why we got into medicine in the first place. But then something happened. We became jaded. We became cynical. We saw the worst in people.
The Code STEMI Web Series is a salute to the individual EMTs, paramedics, nurses, and physicians who had the courage and the insight to change the status quo and build something very meaningful that directly influences whether our friends, neighbors, or even our family members live or die.
Change can be difficult. It can be painful. It takes us out of our comfort zone and sometimes it rearranges the pecking order. Yet, we must change, whether it’s allowing EMTs to acquire and transmit a 12-lead ECG, activating the cardiac cath lab at 3:00 a.m. Sunday morning, or learning how to reduce “door-in to door-out” (DIDO) times at Critical Access Hospitals so that heart attack patients have the best possible chance of survival.
As Michael Hibbard, M.D. reminds us, it’s not the strong who survive. It’s those who are most able to adapt to change.
Our most recent episode of the Code STEMI web series looks at the London Ambulance Service. It is the busiest, and arguably one of the best EMS systems in the world. We interview front line EMTs, paramedics, nurses, and physicians as well as survivors. We hope you enjoy watching it as much as we enjoyed filming it so you can share our enthusiasm for witnessing a job well done.
Follow the #CodeSTEMI hashtag on Twitter!
Seaon 2 of the Code STEMI Web Series is set to launch on March 7, 2013 at EMS Today in Washington, D.C.! This season starts out with our most exciting location ever — London, England as we feature the London Ambulance Service (LAS).
Special thanks to Physio-Control for sponsoring this web series!
Speaking of which, you can download the schedule for Physio-Control University at EMS Today by clicking here (PDF).
I'll be teaching an educational session called Hilton Head Island – Strengthening a Community's Chain-of-Survival. I'll explain how we achieved on of the highest cardiac arrest save rates in the nation (Utstein survival of 66% for 2012).
Hope to see you there!
EMS 12-Lead podcast – Episode #10 – Brooks Walsh, M.D. from the Mill Hill Ave Command blog
In this episode of the EMS 12-Lead podcast we're joined by Brooks Walsh, M.D., Emergency Physician and Editor of Mill Hill Ave Command and Doc Cottle's Desk. We discuss paramedic education, ECGs, blogging, science fiction doctors, "treating the patient and not the monitor", reperfusion therapy for acute STEMI, and preactivation of the cardiac cath lab.
Brooks Walsh, M.D.
Follow Brooks Walsh, M.D. on Twitter: @BrooksWalsh
Follow the Mill Hill Ave Command blog on Facebook
Episode #9 – Thomas Concannon, ph.D. talks about regionalization of STEMI care and the proliferation of PCI hospitals in the United StatesNo comments
EMS 12-Lead podcast – Episode #9 – Thomas Concannon, ph.D. talks about the regionalization of STEMI care and the proliferation of PCI hospitals in the United States
In this episode of the EMS 12-Lead podcast we're joined by Thomas Concannon, ph.D., Assistant Professor of Medicine at Tufts Medical Center and Tufts University School of Medicine. He's an academic researcher who has analyzed the explosion of PCI hospitals in the United States and reached the un-intuitive conclusion that the increased number of PCI hospitals has not resulted in more timely access to reperfusion for patients suffering an acute STEMI. The reasons are interesting and it turns out that EMS may play the most important role of all going forward!
Thomas Concannon, ph.D.
(click here for photo credit)
"Hospitals invested heavily in new PCI capability during the 5 years from 2001 to 2006, making it newly available in 519 hospitals, for a total of 1695 (36.3% of all eligible hospitals) acute care hospitals in the United States This heavy investment in new PCI capability represented a relative increase of 44% over 2001 but did not result in an appreciable change in timely access to the procedure."
Connect with Thomas Concannon, ph.D. on Twitter: @tconcannon
Find more of his research at his personal website: www.thomasconcannon.com
Any paramedic who has studied the STEMI mimics has heard of the classic benign early repolarization pattern of a "fish-hooked" J-point with upwardly concave (smiley-faced) ST-segment, often best appreciated in lead V4.
But, as the excellent work of Stephen Smith, M.D. demonstrates, not all cases of early repolarization present this way, and it can often be very difficult to differentiate between early repolarization and LAD occlusion.
So, we took a run-of-the-mill "male pattern" early repolarization pattern, removed the computerized interpretation, and posted the ECG to our Facebook fan page.
The variety of interpretations was shocking!
Some of the common interpretations included Wolff-Parkinsons-White syndrome, pericarditis, hyperkalemia, and (less commonly) acute anterior STEMI. Very few mentioned early repolarization.
This just goes to show how important and valuable Stephen Smith's work on this topic really is!
Here's the same ECG with the computerized interpretation.
I have a sneaking suspicion that some of the very same paramedics who rail against computerized interpretive algorithms are unconsciously influenced by the computerized interpretation whether they realize it or not.
