Once again, owner "Doctor" Jon Basso is full of shit.
"The gentleman could barely talk…He was sweating, suffering. Anyone with an ounce of compassion would've felt for him…I actually felt horrible for the gentleman because the tourists were taking photos of him as if it were some type of stunt. Even with our own morbid sense of humor, we would never pull a stunt like that."
If you believe that one I've got some swamp land in Florida you might be interested in. He's loving this publicity.
Don't get me wrong. I like naughty nurses as much as the next guy.
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.
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.”
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.”
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."
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."
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."
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."
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."
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."
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.
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.
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.
We hold PCI hospitals to a 90-minute standard for walk-in patients
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).
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.)
188.8.131.52. Primary PCI of the Infarct Artery: Recommendations
Primary PCI should be performed in patients within 12 hours of onset of STEMI. (Level of Evidence: A)
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)
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)
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)
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)
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)
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
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!
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.
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.
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?
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.
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.
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.”
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
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!
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.
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.
A post-conversion 12-lead ECG was captured.
The patient was transported to the hospital in a position of comfort.
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
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."
Pulse: Rapid and weak
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).
"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.
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.
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.
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.
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).
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.