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Why we need health care reform

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Image credit: whitehouse.gov

I went to the emergency department with a kidney stone yesterday.

Here's the estimate I was provided at discharge.

  • ER Level 4: $4,631.94 
  • Insurance contractual discount: -$4,154.03
  • Adjusted estimated charges: $477.91
  • Estimated insurance responsibility: -$257.33
  • Patient co-pay: $125.00
  • Patient applied co-insurance: $95.58
  • Estimated patient responsibility: $220.58

So, I paid $220.58 on my way out the door (on a credit card). I imagine I'll also be receiving bills from the ED physician and radiologist.

What really amazes me about this estimate is the fact that $4,154.03 (almost 90% of the bill) was written off because of the contract between the hospital and Blue Cross.

Keep in mind that doesn't mean Blue Cross paid this amount. It just goes into oblivion. But it was a made-up number in the first place. No reasonable person believes that $4,631.94 is an appropriate amount of money for a visit to the emergency department.

Now imagine that I didn't have insurance. What would my bill have been? $4,631.94.

So, all you folks out there that buy into the propaganda that we don't need health care reform, be glad you have insurance. The system is stacked against the most vulnerable.

Posted by on January 18, 2012 • Filed under: patient-management • Tagged: ,

Behind the scenes video from the Code STEMI web series

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Some excellent behind the scenes video has been posted at the Code STEMI web series.

Click HERE

Mayme Lou Roettig RN, MSN and Chris Granger, MD from Duke University (RACE program North Carolina) explain how first responders are a critical part of the early management of acute STEMI. “Things are shifting more and more into paramedics playing the key role in providing the initiation of these time-dependent processes for improving care.”

Click HERE.

Michael Hibbard, M.D. talks about the importance of technology in maximizing the benefit of the prehospital 12-lead ECG. Many patients have baseline abnormalities such as bundle branch blocks, conduction defects, or persistent ST-elevation from previous heart attacks. “It’s a lot easier to determine going from normal to abnormal than to determine abnormal to more abnormal.”

Click HERE.

Jodi Doering, R.N. from Mission: Lifeline South Dakota shares what it's like helping build regional systems of care in a rural state. "This is such a once in a lifetime opportunity which is why I'm in this role. I live in a rural environment. I live 40 miles from the nearest Critical Access Hospital and about 120 miles from the nearest PCI facility. This is me. This is my family. We need to have not only plan A but plan B and plan C in South Dakota."

Click HERE.

STEMI survivor Forrest “Mick” Stanton encourages a neighbor to get his chest discomfort checked out and saves his life. "They were calling for the air ambulance and took him to the heart hospital in Sioux Falls. He got home 2-3 days ago. A triple bypass he had. His main artery — his widow maker artery — was so closed up they said there was probably no more than a hair's width — the width of a hair — left in that." 

Click HERE.

Arthur Reba, M.D. F.A.C.C. talks about the problem of patient delay in seeking treatment for acute myocardial infarction and the importance of considering total ischemic time. "We know why people delay but how do we get this message out? Public education campaigns have not been very effective…We need a very innovative way." 

Click HERE.

Lt. Stuart Debrowsky and Lt. Steve Worden talk about Dearborn Fire Department, what it's like to walk in your father's footsteps, and their commitment to being good at both EMS and fire suppression. "Nobody here got hired saying, 'You're a great paramedic don't worry about that fire stuff' or 'you're big enough to carry the truck around the block don't worry about that medical stuff'. From day one when you put that patch on your shoulder you're expected to have a high standard in both fields." 

Click HERE.

National Director for AHA Mission: Lifeline Chris Bjerke, R.N., B.S.N. talks about the American Heart Association and evidence-based care for acute STEMI. "Not all patients can go directly for primary PCI to open up that blood vessel which is what they really need. So for those patients that are located where they can't get to primary PCI within that recommended timeframe — which just went from 90 minutes to 120 minutes — what we want our facilities to do is look at those patients and determine if they would be eligible to receive fibrinolytics." 

Click HERE.

Interventional cardiologist Tim Henry talks about the state-wide STEMI system in Minnesota. "What we've shown with this program is by having a standardized protocols and individualized transfer plans for that community and that hospital, you can effectively transfer patients up to distances of 210 miles away with outcomes that are identical for those patients who present to that PCI hospital itself."

 

*** SPECIAL ANNOUNCEMENT ***

The premier episode of the Code STEMI web series

will debut at EMS Today 2012!

Posted by on January 10, 2012 • Filed under: ems-topics, patient-management • Tagged:

The politics of transporting a patient in a fire engine

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Image credit: WJLA-TV News 7

The EMS blogosphere, Facebook fan pages, and internet forums are buzzing with discussion (and criticism) of the firefighters who transported a pediatric asthma patient in a fire engine rather than wait for the ambulance.

Apparently a 5 year old girl named Christina Luckett was having a severe asthma attack to the point where volunteer firefighters (at least one of whom was paramedic trained) started chest compressions and mechanical ventilations. I wasn't there but I have my doubts as to whether or not the patient was truly pulseless but that's besides the point.

The ETA of the transport ambulance was reported to be 5-minutes. The hospital was 2.8 miles away down a highway. Rather than wait for the ambulance to arrive, they placed the child in the back of a fire engine and transported the patient to the hospital, continuing care en route.

She lived. 

Fantastic, right? Well, not exactly. Plenty of folks are second-guessing the actions of these firefighters. Scott Kier called it 100% absolutely wrong. None other than Thom Dick commented on JEMS Connect: "Really, 5 minutes? I congratulate the crew and the Good Lord for their outcome. But I generally wish first responders would just do their own jobs well. This makes me think of the prospect of a transport medic fiddling with a pump panel, over an engineer's shoulder. There's no ME in TEAM."

That seems a bit harsh to me. I considered the example of the transport medic fiddling with a pump panel over an engineer's shoulder for about 24 hours and ultimatley reached the conclusion that the parallel doesn't work. This would be more like a paramedic in a third service agency who also happened to be a firefighter arriving at the scene of a structure fire on an ambulance and making a rescue prior to the arrival of the first-due engine. 

If that happened I would hope that no one from fire department wouldn't say, "You know, I thank the Good Lord for this rescue but I honestly wish the transport medic would leave the firefighting to the real firefighters." Ummm…. you mean the ones who weren't there? Yeah, those ones. You're right, Mr. Dick. There's no "me" in team.