That may not be a bad thing.
A baseline reading of "normal ECG" creates a comfort level for this normal variant. Keep in mind, ST-elevation in leads V2 and V3 for a young male is not a normal variant. It's a normal finding! But these T-waves are a little more impressive than we might expect, so I'm calling it a variant.
So what gives away that it's not hyperacute anterior STEMI?
Dr. Smith has an abstruse formula (he probably doesn't think it's abstruse but then again the man's a physicist as well as a physician) that was recently published in the Annals of Emergency Medicine.
(1.196 x STE at 60 ms after the J-point in V3 in mm) + (0.059 x computerized QTc) – (0.326 x R-wave Amplitude in V4 in mm)
A value greater than 23.4 is quite sensitive and specific for LAD occlusion.
Dr. Smith adds these qualifiers:
"It is critical to use it only when the differential is subtle LAD occlusion vs. early repol. If there is LVH, it may not apply. If there are features that make LAD occlusion obvious (inferior or anterior ST depression, convexity, terminal QRS distortion, Q-waves), then the equation MAY NOT apply. These kinds of cases were excluded from the study as obvious anterior STEMI. ST elevation (STE) is measured at 60 milliseconds after the J-point, relative to the PR segment, in millimeters."
What does this mean for the field provider? I'm a firm believer in keeping it simple.
The bottom line (in my opinion) is that we should suspect the possibility of benign early repolarization when:
- R-wave progression is intact (this is big)
- There is a tall R-wave in lead V4
- The QTc is on the low end of normal (in this case < 400 ms)
- There is an absence of reciprocal changes
- ST-elevation is upwardly concave
- U-waves are easily identifiable (additional tip shared by Dr. Smith in private conversation)
- There are no changes on serially obtained ECGs
None of these rules of thumb are 100% but we're trying to make a logical game-time decision and knowledge is power.
Simply knowing that the differential diagnosis is early repolarization vs. LAD occlusion would be an important improvement when faced with an ECG like this (which frankly isn't anywhere near as difficult as some others we've seen).
- Early repolarization is a common and underappreciated STEMI mimic
- It does not always present with "fish-hooked" J-points
- The ST-elevation and T-waves can often be scary with early repolarization
- The key here is knowing that the differential is LAD occlusion vs. early repolarization
I encourage everyone to read the archived early repolarization cases at Dr. Smith's ECG Blog by clicking here.
EMS 12-Lead podcast – Episode #8 – Jim Broselow, M.D.
In this episode of the EMS 12-Lead podcast we're joined by Jim Broselow, M.D., inventor of the Broselow Tape for pediatric resuscitation. We discuss the Broselow Tape as well as eBroselow.com, the Artemis Pediatric System and the SafeDose app.
If you've been in EMS for any length of time you're probably familiar with this.
But you need to become familiar with this!
Check out Artemis and SafeDose at eBroselow.com!
Follow Jim Broselow, M.D. on Twitter.
Follow eBroselow on Facebook.
August 16, 2012 @ 2:00 p.m. (14:00) EST.
Sponsored by Physio Control (thank you).
Direct link for registration is here.
EMS 12-Lead Podcast – Episode #7 – PulsePoint
In this episode of the EMS 12-Lead podcast we're joined by Richard Price of the PulsePoint Foundation. If you're not familiar with PulsePoint it used to be referred to as the San Ramon Valley Fire Department app.
Fire Chief, San Ramon Valley FPD
Check out this amazing video to see how the PulsePoint app works!
Follow the PulsePoint Foundation on Twitter: @PulsePoint
Follow PulsePoint activatios on Twitter: @1000livesaday
This is the conclusion to 65 year old male CC: Fall with injury. You may wish to review the history and clinical presentation.
When we left off the patient was in severe heart failure with the following 12-lead ECG.
As we have mentioned before on several occasions, the most important thing when treating a patient with a tachycardia is to decide whether or not the tachycardia is causing the symptoms or the symptoms are causing the tachycardia.
In other words, you should try to rule out the possibility that it's a compensatory tachycardia. As this case clearly demonstrates, this can be very difficult!
The crew felt that the differential diagnosis for this wide complex tachycardia (from most likely to least likely) was VT, 2:1 atrial flutter with LBBB, sinus tachycardia with LBBB, or some other SVT with aberrancy.
Due to the patient's instability, the treating paramedic felt there was little to lose and much to gain by attempting synchronized cardioversion. If the rhythm was VT or 2:1 flutter the patient's condition might improve dramatically. If it turned out to be sinus tachycardia with LBBB he'd be in the exact same position.
There appeared to be no change in the heart rhythm.
A report was given to online medical control and the patient was transported emergently to the hospital.
On arrival the patient was placed on BiPAP and started on a NTG drip.
Here was the 12-lead ECG on arrival.
