Personal ED Experience...

[EM_Rebuilder]

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I was at one of the better completly fried everything southern buffets in town and had just put two stuffed crabs on my plate when the phone rang. Darn, its mom. Guess I'll get it.

Frantically, "we are at the casino buffet (in Oklahoma) you dad just blacked totally out at the table, fell into his food then to the floor! Hes all sweaty now. There is some paramedic guy that works here, he wants to talk."

"Hello sir, your dad evidently just blacked out at the table. He is not having any pain anywhere, but he is sweating profusely. We want to call an ambulance, but he doesnt want us to. We can hook him up to a monitor here and get some vitals."

Me: "Ok, get some vitals, let me know what the monitor shows, can you give him or find someone with an aspirin? Let me talk to my mom. Listen, I dunno what this is, he could very well be having a heartattack orhe could have just passed out for no real reason. Let this guy get these vitals then do you feel confident enough to drive him?" (I should mentioned I talked to my dad at some point around here...he said he was feeling completly fine...otherwise, I would not have opted for mom to drive him).

I hang up, they call back a few mins later...I was now on my way home to pack some bags..just in case. Paramedic: "Hey sir, his pulse is 60, his BP is 90/70, he fingerstick is 127, and he has ST elevations in Lead I and II and AVf".... Me: "Da*n, do you have nitro or really his BP is probably too low and he isnt having any chest pain? Let me talk to him"

Me: "Listen, you might very well be having a heartattack, we are going to have these people call an ambulance. I know you are feeling fine, but if something was to happen in route, mom would freak out... and the ambulance can get things up and ready for when you get to the ED"

Dad: "I really fell fine, but if you think I need to go...."

So the ambulances are called (required 2... one to go to the OK border, other one met them there... we live in Texas, 15 miles from OK and there is a casino like 1 mile into OK). They actually ran him hot! My brother is a paramedic and met at the hospital...

At this point, my bags are in the car with my dogs and I am rolling down the road; Texas bound. I figure its better to have a head start on getting there if a cath was going to be done.


They get to the ED, Twelve lead EKG done.. NSR, no signs of nothing per my brother... and later confirmed by the doctor. BP much betters, 130s systolic, pulse in the 60s. Cardiac enzymes negative times one. Did some other 'lab work' that was all negative. Should also mention that he is early 50s, his father had a cath and MI at late 50s, he chews snuff, unknown chole/HTN/DM but nada as of ~5 yrs prior. Otherwise healthy, not obese, does lots of work out side but doesnt 'work out'.

It was all chaulked up to a vaso-vagal response, FU with the PCP early in the week.


The Take Home:
So as a teaching point for myself on this case, what gives with the 'ST elevation' that the paramedic saw? I want to think that the guy had no clue what he was doing, but it turns out he is an old hat at this and is one of the teachers in the area... my brother knows him well from classes, and the guys on both ambulances were telling my dad that he was lucky that this guy was there since he is one of the best paramedics in the area. He evidently teaches, works paramedic shifts, and works the casino occasionaly.

I am not overly familiar with what all exactly is used in the field. I would assume the monitors are less than stellar and that it probably was not a twelve lead and just something that they could cycle through on the screen....like the code machines do.

Who knows, but I am glad things were ok. I turned the car around at the Louisiana border and headed back to mi casa.

We are also curious to see what the little bill is going to cost. I am going to say $3500 for all. The bad thing is that it will be darn hard for me to get my dad in an ambulance again after he sees what that ride costs....

 

[DrQuinn]

I can't tell you how many "heads up" EMS has given me here in DC that mention ST segment elevation. Of course this cause a rustle in the ED as we try to get a very full ED an open bed....

And when they come in, I examine their 12 lead (and ours) and of course the patient history very closely, and find absolutely nothing. IN fact this again just happend to me last week, kind of frustrating.

A lot of times they will call us and tell us "ST segement elevation in lead V3."

....... *sigh* Anyways, DC EMS isn't known for its stellar performance anyways.

But I am glad to hear your dad is doing better! Its scary to have family members fall ill.

Q

 

[tkim]

I am not overly familiar with what all exactly is used in the field. I would assume the monitors are less than stellar and that it probably was not a twelve lead and just something that they could cycle through on the screen....like the code machines do.

I worked as a medic for 12 years before med school, and also worked in an ED-based fly car, so between the two jobs I've been through 5 LifePak models, plus the odd Zoll and HP monitor/defib.