That means we can all be happy when a teammate scores a goal.

The Social Medic (David Konig) gets it. "Rules can be wrong. That’s a possibility few people take into consideration, but an important possibility we always have to look at. Especially when we are leaders looking at the actions of our crews, which is why it was refreshing to see the leadership of Prince George County recognize the efforts of their crews with commendations instead of condemnations."

What's important is that Christina Luckett is alive.

See also:

Firefighters honored for saving girl's life

Firefighters ignore the rules, save girl

5-year-old Md. girl thanks firefighters who saved her life

5-year-old thanks Md. firefighters for breaking rules

Feel free to leave a comment below. If you include a URL in the comment it will revert to moderated status which will cause a delay.

Posted by on January 5, 2012 • Filed under: ems-topics • Tagged: , ,

AHA changes acceptable time to primary PCI from 90 to 120 minutes for acute STEMI

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Thanks to Ivan Rokos, M.D. for pointing out an important change in the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention.

Photo credit: Code STEMI Web Series at First Responders Network

For years now many have complained about the AHA's official recommendation that primary PCI for acute STEMI be accomplished within 90 minutes of first medical contact (which can be a Critical Access Hospital 1 or 2 hours away from a PCI hospital or a volunteer BLS EMS system in the rural setting).

There are two main reasons the 90-minute standard for rural patients is problematic.

You could argue that it's time to change the recommendation from 90-minutes to 60-minutes for walk-in patients at PCI hopsitals (which I agree with). But even so, for many patients the mortality benefit of primary PCI over fibrinolytic therapy persists well past 90-minutes.

It's also important to remember that many patients have contraindications to fibrinolytic therapy, meet high-risk criteria (pulmonary edema, hypotension, tachycardia) that make primary PCI necessary, and that up to 30% of patients who receive fibrinolytic therapy will have "failed fibrinolysis" (their symptoms and ST-elevation will not resolve after being given clot-busing drugs indicating that they have not been reperfused).

In other words, all hospitals need (in the words of Jodi Doering, R.N.) "a Plan A, a Plan B and a Plan C." This is far too important to leave to chance. There is mounting evidence that transfer PCI takes too long and that rural hospitals are not achieving door-in to door-out (DIDO) times of less than 30-minutes so there is plenty of room for improvement and my intent here is not to blame the guidelines for preventable delays.

Having said that it's simply not possible for some patients who would benefit from primary PCI to have their infarct-related artery opened up on the cath table within 90-minutes of first medical contact (which, let's face it, is not even being measured in the vast majority of STEMI "systems" — the word "systems" in scare quotes because if it's not measured it's not a system.)

Which brings me to the 2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (free full text).

5.2.2.2. Primary PCI of the Infarct Artery: Recommendations

  • Class I

    1. Primary PCI should be performed in patients within 12 hours of onset of STEMI. (Level of Evidence: A)

    2. Primary PCI should be performed in patients with STEMI presenting to a hospital with PCI capability within 90 minutes of first medical contact as a systems goal. (Level of Evidence: B)

    3. Primary PCI should be performed in patients with STEMI presenting to a hospital without PCI capability within 120 minutes of first medical contact as a systems goal. (Level of Evidence: B)

    4. Primary PCI should be performed in patients with STEMI who develop severe heart failure or cardiogenic shock and are suitable candidates for revascularization as soon as possible, irrespective of time delay. (Level of Evidence: B)

    5. Primary PCI should be performed as soon as possible in patients with STEMI and contraindications to fibrinolytic therapy with ischemic symptoms for less than 12 hours. (Level of Evidence: B)

  • Class IIa

    1. Primary PCI is reasonable in patients with STEMI if there is clinical and/or electrocardiographic evidence of ongoing ischemia between 12 and 24 hours after symptom onset. (Level of Evidence: B)

  • Class IIb

    1. Primary PCI might be considered in asymptomatic patients with STEMI and higher risk presenting between 12 and 24 hours after symptom onset. (Level of Evidence: C)

  • Class III: HARM

    1. PCI should not be performed in a noninfarct artery at the time of primary PCI in patients with STEMI without hemodynamic compromise. (Level of Evidence: B)

The following statement accompanies the change in guidelines:

"Several reports have shown excellent outcomes for patients with STEMI undergoing interhospital transfer where first medical contact–to-door balloon time modestly exceeded the systematic goal of <90 minutes. In these reports, the referring hospital and the receiving hospital established a transfer protocol that minimized transfer delays, and outcomes were similar to those of direct-admission patients. On the basis of these results, the PCI and STEMI guideline writing committees have modified the first medical contact–to-device time goal from 90 minutes to 120 minutes for interhospital transfer patients, while emphasizing that systems should continue to strive for times ≤90 minutes. Hospitals that cannot meet these criteria should use fibrinolytic therapy as their primary reperfusion strategy."

This is an important change that every state, Critical Access Hopsital and rural EMS system should make note of and take steps to act upon.

The lives of our rural STEMI patients may depend upon it! 

See also:

AHA Mission: Lifeline

Code STEMI Web Series at First Responders Network

Posted by on December 30, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

The importance of data collection and sharing

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Cross-posted from the Follow the Crew blog at CodeSTEMI.tv.

We had a wonderful time in Dearborn. I was welcomed as a brother at Dearborn Fire Department and got to learn about an awesome fire-based EMS system which made me happy. In addition, we met some motivated and passionate caregivers at Oakwood Hospital.

They are doing some awesome things in Dearborn and it's clear they're doing a great job treating STEMI patients. However, there's one area that created some cognitive dissonance for me and it's data sharing (or lack thereof) between the hospital and the EMS system.

One of the first questions I asked when we arrived at Oakwood was whether or not they had a multi-disciplinary STEMI meeting. "Absolutely!" we were told. Every Wednesday morning and all the stakeholders were present from emergency medicine, nursing, cardiology and administration.

"What about EMS?" Blank stare.

Finally I was told, "We have an EMS liaison." Unfortunately, it soon became clear that it wasn't enough. The bottom line is that the EMS Chief does not have a seat at the adult table in this hospital. That doesn't mean it isn't a great hospital.

