Jaymazing

I'd like to give him a good fluid bolus

The ekg is looking like a base of atrial flutter in leads 2 & 3 and V5 V3 is making it look kind of like a low/lateral wall infarct with early repolatization... but I tend to suck at 12 leads so I may be completely off at this one...

Either way some fluid would be good and transport with a possible helo ride waiting for transfer to the city ?

The stuff that looks like flutter waves, just so you know, is artifact.

Can I ask what the fluid bolus is for? and how much you'd like to give?

Sounds like a call I did but was a 79 yr old female. Treated as cadiac ended up as a hernia around the chest cavity, near the heart.

That's really interesting! What's that called? I haven't heard of that before

BP? O2?

Throw a NRB on him and see if that helps... hesitant to give NTG unless I can get him to go...

Tell him he's having unresolved CP that could be an MI and he could die at home and does he want to do all that to his wife....blah blah

Definitely would liket o see him go to a cath lab hospital if possible... If he consents to going NTG, ASA, O2, Morphine if we have it (4mg) if not 100mcg Fentanyl, monitor and transport...

BP is 114/76, and his Sp02 on room air is 93%. You throw on an NRB, and his sats go up to 95%.

His wife starts crying as soon as you bring up the possibility of dying, and he decides he'll go "because now I'm an as**ole, apparently".

You get him on the stretcher and wheel him to the ambulance. One spray of Nitro is given, with ASA PO chewed, but he refuses all narcotics.

See above for further ECG's

It's a 20-30 minute transport to the closest rural hospital, and 90-100 minutes to the city, where there's PCI capabilities.

My diagnosis is now exertional angina until proven to be otherwise

His ECG possibly shows some inferior ST depression however eh, its so-so

I'd like to give him some GTN and see what that does to the ECG as well as his pain; if he feels significantly better with the GTN and/or his ? ST depression completely resolves but then comes back or post-GTN he feels the same pain then I'd repeat it; but if after 2 sprays of 0.8 mg GTN it has little or no effect I would not give any more.

What is his take on being transported to the hospital, still doesn't want to go?

His wife puts up a pretty convincing argument, and convinces him to go with you to get checked out. "He really doesn't look like himself," she says. Her concern is far greater than her husband's.

You get him on the stretcher and give him a spray of nitro. He says it really didn't change anything, and his condition remains unchanged. A second strip is acquired a few minutes after the spray.

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http://sphotos-b.ak.fbcdn.net/hphotos-ak-ash4/314134_10152477061830026_13020943_n.jpg

Would you like to continue nitro Tx? Any other treatments you'd like to consider? and would you deem this a "hot transport" or a "cold transport"?

It's a 20-30 minute transport to the closest rural hospital, and 90-100 minutes to the city, where there's PCI capabilities.

Has he ever had pain like this before? "Sort of, I had a bit of it last week when I was mowing the lawn"

Does the pain go anywhere apart from in his chest? "Nah, it's not pain. It's just...unpleasant. And it's right here" *Gestures a wide circle around his sternum*

What type of pain is it? sharp? stabbing? cramping? "It's not pain. It's just like, almost a squeezing feeling. But it's not pain"

How bad is the pain? "It's not that bad. It was worse earlier"

Does anything make the pain better or worse? "Last time, sitting down made it go away. Today, it's going away but it's taking a long time"

What is his past medical history like? "I don't like doctors, and they don't like me"

Does he have any family history of heart disease? "My dad died at 60. We don't know why"

When did he last eat? "Breakfast. Bacon and eggs. What does that matter? It's not like I'm on a diet"

Ix - obs and 12 lead ECG including V4R, right sided or posterior leads as appropriate? ***ECG to be attached below. Sorry, no posterior leads to share****

Does physical exam reveal anything? lung sounds? heart sounds? JVP? Physical exam reveals pale, diaphoretic throughout, weak/irregular radial pulses, No trauma, abdo soft/nontender, denies N/V, No JVD, Lung sounds clear to all fields, and unfortunately I do not remember the heart sounds (or if we even listened to them). The rest of the physical exam was unremarkable

PDx - myocardial ischaemia until proven otherwise

DDx - MSK pain, spontaneous pneumothorax, trauma, PE, chest infection, pneumomediastinum, AAA, acute ventricular aneurysm, acute valve rupture, pericarditis/myocarditis, epigastric pain, GERD

If he doesn't want to go nowhere then that's fine by me, a competent patient has the right to refuse treatment, including life saving treatment, put big green pack and monitor back in ambulance, get in ambulance, drive home, done.