The patient was given lopressor 5 mg slow IV push.
The conversion rhythm shows sinus rhythm at 92 bpm with left bundle branch block.
So, we now know that the patient probably had LBBB at baseline. However, without a heart rate histogram it's difficult to say whether or not this was 2:1 flutter that converted sinus rhythm or sinus tachycardia that was slowed down with the lopressor.
This is often overlooked in the emergency setting but in the inhospital setting it's very important to document the onset or termination of an arrhythmia for this very reason.
The patient's SpO2 came up above 90% and the patient became more alert and was attempting to communicate by the time EMS was done writing their report. No further information is available.
Here's a very interesting case submitted by a faithful reader who wishes to remain anonymous. Some changes have been made to preserve patient confidentiality.
EMS is called to a local breakfast restaurant for a 65 year old male who fell in the parking lot. He was reported to have suffered a head injury.
On arrival the patient is found sitting in his car. He appears critically ill. Skin is pale and diaphoretic. Nail beds are blue. The patient's level of consciousness is significantly diminished. His shirt and pants are wet and it's not clear if he was incontinent of urine or spilled a drink on himself. He has audible expiratory rales without the need for a stethescope.
The patient states that he tripped and fell. His wife states that he was "fine" prior to falling but she does not impress EMS as a good historian. When asked about his history she says, "heart."
The head appears atraumatic with the exception of some abrasions to the face. He admits to head pain "all over" and keeps muttering "please take me to the hospital."
Due to the patient's diminished level of consciousness it is not possible to clear the cervical spine with any established criteria. However, the paramedics conclude that the patient cannot be laid flat and elect to defer spinal immobilization. The patient is placed on the gurney with the head elevated and vital signs are assessed.
- RR: 30
- HR: 148
- NIBP: 150/77
- SpO2: 58 on room air
The patient is placed on a NRB mask @ 15 LPM. The chest is exposed and no chest trauma is apparent. Breath sounds: rhonchi and rales bilaterally
The patient is given a dose of SL NTG and loaded in the back of the ambulance. At this point the patient appears peri-arrest.
The cardiac monitor is attached.
A 12-lead ECG is obtained.
What would you do next?
Cam Pollock and John Friederich from Physio-Control put on a demonstration for us at Fire-Rescue Med 2012 to show how the LUCAS Chest Compression System can be incorporated into a "pic crew" concept for CPR and resuscitation. As you will see the application of the LUCAS device need not cause a significant delay in chest comrpessions.
This is an outstanding video that shows clips of an actual resuscitation and features a sudden cardiac arrest survivor.
It's important to collect data so we can measure our progress and prove that we are saving lives, but as we build these systems of care we must always remember that these are our mothers, fathers, sisters, brothers, sons and daughters.
Excellent job by AMR and Portland Fire Department!
Here's a case submitted by a faithful reader who wishes to remain anonymous. He has submitted several cases before and they are always excellent so thank you, Mr. Anonymous!
EMS is called to the residence of a 69 year old female who is complaining of sudden onset of shortness of breath and weakness.
- Past medical history: Healthy
- Medications: None
The patient is seen in the emergency department of a local community hospital where she is found to have slight J-point elevation in the anterior leads.
(The vital signs and results of the physical exam are not available.)
Approximately 2 hours later there is a slight change in ST-segment morphology and new T-wave inversion in lead aVL. A cardiologist is consulted via telemedicine at the tertiary care center and the decision is made to transfer the patient.
Concurrently with this decision the patient is given 3 doses of SL NTG with complete resolution of her symptoms.
The transport ambulance arrives and records the following 12-lead ECG.
Several more are recorded en route. Here's the ECG captured on arrival at the PCI-hospital.
Do you think this patient is having a STEMI? Why or why not?
Click HERE to check it out!
Kudos to the HeartRescue Project for developing this "Save a Life" Simulator!
This should go a long way toward preparing lay bystanders for the "shocking" reality of encountering a sudden cardiac arrest in the community. I think this is an excellent tool to leverage through social media so be sure to share with friends and family!
My only criticism is that there are no post-shock compressions.
I was just watching the "podmedic" Jamie Davis interview Physio-Control's VP of Marketing Cam Pollock and noticed another video of Jamie interviewing Ted Setla from Setla Films and First Responders Network about the Code STEMI Web Series.
You can watch the first two episodes of the Code STEMI Web Series and all the behind the scenes footage at CodeSTEMI.tv.
In this episode Tom Bouthillet sits down with Christopher Granger, M.D., Mayme Lou Roettig, R.N and James Jollis, M.D. from the RACE Program in North Carolina. In the course of our "unplugged" session some incredible insights are developed from one of the highest functioning STEMI systems in the United States!
On behalf of Team EMS 12-Lead (Tom Bouthillet, David Baumrind and Christopher Watford) I am pleased to officially acknowledge that the EMS 12-Lead blog won Judges' Choice for 2012 EMS Blog of the Year.