I dragged my feet before writing this blog post because I don't want to cause any offense or ruffle any feathers. However, we are the First Responders Network. We tell stories from the point of view of EMS. The bottom line is that everyone we met at Oakwood talked about their extraordinary door-to-balloon times (less than 60 minutes and even less than 40 minutes) but we still haven't seen it on paper in context.

The door-to-balloon times at Hilton Head Hospital hang on the wall of the emergency department (warts and all).

As Carl Sagan said, "Extraordinary claims require extraordinary evidence." Another quote from Thom Dick comes to mind. "Your agency is not the best in the nation. It's not the best in the state, either. In fact, it's probably not very good at all, unless you can prove it." We're not doing a commercial for Oakwood Hospital we're telling the story of their system which includes EMS and their interaction with EMS.

Every EMS system has room for improvement and my own EMS system is far from perfect. We have our own politics and our own struggles. In some areas Dearborn Fire Department and Oakwood Hospital are better than we are. Having said that, when it comes to quality and process improvement I'm a bit of a skeptic, and justifiably so. I'll spare you the details but I still don't know the actual "call received" time in my own EMS system.

The bottom line is, you might be the best EMS system or the best hospital on Earth.

Don't tell me. Show me.

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

90 year old male CC: “Possible stroke” – Conclusion

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This is the conclusion to 90 year old male CC: "Possible stroke". You might want to go back and familiarize yourself with the details of the case. Let's take another look at the 12-lead ECG.

Now with the computerized interpretive algorithm.

On Facebook I had asked whether or not this ECG showed signs of ischemia.

This ECG shows ST-depression in the lateral leads (I, aVL, V5 and V6) and modest ST-elevation in the right precordial leads (V1-V3). That's because it shows a strain pattern or secondary repolarization abormality due to left ventricular hypertrophy.

According to at least one study this is the most common cause of ST-elevation in chest pain patients. Hence, it is a very important pattern for paramedics to recognize in the field (although it's rare for LVH with strain to fool the GE-Marquette 12SL interpretive algorithm).

How would we know it's a strain pattern?

When we look at any 12-lead ECG we should consider the Six Step Method (or some other standardized approach).

Here we see that the patient is in sinus rhythm with a normal frontal plane axis. The QRS duration is < 120 ms so it's not a bundle branch block or paced rhythm.

At this point we might pick up on ST-depression in the lateral leads but it's too early to call it ischemia. We need to consider other possible causes. Since left ventricular hypertrophy often presents with ST-depression in the lateral leads that is a likely culprit.

Let's add the depth of the S-wave in lead V2 with the height of the R-wave in lead V5 (or V6 — they're both about the same). Is the result equal or greater than 35 mm?

Yes!

You don't need calipers for this because it doesn't have to be perfect. 35 mm is 7 large blocks so eye-ball it. The S-wave in lead V2 is at least 4 large blocks deep (it's actually more than 5 but this is the "fast and dirty" method) and the R-wave in lead V6 is at least 3 large blocks in amplitude. That's greater than 35 mm so you've met the criteria.

There are other criteria for LVH but this is the most important for ruling out STEMI mimics because LVH is usually an anterior STEMI mimic so the most important issue here is the depth of the S-waves in the right precordial leads (V1-V3). With a "strain pattern" the deeper the S-waves the more pronounced the secondary ST-T abnormality in the opposite direction.

Conversely, the taller the R-waves, the more pronounced the ST-depression and T-wave inversion. A lot of people talk about the shape of the ST-segments and T-waves in the presence of LVH, how it should be asymmetrical and upwardly or downwardly concave. That's ususally true but it's not always the case.

In this case the "strain pattern" is fairly modest. The ST-elevation in V1-V3 is not particularly impressive. Other times the result can be quite profound.

If you're still not clear on what a "strain pattern" is with LVH, take a look at the precordial leads. The QRS complex starts out negative in lead V1 and ends up positive in lead V6. The transition lead is lead V4 (which is equiphastic). As the QRS complex transitions from negative to positive, the T-wave transitions from positive to negative.

That's what we call a "widened QRS/T angle" which means that there is more than 100 degrees difference between the QRS axis and the T-wave axis. Let's take a look at the computerized measurements. The QRS axis is 16 degrees and the T-wave axis is 148 degrees.

To be much simpler about it, with a strain pattern positive QRS complexes have negative T-waves and negative QRS complexes have upright T-waves. (You should not include isoelectric or equiphasic QRS complexes in this analysis).

The general appearance of this 12-lead ECG is one of T-wave discordance. That's a finding that should almost always make you pause and consider that you're dealing with a secondary ST-T abnormality — in other words a STEMI mimic.

This patient received a fairly extensive workup for his near-syncope including a CT scan and nothing was found. He was discharged from the emergency department.

You can find previous posts about left ventricular hypertrophy here.

See also:

The Code STEMI Web Series comes to First Responders Network! 

Posted by on December 6, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

Code STEMI Web TV Series in South Dakota – That’s a wrap!

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I just got back from South Dakota and principal photography for the 2nd episde of the Code STEMI web TV series is complete! What an awesome time! 

We attended the 2nd Annual South Dakota STEMI Summit, visited the two major health systems in South Dakota, interviewed EMTs, paramedics, nurses and physicians, met a STEMI survivor and took in the hospitality! 

The platform for the Code STEMI web series is here. The "follow our crew" blog is here. You can find our Flickr feed with lots of "behind the scenes" images here.

Special thanks to Setla Films, Mission: Lifeline South Dakota, Avera McKennan hospital, Sanford USD Medical Center, Prairie Lakes Healthcare Sysem, Watertown Fire Department, and our sponsor Physio-Control! 

Next stop: Dearborn, Michigan!

*** UPDATE ***

Behind the scenes footage from AHA Scientific Sessions 2011 in Orlando: Mayme Lou Roettig, RN, MSN and Chris Granger, MD (Duke University and North Carolina's RACE program) talk about the critical role EMS plays in the early treatment and triage of acute STEMI patients here.

“Things are shifting more and more into paramedics playing the key role in providing the initiation of these time-dependent processes for improving care.”

Posted by on December 3, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , ,

90 year old male CC: “Possible stroke”

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EMS responds to a 90 year old male with a "possible stroke".

