One of the more enjoyable aspects of the job

It's amazing how much trust the community places in us.

82 yof CC: "Flu-like" symptoms

EMS is called to the residence of a 82 year old female complaining of "flu-like" symptoms, including vomiting x 4-5 hours.

On arrival, the patient is found sitting on her bed alert and oriented to person, place, time, and event.

The patient's skin is pale but warm and dry.

Past medical history: Breast CA, double mastectomy, HTN, hyperlipidemia

Meds: Unknown antihypertensives

The cardiac monitor is attached.


The patient is relocated to the ambulance.

Upon questioning the patient admits to chest discomfort and mild dyspnea.

Onset: 4-5 hours ago
Provoke: Nothing makes the pain better or worse
Quality: Described as "discomfort" and "rock-like"
Radiate: The pain does not radiate
Severity: Patient gives the pain a 8/10
Time: No previous similar episodes

A 12-lead ECG is captured.


An additional ECG is captured en route to the hospital.


And upon arrival at the emergency department.


Your thoughts about the case?

ACC/AHA focused update for STEMI and PCI

The ACC/AHA focused update of guidelines for STEMI and PCI have been released. They offer new insight into which patients should be given thrombolytics prior to transfer for PCI. They also give a "shout out" to Mission: Lifeline!

2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction (Updating the 2004 Guideline and 2007 Focused Update) and ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (Updating the 2005 Guideline and 2007 Focused Update)

Here are some highlights (with emphasis added in some key areas):

STEMI Patients Who Are Candidates for Reperfusion

The 2007 STEMI Focused Update describes several strategies for reperfusion, among them facilitated PCI and rescue PCI. These terms are no longer used for the recommendations in this update so that the contemporary therapeutic choices that lead to reperfusion as part of the treatment of patients presenting with STEMI can be described without these potentially misleading labels.

Very interesting indeed!

A detailed discussion about facilitated PCI and rescue PCI follows (including the ASSENT-4, FINESSE, REACT, CARESS, and TRANSFER-AMI trials). And then:

[A] pathway has been suggested for the care of STEMI patients that has been divided into those patients presenting to a PCI-capable facility and those presenting to a non–PCI-capable facility. Those seen at a PCI-capable facility should be moved expeditiously to the catheterization laboratory, with appropriate antithrombotic therapy for catheterization and PCI if appropriate. There has been discussion about whether the recommended door-to-balloon time (or first medical contact–to-balloon time) should be greater than 90 minutes, with the recognition that in certain patients, the mortality advantage of primary PCI compared with fibrinolytic therapy is maintained with more prolonged door-to-balloon times. However, the writing groups continue to believe that the focus should be on developing systems of care to increase the number of patients with timely access to primary PCI rather than extending the acceptable window for door-to-balloon time.

The update continues:

Those patients presenting to a non–PCI-capable facility should be triaged to fibrinolytic therapy or immediate transfer for PCI. This decision will depend on multiple clinical observations that allow judgment of the mortality risk of the STEMI, the risk of fibrinolytic therapy, the duration of the symptoms when first seen, and the time required for transport to a PCI-capable facility. If primary PCI is chosen, the patient will be transferred for PCI. If fibrinolytic therapy is chosen, the patient will receive the agent(s), and a judgment as to whether the patient is high risk or not will be made. If high risk, the patient should receive appropriate antithrombotic therapy and be moved immediately to a PCI-capable facility for diagnostic catheterization and consideration of PCI. If not high risk, the patient may be moved to a PCI-capable facility after receiving antithrombotic therapy or may be observed in the initial facility.

Patients best suited for transfer for PCI are those STEMI patients who present with high-risk features, those with high bleeding risk from fibrinolytic therapy, and patients presenting late, that is, more than 4 hours after onset of symptoms. The decision to transfer is a judgment made after consideration of the time required for transport and the capabilities of the receiving hospital. Patients best suited for fibrinolytic therapy are those who present early after symptom onset with low bleeding risk. After fibrinolytic therapy, if the patient is not at high risk, transfer to a PCI-capable facility may be considered, especially if symptoms persist and failure to reperfuse is suspected.