The total list of nominees can be found here. Lots of good reading can be found here!
Congratulations to Insomniac Medic who took home the Readers' Choice award.
Here are the submission criteria that were used to select the winners.
"Our judges will choose ten finalists from the first round of nominations. The finalists will then be eligible for a ‘Judge’s Choice’ prize as well as a ‘Reader’s Choice’ prize.
Judges will choose these finalists based on the following criteria:
- Calibre of posts relating to the Fire and/or EMS fields
- Frequency of posting Professionalism towards our service(s)
- Quality of content
- Longevity as a blogger
For the second part of the contest, readers will then be able to vote in our poll for their favorite blog, which will provide us with a ‘Reader’s Choice’ winner. The ‘Judge’s Choice’ winner will be ascertained by judges then considering the following criteria:
- Use of other online channels to promote their content
- Blog design
- Blogger creativity
- Reader engagement"
The judges were:
- Captain Willie Wines Jr. – IronFiremen.com
- Kelly Grayson – A Day in the Life of an Ambulance Driver
- Greg Friese – Everyday EMS Tips
- Rick Markley – FireRescue1.com
I'd say we didn't bribe them but I haven't checked with David and Christopher yet.
It's been a good year for the EMS 12-Lead blog and we'd like to thank all of our friends, colleagues, followers, fellow bloggers and podcasters, and everyone else who helps to make the EMS blogosphere (EMS 2.0) a dynamic environment where learning can be interesting and "cool" again.
We'll do our best to continue innovating, sharing awesome cases, hosting interesting guests, expanding into new media and challenging you in engaging and participatory ways!
Check out our archives here.
EMS is called to a 88 year old male with a chief complaint of chest discomfort.
On arrival the patient meets EMS at the front door. His skin is slightly pale and moist. He appears anxious.
- Past medical history: "Cardiac", pacemaker, hypertension, dyslipidemia
- Medications: Numerous, unavailable at the time of EMS evaluation
Paramedics lead the man to a chair and the assessment begins.
- Onset: 30 minutes prior to EMS arrival
- Provoke: Nothing makes the pain better or worse
- Quality: Poorly localized pressure
- Radiate: Does not radiate
- Severity: 7/10
- Time: Admits to previous episodes but unable to give details
Vital signs are assessed.
- RR: 18
- Pulse: 70
- NIBP: 140/92
- SpO2: 90 on RA
Breath sounds: Clear in the apexes, diminished in the bases.
No JVD or pitting edema.
The patient is placed on the cardiac monitor.
A 12-lead ECG is obtained.
The patient is placed on oxygen via NC @ 4 LPM and is removed to the back of the ambulance. An IV is initiated and the patient is given 0.4 mg NTG spray SL.
The pain subsides to 3/10.
En route an additional 12-lead ECGs is obtained.
And one more just prior to arrival.
Do you see anything here to be concerned about?
Photo credit: Kelly Arashin
"Team EMS-12 Lead" (Christopher Watford, Tom Bouthillet and David Baumrind) at the EMS 10 Awards
It's been an amazing week at EMS Today 2012! As you probably already know (if you've been following our Facebook page) I won an EMS 10 Award on Wednesday night.
I was nominated by our good friend David Hiltz from the American Heart Association (a previous EMS 10 Award honoree and well known for his work with HeartSafe Communites) and co-nominated by Associate Editors Christopher Watford and David Baumrind.
This is a tremendous honor but I'm very congizant that I couldn't do it without such awesome friends and mentors! The EMS 12-Lead blog and podcast would not be what it is without Christopher and David.
Photo credit: Chris Montera
"Podmedic" Jamie Davis, Tom Bouthillet and Ted Setla discuss the Code STEMI Web Series on the MedicCast
This week was also marked by the release of Episode 1 of the Code STEMI Web Series at First Responders Network! I've seen the first episode a couple of times but being there at the premier was really amazing!
Special thanks to Ted Setla and Chris Eldridge from First Responders Network and Erik Denny from Physio-Control (our indispensable partner on the road) for making this possible! I'm delighted to have been a part of it!
Episode 1 was very well received! In fact, a couple of top-notch EMS systems are very interested in having us come out to feature their STEMI systems and the locations sound amazing! So keep your fingers crossed. We'd love to continue this series!
If you haven't watched the first episode yet, what are you waiting for? CLICK HERE!
Photo credit: Dave Konig
Premier of the Code STEMI Web Series at the Physio-Control Learning Center
Kelly and I are having a wonderful time. We're seeing lots of old friends and making some new ones, too! EMS 2.0 has been called an idea and it's been called a movement. More than anything else we've come to realize it's about friendship and it's about relationships.
It may have started online but it's accomplishing some amazing things in the real world!