On arrival the patient is found sitting on the toilet (lid down). His spouse states that he had walked outside to retrieve the newpaper when he lost his balance and skinned his knee. She helped him inside and sat him down on the toilet in the bathroom when his eyes rolled back in his head and he started "shaking all over".

At the time of evaluation he is conscious, alert and oriented to person, place and time. He remembers falling while retrieving the newspaper but denies losing consciousness in the bathroom.

His skin is pale and diaphoretic.

He denies chest pain or shortness of breath.

Past medical history: Mild cognitive impairment, HTN, dyslipidemia

Medications: Metropolol, donepezil (Aricept), lovastatin (Mevacor)

Vital signs are assessed.

  • RR: 16
  • Pulse: 116
  • NIBP: 115/53
  • SpO2: 96 on RA

Breath sounds clear bilaterally.

Neuro exam: No facial droop, equal smile, clear speech. Slight pass pointing on the right side.

The cardiac monitor is attached which shows sinus rhythm, borderline sinus tachycardia.

A 12-lead ECG is captured.

What is your impression of this ECG?

See also:

90 year old male CC: "Possible stroke" – Conclusion

Posted by on November 29, 2011 • Filed under: ems-health-safety • Tagged: , , , , , , , ,

Code STEMI Web Series – EMS 12-Lead Podcast Episode #6

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EMS 12-Lead podcast – Episode #6 – Code STEMI Web Series (Special Episode)

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Podcast: Play in new window | Download

As you probably already know if you've been following EMS 12-Lead or First Responders Network on Twitter or Facebook, we're working on a new web series called Code STEMI.

We just got back from AHA Scientific Sessions 2011 in Orlando which was our first location. We met some incredibly passionate people and had some amazing experiences! 

Ted Setla, Jamie Davis and I discussed it on a special episode of the EMS 12-Lead podcast.

Ted Setla
Executive Producer of the Code STEMI Web series
Setla Films
First Responders Network

Jamie Davis
Executive Producer of the EMS 12-Lead podcast
MedicCast
ProMed Network

The first teaser for the series has also been released at the First Responders Network.

Click HERE to watch.

Chris "the Dridge" Eldridge, Ted Setla and Tom Bouthillet
at AHA Scientific Sessions 2011

Posted by on November 21, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , ,

Philips introduces the HeartStart FR3 Defibrillator

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Believe it or not I've only used an AED once in my entire career and I wasn't even on duty! It was over 10 years ago on a commercial jet airliner. It was a nice little AED complete with an ECG screen (it's nice to see what you're shocking) made by Philips. Afterwards I did an internet search and my best guess at the time was that the AED on the plane was the HeartStart FR2 or FR2+. 

Even though I had never used this particular AED before it was remarkably similar to the Laerdal AED Trainer. The device worked flawlessly and led to a positive outcome. Fast forward to 2011 and Philips has announced the HeartStart FR3, a device that Philips promises to make life-saving faster, easier and better. 

Features of the device:

  • Small, lightweight and rugged
  • Reduced deployment time (automatically powers on when opened and pads pre-connected)
  • Patient-specific guidance (chest compressions vs. shock)
  • Bright, high-resolution color LCD for use in noisy environments
  • Data management solution with efficient event review

See demo video here. The Philips product page on JEMS is here. Connect on Facebook here.

Tom Bouthillet and ems12lead.com have no conflict of interest with Philips Healthcare although we have noticed an ad for this product running occasionally on our blog which means we receive some modest ad revenue if you click on it. So feel free!

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

Product Reviews from EMS World Expo 2011 Part 2 – EMS 12-Lead Podcast Episode #5

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EMS 12-Lead podcast – Episode #5 – Product Review from EMS World Expo 2011 (Part 2)

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Podcast: Play in new window | Download

In this episode Tom Bouthillet, David Baumrind, Executive Producer Jamie Davis (MedicCast and ProMed Network) and Rob Theriault (Paramedic Tutor and EMS EduCast) discuss 12-lead ECG interpretation, regional systems of care for acute STEMI, and quality and process improvement for cardiac arrest.

Specifically we discuss Physio-Control's CODE STAT Suite software and ZOLL Medical Corp's CPR Dashboard and See Thru CPR.

Rob Theriault
Paramedic Tutor
EMS EduCast
YouTube Channel (highly recommended)

"Podmedic" Jamie Davis
Executive Producer of the EMS 12-Lead podcast
MedicCast
ProMed Network

 

See also:

Product Reviews from EMS World Expo 2011 Part 1 – EMS 12-Lead Podcast #4

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

Product Reviews from EMS World Expo 2011 Part 1 – EMS 12-Lead Podcast Episode #4

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EMS 12-Lead podcast – Episode #4 – Product Review from EMS World Expo 2011 (Part 1)

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Podcast: Play in new window | Download

In this episode Tom Bouthillet and David Baumrind are joined by Executive Producer Jamie Davis (MedicCast and ProMed Network) and Rob Theriault (Paramedic Tutor and EMS EduCast).

We discuss the ReadyLink 12-Lead ECG by Physio-Control , the RescueNet 12-Lead by ZOLL Medical Corp., 12-lead ECG interpretation, regional STEMI care, and ECG transmission in general.

Rob Theriault
Paramedic Tutor
EMS EduCast
YouTube Channel (highly recommended)

"Podmedic" Jamie Davis
Executive Producer of the EMS 12-Lead podcast
MedicCast
ProMed Network

See also:

Previous coverage of the ReadyLink 12-Lead ECG by Physio-Control can be found here, here and here.

Previous coverage of the RescueNet 12-Lead ECG by ZOLL Medical Corp. can be found here.

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

83 year old male CC: “Cardiac patient in distress” – Conclusion

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This is the conclusion to 83 year old male CC: "Cardiac patient in distress". You may wish to check out the previous post for details about the patient's clinical presentation.

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

This ECG shows a regular narrow complex tachycardia at a rate of 170.

Could it be sinus tachycardia? One of the "rules of thumb" for the maximum sinus rate is 220 minus age. This patient is 83 years old. 220 – 83 = 137. Granted, this is just a rule of thumb so I'm sure expections exist but 170 is a good distance from 137.

I agree with some commenters that atrial fibrillation can appear regular at very fast heart rates. However, a trained eye can still pick up on some irregularity with rates < 200. You can also use calipers or fold the ECG paper in half and line up the R-waves to verify that the rhythm is regular.