The duration of symptoms should continue to serve as a modulating factor in selecting a reperfusion strategy for STEMI patients. Although patients at high risk (e.g., those with congestive heart failure, shock, and contraindications to fibrinolytic therapy) are best served with timely PCI, "inordinate delays between the time from symptom onset and effective reperfusion with PCI may prove deleterious, especially among the majority of STEMI patients at relatively low risk". Accordingly, each community and each facility in that community should have an agreed-upon plan for how STEMI patients are to be treated. This includes which hospitals should receive STEMI patients from emergency medical services units capable of obtaining diagnostic ECGs, management at the initial receiving hospital, and written criteria and agreements for expeditious transfer of patients from non–PCI-capable to PCI-capable facilities.

The development of regional systems of STEMI care is a matter of utmost importance. This includes encouraging the participation of key stakeholders in collaborative efforts to evaluate care using standardized performance and quality improvement measures, such as those endorsed by the ACC and the AHA for ACS. Standardized quality-of-care data registries designed to track and measure outcomes, complications, and adherence to evidence-based processes of care for ACS are also critical: programs such as the National Cardiovascular Data Registry ACTION Registry, the AHA's "Get With The Guidelines" quality improvement program, and those performance-measurement systems required by the Joint Commission and the Centers for Medicare and Medicaid Services. More recently, the AHA has promoted its "Mission: Lifeline" initiative, which was developed to encourage closer cooperation and trust among prehospital emergency services, and cardiac care professionals. The evaluation of STEMI care delivery across traditional care-delivery boundaries with these tools and other resources is imperative to identify systems problems and to enable the application of modern quality improvement methods, such as Six Sigma, to make necessary improvements.

Let's hear it for Mission: Lifeline!

65 yom CC: Cardiac arrest

65 year old male collapses while playing tennis. The scene is less than 1 minute from the fire station.

On arrival, bystanders are providing rescue breaths but no chest compressions.

Medical history is unknown.

Initial rhythm:


First shock:


Return of spontaneous circulation (ROSC) noted.


Rhythm strip:



12 lead ECG:


The patient is still unconscious. LMA is placed and patient is ventilated 8/min. with 100% oxygen.

Vital signs:

Resp: No spontaneous ventilations noted
Pulse: 82
BP: 112/82
SpO2: 100

What should happen next?

What is the patient's prognosis?

Honoring Our Veterans

Since the Veteran's Day activities at Shelter Cove Community Park scheduled for today have been canceled due to inclement weather, I'd thought I'd repeat last year's dedication to America's veterans.

Happy Veteran's Day!

11/11/08

To all the brave veterans of America's wars, the Prehospital 12 Lead ECG blog says "Thank you for your service to our country!"



Today Engine 6, Medic 6, and Truck 6 had the honor of attending the Veteran's Day Memorial service at Shelter Cove Community Park.

The keynote speaker was Medal of Honor recipient Major General James E. Livingston - Retired. To my knowledge, this is the first time I've seen a Medal of Honor recipient in real life. Like all Medal of Honor recipients, the citation for his medal is amazing (see link).

The Parris Island Marine Band was also in attendence, and did a fantastic job (as always). Oorah!

Remembering the sacrifice of America's heroes gave me pause to consider the sacrifices that I haven't made in the service of my country.

I remember the quote from the 2002 adaptation of The Four Feathers. "Dr. Johnson once said, 'Every man feels meanly about himself for not having been a soldier.' Well, that's something no one here tonight need fear."

I do feel meanly about myself for not having been a soldier. I often wish I would have joined the military right out of high school. I serve my community as a firefighter and a paramedic, and while the job can be dangerous, no one's shooting at me (at least not yet).