If the medic specifically mentioned avf, then I strongly suspect he had a newer 12-lead model. The older portable monitors offered Leads I/II/III and you had to cycle through them, but you couldn't get avf as a lead. Newer, non-12 lead models offer avf but you still have to cycle through them.

Besides, if the OK casinos are like any other casino, they probably sport better equipment and pay pretty good, too. I'm surprised that the medic didn't hand off a copy of the tracing to the transporting medics. Did you get a chance to see any of the pre-hospital strips?

Glad your dad's okay.

 

[hyperbaric]

I hope I never get that call. Glad he is ok.

 

[FoughtFyr]

The medic was right, sort of. Look here ( http://forums.studentdoctor.net/showthread.php?t=290287 ) for a complete discussion - with pictures even, but the short answer is that the frequency response of a transport monitor is very different than that of a diagnostic 12-lead. This can lead to some wild variances. I have a whole talk I give on this point but it is too large to post here.

- H

 

[DrQuinn]

Interesting thread, Fought....

Regardless, I've looked at the EKGs (we do 12 leads in DC) and haven't seen any of the so called ST segement elevations that they tell us over the phone. Of course I repeat multiple 12 leads to make sure we're not missing anything.... DC EMS is a very different bird than the rest of the US. In Tampa where I did my residency, if they called an AMI, you bet your as$ it was one. In DC, I would say our positive catch is about 5%.

And I've seen multiple STEMIs that get brought in as basic chest pains, and when I do our 12 lead, they are very obvious STEMIs. When I look at EMS's 12 leads, its allso very obvious. I don't know why they locally have such issues iwth this sort of thing. Sounds like they need some CQI.

Q

 

[TerraMedicX]

I would have to agree that this is VERY region dependent! Our system has a cardiac alert program that is currenly >95% sensitive. We carry the Physio Lifepack 12s. One other thing I would say would be that, if you JUST put on the 4 limb leads, we often see elevation in some of the leads (usually II, III aVf). Once you run a 12-lead all the elevation disappears. Its possible that this was what happened. Anyway, just thought I'd interject a little.

Nate.

 

[FoughtFyr]

I would have to agree that this is VERY region dependent! Our system has a cardiac alert program that is currenly >95% sensitive. We carry the Physio Lifepack 12s. One other thing I would say would be that, if you JUST put on the 4 limb leads, we often see elevation in some of the leads (usually II, III aVf). Once you run a 12-lead all the elevation disappears. Its possible that this was what happened. Anyway, just thought I'd interject a little.

Nate.

EXACTLY - when you put on the limb leads you are sampling a frequency response that excludes the ST-T segment (in order to focus on the QRS complex). The diagnostic or 12 lead setting catches all of it - but if you do it in the bus you will likely also pickup significant baseline variability from the engine...

- H

 

[141837]

... am wondering, too, if they were actual 'limb' leads, placed distally. Did you hear if your father actually allowed central torso electrodes in that public place? The artifact from true limbs alone, besides the four bajillion volts of AC pumping through a casino, may have contributed a pinch even if obvious 60-Hz wasn't observed.

Hopefully there was some MCL use considered, incl a MCL4R... though not optimal, of course. A RV infarct can drop folks, too, and I've caught a few with basic 3 lead machines, eg. Lifepak 5's... remember those little tanks!? You could drop them down multiple flights of stairs, banging down like and empty keg, and they'd still fire up and work. Gotta love obsolete simplicity!

Glad he's ok... and better that story than the 'reciprocal' (nyuk, nyuk).

 

[EM_Rebuilder]

Good replies thus far... I learned a little.


Just some more info... The paramedic guy first went to my dad in the restaruant where he was sitting on the floor. They summoned a wheelchair, but of course my dad refused that and walked with the guy to a 'room'. The room had a bed and some other medical stuff. He thinks they did hook something to his chest there, but not 100% sure....but he says he knows they did at the hospital. So maybe there was a 12 lead done at the casino? I dunno.

Either way, hes been feeling fine and has been working as usual today.

Also, just FYI, I was not there, so everything I got was hear-say (aside from I did talk directly to the paramedic)... I am about 550 miles away in Mississippi. My parents are in Northern Texas.


I myself am dressed and about to grab my bow and head for the woods.....

 

[Midwest Medic]

Our county has the ability to transmit the field 12 leads to the hospitals, so we are able to look at it before they arive. This has led to some awesome door-to-balloon times at our little community ED. The record is 19 minutes, with the average being just over 50 minutes. After the transmission was implemented we are having about a 95%-97% catch rate on the STEMIs from the field...