In this case the rhythm is clearly regular which rules out atrial fibrillation but not 2:1 atrial flutter.

In lead V1 we can see atrial complexes (inverted or "retrograde" P-waves) after the QRS complex. We're narrowing in on the mechanism of this tachycardia. If we play the odds there's a good chance this is AV nodal reentrant tachycardia (AVNRT). However, it could still be 2:1 atrial flutter or the less common (but not uncommon) orthodromic AVRT.

You will recall that the paramedics documented "cannon waves" that corresponded to the heart rhythm. Some of you asked, "What are cannon waves?" Cannon waves are pulsations that are visible in the external jugular veins when the right atrium contracts against a closed AV valve. 

Normally atrial systole is an end-diastolic event (the so-called "atrial kick"). When the P-waves follow the QRS complexes the pressure generated by ventricular systole have already forced the AV valves shut. Hence, the atria contract against closed AV valves and back pressure creates a visible "wave" or pulsation that is transmitted back up the superior vena-cava and to the external jugular veins.

Here's an example to give you an idea although this patient's external jugular veins are severely distended and the heart rate is much slower. For the current case study the patient's cannon waves were fast, regular and visible just above the clavicle on the right side.

Does determining the exact mechanism of the tachycardia matter in the field? No, because that's not possible. We don't have an EP lab. However, we can carefully document the arrhythmia before and after treatment on those occasions where the patient is not critically unstable! 

The first thing the treating paramedics did was put this patient in a supine position and place him on oxygen which perked him up a little bit. Remember, BLS before ALS. I am aware of the controversy associated with placing a patient in Trendelenberg. However, I think we can all agree that lying flat is better than sitting or standing when you're hypotensive! 

Vagal maneuvers were attempted (the patient was asked to "bear down" and blow into an empty syringe) with no effect to the tachycardia. An IV was started but unfortunately the only good peripheral access was a 20 G IV in the back of the left hand.

Many (perhaps most) lf you recommended synchronized cardioversion for this patient. I have no quarrel with that. However, I do know that it's easier to say than do when you have a conscious, talking patient in the back of the ambulance. It also helps if you carry the right drugs and don't have to play "mother may I" with online medical control.

In this case paramedics pushed the PRINT button and gave 6 mg of adenosine followed by a 5 ml "flush" of 0.9% NS. It took more than 30 seconds to have an effect (Clinical tip: always follow adenosine with a minimum of a 20 ml flush) but here's what happened. The next four strips are continuous.

With the conversion to sinus rhythm the patient felt much better.

Vital signs were re-assessed.

  • RR: 18
  • Pulse: 100
  • NIBP: 138/81
  • SpO2: 100

A post-conversion 12-lead ECG was captured.

The patient was transported to the hospital in a position of comfort.

No further information is available.

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

EMS World Magazine names ReadyLink 12-Lead ECG as one of the Top Innovations of the Year

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EMS World Magazine has named the ReadyLink 12-Lead ECG by Physio-Control as one of the Top Innovations of the Year. The award was presented at the New York State EMS Symposium – Vital Signs 2011, in Syracuse, NY.

ReadyLink enables basic life support EMS teams to acquire and transmit a patient’s 12-lead ECG to hospitals using Physio-Control’s LIFENET System, a cloud-based data management network for remote physician interpretation and decision support, providing clinicians earlier insight into a chest pain patient’s condition, especially in rural areas with limited access to advanced life support providers.

Physio-Control's Frank Piraino at Vital Signs 2011 

Previous coverage:

Physio-Control to launch ReadyLink 12-Lead ECG — new device will tie rural areas into regional systems of care

ReadyLink 12-Lead ECG by Physio-Control (Update)

Posted by on October 19, 2011 • Filed under: ems-topics • Tagged: ,

83 year old male CC: “Cardiac patient in distress”

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EMS is dispatched to a "cardiac patient in distress".

On arrival paramedics are led to the bathroom where the patient is found sitting on a foot stool. He is conscious but appears acutely ill. Skin is pale and he is slumped over. He states that he feels weak.

Past medical history: High blood pressure, high cholesterol, valve surgery.

Medications: Numerous but his spouse can't locate them. When the patient is asked for his medication list he states, "Ask my wife."

Vital signs:

  • RR: 18
  • Pulse: Rapid and weak
  • NIBP: 85/53
  • SpO2: 99 on RA

Breath sounds: Clear bilaterally.

Cannon waves are noted at the patient's neck.

The cardiac monitor is attached.

A 12-lead ECG is captured (retrieved here from the LIFENET).

What is your impression of the patient's ECG?

How would you treat this patient?

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

AEDs and Emergency Response Plans in Schools – EMS 12-Lead Podcast Episode #3

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EMS 12-Lead podcast – Episode #3 – Syncope and Sudden Death in Student Athletes Part 3 – AEDs and Emergency Response Plans in Schools

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In this episode Tom Bouthillet, David Baumrind and Christopher Watford and joined by Monica Kleinman, M.D. the Chair of the AHA's Emergency Cardiovascular Care Committee.

Monica Kleinman, M.D.
Chair of the AHA's Emergency Cardiovascular Care Committee
Photo credit: www.childrenshospital.org

See also:

Denver schools begin installing AEDs at every facility

School district rejects life-saving technology

LA teen cheerleader dies of cardiac arrest during football game

Coaches save 12-year-old Frisco girl with defibrillator

Previous podcast featuring Dr. Monica Kleinman:

2010 AHA ECC Guidelines with Monica Kleinman, M.D.

Resuscitation Science:

Effectiveness of Emergency Response Planning for Sudden Cardiac Arrest in United States High Schools With Automated External Defibrillators

Other media:

 

Medical Emergency Response Planning Schools

 

View more presentations from David Hiltz

 

 

Posted by on October 4, 2011 • Filed under: ems-topics, patient-management • Tagged: , ,

RescueNet 12-Lead by ZOLL Medical Corporation at EMS World Expo 2011

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Photo credit: EMSWorld.com

ZOLL Medical Corp has some smart people working on their products and a couple of innovations were standouts at EMS World Expo 2011.

The first is the RescueNet 12-Lead.

For a long time I've been preaching about the importance of making 12-lead ECG transmission simple, cost-effective, and interoperable with existing technologies.