In WWII, every man, woman, and child sacrificed. My father once told me a story that illustrates this point. The year was 1942 or 1943 and my father was in the 1st or 2nd grade at St. Gabriel Elementary School in Detroit, Michigan (near Dearborn). The school was run by the Dominican nuns of Adrian. During WWII, scrap metal drives were common, so in the front yard of the rectory, there was a pile of scrap metal. One day when the pile was big enough, a truck came by to pick it up. Before it was taken away, the nun who was the principal of the school (my dad thinks her name was Sister Alphonse) threw the school bell on top of the pile.

Are you listening, Steven Spielberg?

My father went on to mention ration cards. When I asked what they were, he explained they "allowed you to buy things that were hard to get." You know. Things like butter.

The most I've sacrificed in the war on terror is longer lines at the airport and perhaps higher fuel prices.

There's something wrong with that.

My dad went on to serve his country in the U.S. Army. Fortunately for him (and perhaps for me), the Korean War ended while he was in boot camp. He was stationed in Fort Richardson, Alaska.

My heartfelt gratitude goes to all who served, and all who still serve; especially those who were killed, those who were wounded, and those who were left behind.

Thank you for my freedom.

81 yof CC: ICD shocks x6

EMS responds to a 81 year old female who was implanted with "a pacemaker" 2 weeks ago. She complains that the device has shocked her 6 times.

On arrival the patient is found sitting in a chair. She is anxious but alert and oriented to person, place, time and event.

Vital signs:

Resp: 18
Pulse: 164 and irregular
BP: 128/68
SpO2: 98 on RA

The patient is asked if she carries an ID card for her implantable device and she finds this card in her purse.


A 12 lead ECG is captured (I am using the 12-lead that shows the best data quality which was taken en route to the hospital).


Here is a typical looking rhythm strip during the transport.


Why do you think this patient's ICD is firing?

What would you do about it?

Found on the Lifenet Receiving Station

Is there anything about this ECG (other than the poor data quality) that interests you?

The patient was a 90 year old male, fall with injury. Also complaining of pain between the shoulder blades.

*** Update 11/08/09 ***

This ECG caught my eye because it satisfies one of Sgarbossa's criteria for the identification of AMI in the presence of LBBB. Specifically, the concordant ST-segment depression in lead V3 is a highly suspicious finding.

I give a fairly extensive review of Sgarbossa's criteria here:

Identifying AMI in the presence of LBBB - Sgarbossa's Criteria - Part I
Identifying AMI in the presence of LBBB - Sgarbossa's Criteria - Part II


As a stand-alone finding, concordant ST-segment depression in a right precordial lead gives this ECG a score of 3 out of 10 (probability of AMI 66%).

I personally don't think it's necessary to score the ECG. As far as I'm concerned, an ECG that meets any of the criteria should be considered equivalent to an ECG showing acute STEMI, especially when you consider the depth of the S-wave in leads showing discordant ST-elevation (see previous posts on this issue).

So was this patient experiencing an acute STEMI? Here's what I found out.

Patient (90 y.o.) arrived via EMS from XXXXXXXX after falling; there was no LOC, but did complain of back pain between the shoulder blades and diffuse abdominal pain. Extensive PMH: AAA, non-operable, HTN, CAD, CABG, LBBB, anemia, cardiomyopathy and dementia. The ED physician spoke to the daughter extensively who did not want her father worked up, but did consent to a thoracic x-ray and stated she only wanted him to receive pain medication and return transport to the XXXXXXXX and did not want any further diagnostics noting that his dementia worsens when he is out of his environment. He has a living will /advanced directive on file and with him a DNR order.

He was given pain medication in the ED, the thoracic film showed no acute injury and a prescription for Lortab was written and he was sent back to the nursing home. He did not have an EKG performed on this visit or any other diagnostics. The patient was here for an admission in 6/2009 and it appears that the EKGs are very similar.

Very interesting!

When designing a STEMI program you have to make difficult choices when it comes to exclusion criteria like age, DNR status, and neurological status. Was this patient experiencing an acute thrombotic event in an epicardial coronary artery? I guess we'll never know.

It's possible this ECG finding was old and it's possible it was secondary to aortic dissection or aneurysm.