The initial 3-lead and 12-lead

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Bare with me, this is my first time presenting a scenario on EMTCity. I will begin the presentation with a brief summary of chief complaint, dispatch info, and on-arrival info. Everything else, just ask and I'll provide (to the best of my ability).

You are working for a rural service, about 90 minutes away from the city, with one ALS ambulance and one BLS ambulance.

It's 10:45 AM on a moderately warm spring day, and you're called to a rural address about 20 minutes away for a 54 year old male complaining of "Chest discomfort". Due to response time and location, the local fire dept is called for first response, and upon your arrival you find a well-kept home amidst a quiet farming community. First responders are on scene already, and several of them are standing around and waiting for the all-clear to go home.

Your patient is a middle-aged man, sitting on a step in his garage. His wife and a fire-fighter are standing around him. He appears pale and diaphoretic, but is in no obvious distress. Upon seeing you, he sighs deeply and drops his head down; the wife tells you that she's the one who called, and her husband is does not want to go to the hospital.

You introduce yourself, and find out that your patient was working around the yard when he developed some moderate chest discomfort. He had to come inside and sit down, at which point his wife noticed that he appeared "off", so she called 9-1-1. He can't describe the discomfort, he just gestures in a circular manner around his mid-chest.

"I'm not going anywhere," he says when he see's one of the fire-fighters wheeling over your stretcher.

You take it from here.

Jay, though I'm a big fan of you, this thread, and your participation, for me a huge part of EMS is respecting those that came before us, if they deserve it, and being grateful to our betters for taking the time and giving the attention to teach us. Both are categories that ArticKat fits into solidly where both you and I are concerned. His statement was prudent, despite you're being offended by it. I would be curious if, after rereading it, you are happy with the tone that your reply was created in? Being snippy and arrogant in the face of someone that's been a really important member of the City and EMS familes for a long time doesn't look good on you my friend....

Dwayne, you are absolutely correct, and I 100% agree that respect should be given to those who've earned it, and I never intended to take away any of that respect from Arctickat. I do still, however, feel that my comments were intended to defend my own credibility when it was brought into question, and while I don't feel that I crossed any lines in my statements, I do apologize for any disrespect that may very easily have been interpreted from my writing. My mood in my written communication can very easily be misconstrued, and that's my own fault. I hope I simply misconstrued the tone of his comment, as well. And I hope that Arctickat understands.

The point that I intended to make was that I have no intention of "screwing anybody around", but I also have not given any reason to question my credibility aside from being a stranger in a forum of strangers. Perhaps I was overly sensitive, though in my (probably biased) opinion, I feel I deserve the benefit of the doubt. I hope that this can be a forgiveable trait of mine, as I am working on improving it.

It could, and perhaps should be talked about. The problem is that, in the current model, there's just so little time. The training is so short, and basically inadequate, and there's so much material to cover that some things have to suffer. Unfortunately, as you've just seen, the provider is often left to work things out for themselves when they hit the road. I don't want to go on a rant about educational standards, as I think it will end up hijacking your thread.

.......

I like to hope that in EMS, we are slowly moving towards an environment where we can identify errors, and report them, without having as much fear of punitive action. Obviously poor providers need to be counselled and coached, but hopefully we can identify why errors were made, and see if there's anything we can do to prevent them from happening again.

EMS education would definitely be a whole new topic; and one that I would very much enjoy participating in! There's a lot of things I look forward to seeing as this industry grows and matures.

And I very much like the thoughts you've shared so far. Thanks

note: and thank you to everybody so far who's contributed. I've enjoyed this topic very much.

Okay, I think we're getting screwed around with here. Either you were there or you weren't. You can't be sure it was VFib unless you saw it, but you claim you weren't there to see it.

I'm sensing a bit of hostility from Arctickat. In response, I'd like to note that I can be comfortably certain that it was VFib without being there, based on several factors, which include:

1) My confidence in the ECG rhythm interpretation skills provided by the EMT who was there.