As our good friend Ivan Rokos, M.D. said to heartwire back in April 2009:

"It seems incredible that we can email a photograph around the world, but we haven’t yet found an easy way of transmitting an ECG to a nearby hospital."

The reality is that the technology was always there but industry has had little incentive to make it cost-effective or interoperable. Better to charge subscription fees for ECG transmission and make sure that customers are locked into proprietary software. That way you're more likely to continue using Brand X when it's time for a monitor upgrade. After all, now you're committed to a platform. A solution.

In what seems a huge leap of faith, ZOLL Medical Corporation has unlocked the doors. Here's Amy Smith, ZOLL's Director of Data Integration on the EMS Leadership podcast.

"RescueNet 12-Lead is the first fully web-based 12-lead management system. No proprietary software to install. All we need is an internet connection and a web browser to allow EMS and hospitals quick, rapid access anywhere within the world to their critical 12-lead data…ZOLL is offering this service at no cost to EMS and hospitals as an extension of the care we provide through our defibrillator devices." 

When asked if other monitors could use this platform for ECG transmission:

"Absolutely. ZOLL has architected this with open architecture in mind. We will be making available to all of the defibrillator vendors in this market space our APIs that will give them the opportunity at no cost to them to also transmit their 12-lead data into the system. So where we have STEMI regions that use multiple devices…they have an opportunity to use a single software system to receive and manage those 12-leads regardless of their defibrillator devices." 

I was so impressed with this that I mentioned it to Jon Cloutier (Marketing Manager for EMS) who said, simply, "We listened." 

Yes, Jon. You did! 

I went over to the ZOLL both and watched as Amy transmitted a 12-lead ECG from a ZOLL M-series monitor to the RescueNet 12-Lead with a simple cell phone connection.

I said, "Looks good! Can you forward it to my email?" She said, "Absolutely!" Moments later she had entered my email address into the computer and my Droid X vibrated in my pocket.

The 12-lead was attached as a 98K .pdf document.

Piece of cake! 

You couldn't ask for much more. It's nice to see ZOLL step up to the plate and solve this problem. Clearly ZOLL is looking at regional STEMI systems and seeing customers to be served rather than cows to be milked. That's a huge gesture of good faith on their part and will go a long way toward building trust between ZOLL and their customer base.

Bravo! 

See also:

Amy Smith from ZOLL on RescueNet 12-Lead with EMS Leadership Podcast

Jon Cloutier From Zoll Shares Innovations at EMS Today 2011

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

ReadyLink 12-Lead ECG by Physio-Control (update)

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Now that I'm starting to get caught up on my regular duties after my recent trip to EMS World Expo 2011 there are a few products I'd like to highlight from the trip.

The first is Physio-Control's ReadyLink 12-Lead ECG.

You may recall that Physio-Control allowed ems12lead.com the privilege of announcing the launch of this product back at the beginning of August.

One thing I know now (that for whatever reason I didn't understand at the time) is that the ReadyLink 12-Lead ECG has a monitor screen! 

I snapped this photo with my Droid X on the show floor at EMS World Expo 2011.

Apparently the monitor screen is so that basic EMTs can tell if there is wandering baseline, loose lead or muscle tremor artifact. However, to me this is a big deal!

I can imagine the ReadyLink 12-Lead ECG being placed along side AEDs on commercial jet airliners. At any rate, I just wanted to clarify that the ReadyLink 12-Lead ECG has a monitor screen for anyone who, like me, thought it did not.

You will recall that when we announced the product launch we called the the ReadyLink 12-Lead ECG a "game changer" and so it is for rural systems that can now be tied into existing systems of care that are already using the LIFENET.

This is especially important in light of recent evidence that while PCI centers have done an amazing job shortening door-to-ballon times since the advent of the D2B Alliance, there are still significant delays for STEMI patients transferred from non-PCI hospitals.

That shouldn't be a surprise to anyone with a special interest in regional systems of care for acute STEMI.

More than 34% of patients transferred for PCI had a delay in total treatment time (> 120 minutes from presentation at initial hospital). The reasons for the delay included:

  • Awaiting transportation (26%)
  • Emergency department delays (14%)
  • Diagnostic dilemma (9%)
  • Cardiac arrest (6%)

Keep in mind this does not include prehospital time prior to presentation at the initial hospital.

To measure these delays correctly would require that we measure from 9-1-1 call to reperfusion. But let's put that issue aside for the time being.

The point is that 40% of the delays from referring hospitals could be completely eliminated if EMS was capable of identifying acute STEMI in the fiend and bypassing them altogether in the first place.

Even without that there are opportunities for improvement for the transferring hospitals and EMS needs to be a part of that solution (since 50% of acute STEMI patients self-report to non-PCI hospitals).

There is no acceptable reason that an acute STEMI patient should be sitting around waiting for a transport ambulance if the local 9-1-1 system has a unit available.

That's a totally legitimate emergency call and EMS systems that "don't do interfacility transport" need to reconsider their policy for life-threatening emergencies (like acute STEMI) where every minute counts.

Posted by on September 25, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , ,

12-Lead ECG Challenge app now available for Android and Apple iOS

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In a previous review of the ACLS Review app by Limmer Creative I announced that I was working together with Limmer Creative to create a 12-Lead ECG Challenge app.

I'm pleased to announce that the app is now available for Android and Apple iOS! The product made its debut at EMS World Expo 2011 in Las Vegas.

As chance would have it I was there for other reasons and my good friends Ted Setla and Justin Schorr of the First Responders Network were kind enough to interview me about the app.

Here's how it works.

The app has 150 12-lead ECGs that were taken from actual patient encounters.

The user of the app is given a brief scenario. For example, a 95 year old female with a chief complaint of altered level of consciousness.

You can tap on the little magnifying glass to enlarge and expand the 12-lead ECG.

Once you think you know the answer you tap the ANSWER button, the card flips, and the answer text comes up along with (in most cases) an ANSWER graphic.

In this case we are dealing with a bifascicular block (right bundle branch block and left anterior fascicular block) as evidenced by the supraventricular rhythm with a QRS duration > 120 ms, the RBBB morphology in lead V1 and a left axis deviation (QRS complexes positive in lead I and negative in leads II and aVF).

The 12-Lead ECG Challenge app strongly emphasizes acute STEMI and the STEMI mimics (including benign early repolarization, left ventricular hypertrophy, paced rhythm, left bundle branch block, pericarditis, left ventricular aneurysm, hyperkalemia, hypothermia, WPW and Brugada) so it's a great study tool to help paramedics minimize false positive cardiac cath lab activations.

For example, here's an answer graphic that demonstrates the relevant findings for a patient whose 12-lead ECG was consistent with pericarditis.

The app is priced at $4.99, a bargain when you consider that online 12-lead ECG tutorials start at around $45.00. Our goal was to appeal to a world-wide market and make it affordable for everyone.

You can download it here:

(Android)  (Apple iOS)  (Web Based)

If you like the app (or even if you don't) feel free to leave a review, here or at the Android Market or Apple Store.

See also:

The Only 12-Lead ECG App You’ll Ever Need – The Social Medic

Posted by on September 23, 2011 • Filed under: ems-topics, patient-management • Tagged: , , ,

Conclusion to 88 year old male CC: Chest pain

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This is the conclusion to 88 year old male CC: Chest pain. You may wish to review the previous post for the history and clinical presentation.

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

Now with the computerized interpretation.

This 12-lead ECG shows bifascicular block and is very suspicious for acute STEMI.

The first thing that jumps out at me when I look at this 12-lead ECG is the concordant T-wave in lead V2.

With right bundle branch block (RBBB) the T-wave should be deflected opposite the terminal (last) wave of the QRS complex. Because the QRS complex ends in an R-wave the T-wave should be negative. However, in this case it is positive. This is sometimes referred to as "pseudo-normalization" of the T-wave with RBBB. You will also note that the ST-segment is slightly elevated.

Now let's take a closer look at the high lateral leads I and aVL.

Do not let your eye be fooled! I have noticed that in the setting of RBBB the S-wave is often "lifted" when ST-elevation is present. That can create the illusion that the ST-segment is isoelectric. In this case, if you look carefully you will see that the J-point is clearly elevated.

It's debatable as to whether or not 1 mm of ST-elevation is present in the high lateral leads but some ST-elevation is present. Remember, the conventional criterion of 1 mm of ST-elevation in 2 or more contiguous leads is a gross oversimplification. However, computerized interpretive algorithms obey the rules and this ECG has not triggered the ***ACUTE MI SUSPECTED*** message (yet).

When ST-elevation is present in the high lateral leads (I and aVL) we should inspect the inferior leads (II, III and aVF) for reciprocal changes. The converse is also true.

ST-depression is present in leads II, III and aVF. If you're not sure of the exact location of the J-point in leads II and III you can find the J-point in lead I and draw an imaginary line straight down to help you find your landmarks. This finding is subtle (most obvious in lead aVF) but to me this is the strongest evidence that the concordant T-wave in lead V2 and slight J-point elevation in leads I and aVL are pathological.

It can't be repeated often enough. When looking at any ECG abnormality "consider the company it keeps." We might blow off a single lead showing a concordant T-wave. We might blow off a single lead showing a slight amount of J-point elevation. We might blow off a single lead showing an inverted T-wave or ST-depression, but put them all together and a picture starts to emerge.

In this case the picture that emerges is a high-risk patient who is almost certainly experiencing an acute coronary syndrome! 

Unfortunately, this crew obtained only one 12-lead ECG and did not recognize these abnormalities. One of the best quotes I've heard about serial 12-lead ECGs came from Tim Phalen. He said, "Taking a single 12-lead ECG is like taking a single photograph of Old Faithful. Is it a geyser, or is it a hole in the ground?" 

One imagines that if this ECG were to have been repeated it would have shown changes to suggest the dynamic oxygen supply vs. demand characteristics of ACS.

On the plus side, this ECG was transmitted to the hospital and the ED physician found it to be suspicious. The 12-lead ECG was repeated in the emergency department (we do not have a copy of this ECG) and a "Code STEMI" was called. The patient was taken to the cardiac cath lab. We do not have a copy of the cath report. However, we do know that for some reason the cath was unsuccessful and the patient was sent to the OR for a 3-vessel CABG.

Diagnosis: Acute ST-elevation myocardial infarction

Posted by on September 18, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , , ,

Syncope and sudden death in student athletes Part 2 – EMS 12-Lead podcast Episode #2

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EMS 12-Lead podcast – Episode #2 – Syncope and sudden death in student athletes Part 2

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In this episode Tom Bouthillet and David Baumrind are joined by Trudie Lobban of STARS (Syncope Trust And Reflex anoxic Seizures) — a not-for-profit organization that works together with individuals, families and medical professionals to offer support and information about unexplained loss of consciousness (syncope).

Trudie Lobban
Photo credit: http://www.atrialfibrillation-us.org

To learn more about STARS see the following links:

Syncope Trust And Reflex anoxic Seizures (STARS) – International 

Syncope Trust And Reflex anoxic Seizures (STARS) – U.S.

Syncope Trust And Reflex anoxic Seizures (STARS) – International on Facebook

Syncope Trust And Reflex anoxic Seizures (STARS) – U.S. on Facebook

Related content:

EMS 12-Lead podast – Episode #1 – Syncope and sudden death in student athletes Part 1

Posted by on September 15, 2011 • Filed under: ems-topics • Tagged: , , , , ,

88 year old male CC: Chest pain

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EMS is called to the residence of a 88 year old male patient with a chief complaint of chest pain.

On arrival the patient is found standing at the front door. He appears anxious and acutely ill.

Skin is pink and warm but diaphoretic.

The patient is led to a kitchen chair and the assessment begins.

Past medical history: Hypothyroidism, Dyslipidemia

Medications: Synthroid, Lipitor

History of present illness:

The patient states that he was cleaning the house when symptoms began.

  • Onset: Sudden and getting worse over time
  • Provoke: Nothing make the pain better or worse
  • Quality: Sharp
  • Radiate: Pain radiates to the left arm
  • Severity: 10/10
  • Time: No previous episodes

Breath sounds are clear bilaterally.

No JVD or pitting edema noted.

Vital signs are assessed.

  • RR: 20
  • Pulse: 68
  • NIBP: 145/85
  • SpO2: 96 on RA

The patient admits to nausea but has not vomited. He denies palpitations.

The cardiac monitor is attached and a 12-lead ECG is obtained.

Computerized measurements:

  • HR: 66
  • PR: 292
  • QRS: 146
  • QT/QTc: 414/434
  • P-QRS-T: 21, -50, -19

What is your interpretation of this 12-lead ECG?

What do you think is going on with this patient?

Posted by on September 7, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , , ,

ProMed Network Podcasting Schedule at EMS World Expo

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Live Video streaming by Ustream

 

ProMed Network Podcasting Schedule

Wednesday

11:30 a.m. MedicCast / EMS Garage

12:30 p.m. EMS Leadership

1:30 p.m. GenMed

2:30 p.m. EMS EduCast

3:30 p.m. EMS Newbie

4:30 p.m. CHEPcast

Thursday

11:00 a.m. EMS Garage

12:00 p.m. EMS Leadership

1:00 p.m. EMS Standing Orders

2:00 p.m. First Few Moments

3:00 p.m. MedicCast

Friday

10:00 a.m. EMS EduCast

11:00 a.m. GenMed

12:00 p.m. MedicCast / EMS Garage

* All times listed in Pacific Time Zone

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

Syncope and sudden death in student athletes – EMS 12-Lead podcast Episode #1

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EMS 12-Lead podcast – Episode #1 – Syncope and sudden death in student athletes.

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Tom Bouthillet, David Baumrind and Christopher Watford are joined by Dr. John Mandrola from the Dr. John M blog. We discuss sudden death in student athletes, the controversy surounding the prescreening of student athletes, the need for AEDs in the schools, abnormal ECG findings that indicate higher risk, and the EMS evaluation of syncope patients in general.

Related content from EMS 12 Lead:

13 year old female CC: Syncope

17 year old male CC: Syncope

37 year old male CC: Unconscious (syncope in an endurance athlete)

From the Pedi-U podcast:

Done Fell Out! Pediatric Syncope

From the Dr. John M blog:

CW: The ECG of the athlete

What is a normal heart rate?

Screening seemingly healthy young athletes?

The feasibility of routine ECG screening of athletes?

The mysterious athletic heart

Related media

See also:

The Ongoing Controversy Over Screening Young Athletes With ECG – The Wall Street Journal Health Blog

Experts create "cook book" for interpreting young athletes' ECGs – heartwire

Doctors frequently make mistakes when interpreting young athletes' ECGs – heartwire

Accuracy of interpretation of preparticipation screening electrocardiograms. J Pediatr 2011 Jul 9

Interpretation of the Electrocardiogram of Young Athletes. Circulation. 2011;124:746-757 (subscription)

How Important Is the Electrocardiogram in Protecting and Guiding the Athlete? Circulation. 2011;124:669-671 (subscription)

Posted by on August 25, 2011 • Filed under: ems-topics, patient-management • Tagged: , , , , , , , ,

47 year old male CC: Crushing chest pain – Conclusion

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Here is the conclusion to 47 year old male CC: Crushing chest pain.

You may want to go back and read the original case presentation to see how we got to this point.

When we left off we had this rhythm on the monitor and surprisingly the patient was conscious and talking! 

As usual there was an excellent discussion in the comments.

I certainly agree that the first step is to check the leads. I've seen artifact mimic VF before! When I worked in the Critical Care Stepdown Unit as a cardiac monitoring technician this would sometimes happen when a patient brushed their teeth.

However, this time it was the real McCoy (hyperlinked explanation of this idiom for my international friends).

  • This has the general appearance of Torsades de Pointes.
  • It's fast, wide and polymorphic.
  • There appears to be a "streamer" effect.
  • The patient is conscious.

However, several features point away from Torsades de Pointes.

  • The ventricular rate (using the small block method) is 375
  • The QTc of the underlying rhythm is 447 ms

The rate of TdP is typically in the 150 – 300 range. A QTc of 447 while technically prolonged is still < 500 ms which is generally considered to be "safe". 

It seems to go against everything we've been taught but could this patient have been conscious with VF on the monitor?

The answer is "Yes!" There are two reasons for this.

First, the onset of VF is often course and slow (relatively speaking). A ventricular rate of 375 is a lot different from a ventricular rate of 720. We like to think of VF as if it's all the same and it usually is from a treatment standpoint. But there is quite a lot of variability as I'm sure anyone who has worked on VF detection algorithms could tell you.

The second reason is that forward blood flow continues for several minutes after the onset of cardiac arrest. That's because there is a pressure gradient between aortic pressure and central venous pressure.

This chart from a white paper on the LUCAS device helps illustrate the point.

This is a busy chart but you will note that it takes several minutes for aortic pressure and central venous pressure to merge together after the onset of VF.

Mark Glencorse over at the (retired) 999Medic.com blog presented another case of transient VF where we had the same lively debate as to whether or not we were dealing with Torsades de Pointes.

Some of you are probably thinking, "It's not VF! It's polymorphic VT!" I will simply ask, isn't VF a form of polymorphic VT? At what rate does polymorphic VT become VF?

From a treatment standpoint it doesn't matter in this case because I'd treat both rhythms exactly the same. I'd apply the combo-pads and I'd give 2 g of magnesium sulfate while I was waiting to see if the patient lost consciousness. Tim Noonan (Scallywag Medic) will be disappointed in me for saying so but you really can't hurt a patient with MgSO4 and it might help.

In this case the treating paramedic didn't carry magnesium sulfate but he did apply the combo-pads.

About a minute and a half later the patient lost consciousness.

Now I think we'll all agree that the patient is in VF and we'll also agree on the treatment! 

After another 2 cycles the patient was shocked back into a perfusing rhythm. Interestingly, the patient "woke up" several times during chest compressions.

The patient regained consciousness after return of spontaneous circulation.

Another 12-lead ECG was captured.

Now we're back where we started! (Okay, it's a little worse.)

Advanced notification was given to the receiving hospital and the cardiologist was waiting for the patient. He was taken directly to the cardiac cath lab where angiography revealed a 100% occlusion of the proximal LAD.

The lesion was successfully stented and the patient made a full recovery.

Congratulations to Phil, the Intensive Care Paramedic from Australia (and his crew) for a job well done!

Got an awesome case? Submit it to the EMS 12-Lead blog at ems12lead@gmail.com

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