2) The documentation of the call, which says Vfib was on the monitor at time of Tx

3) My own interpretation of the code summary provided, event markers included (a handy feature, I might add)

and 4) My own experience studying ECG's, and the perception that V-Fib is an easy rhythm to distinguish from bradycardia and PEA. If you disagree that it's an easy differential to make, then your concerns should lie elsewhere. I trust this isn't the case....

So no. I am not "screwing around" with you. And please, try not to sidetrack my discussion, as the purpose was not to discuss treatment methods or ACLS, but to seek advice for the various ethical and moral questions surrounding disagreements made in a public setting.

Thank you for your participation.

Yeah, there are quite a few things wrong with this scenario as presented...

Only three shocks in 30 mins for continuing Vfib?

Only one round of Epi in the same amount of time?

A decision to transport yet discontinue meds? (Though perhaps with a 30 minute transport, after a 30 minute effort where Epi was pushed properly, it's likely that the truck had no more onboard.)

It sounds to me Brother like your friend is making up stories, or else everyone on scene, not just the medic, needs to be removed from patient care as incompetent...Or, maybe this is a question that you had but didn't think that we'd take it seriously if you presented the scenario other than factual.

Either way, your presentation was intelligent and thorough, you've been participating completely, so I don't really see how these inconsistencies change the context of your question, and I think that it's a really important question. And, I think that you've gotten some really amazing answers...Great job! To my way of thinking, these kinds of threads are the best of what happens in the forums, and yeah, including the discussions as to whether or not this really happened.

Let's try not to derail his thread with other things not pertinent to the OP's real question if we can avoid it...

I regret to inform you that I did not alter the medications given, nor the timing of the call (though I did round the numbers, for the sake of making the math easier). There were many faults made, but unfortunately some medic's do not listen to reason in high-stress situations. To make matters worse, the EMT was still fairly new, and rather shy as well.

This question is just stuck in my head. I can't begin to tell you how much I love it, as it represents the very best of the EMS spirit in my opinion.

It sticks not only because I love it, but because despite thinking about it almost constantly for the last 24hrs, I have no idea how to answer it. Since my first paid day as an EMS provider I've been a paramedic, so I don't really have much context.

I once disobeyed several orders given to me by a doctor that I know, beyond any doubt were dangerous and possibly terminal to my patient, but I just did it. I was alone in the back of the ambulance, I had no question whatsoever that I was given really bad orders, I knew beyond any doubt that calling to get them changed wouldn't get it done as he'd continue to insist that I follow his instructions, so I just didn't call. I changed to my treatment path, things worked out as I'd hoped, I reported the instructions given to me and my reasons for disobeying them to the recieving doc, and they, I assume, took over from there.

The perfect way to resolve your question involves perfect timing, a great approach to the correction, aggressive enough to be heard but not so aggressive as to be ignored, a strong justification for your recommendation, and a medic that's open and willing to hear it all. Yeah man, depending on the medic you're working with, you're likely screwed... :-)

This statement resonates with me, once again from systemet, "If I worked a shift and was allowed to make an error this big, when someone there could have spoken up, I'd be pissed...."

Yeah, me too...As he mentioned in that same post, one of the things that I'm most afraid of is making a preventable error because I'd forgotten something, or was distracted. I will never, ever thank you for watching that happen while you stand quietly by.

I'm really glad that the question resonates with you, as it's one that has been on my mind for a while. As you realized, the point of the scenario was simply to paint a black-and-white picture for which to give the question context. Obviously, it's not all that uncommon of a problem, though sometimes the results can differ drastically.

I'm lucky in that I don't often work with bad medics, however there's always the occasional casual or burnt-out medic that gives the rest of us a bad name.

I think this question is something that could almost benefit from being brought up in EMT school, during discussion about ethics and moral obligations. As a student, I always just assumed paramedics knew everything.

An open mind is the most essential element of progress.

Odd. Are you sure that coarse VF is actually on the monitor, and that you're not seeing CPR artefact? This is more commonly mistaken for VT than coarse VF.

..............

Two more bits of weirdness here:

(1) If the patient has been pulseless for some 30 minutes or so, after an initial downtime of 20 mins, there's no reason to transport, this code should be called on-scene.

(2) If we're working a code it's epi q5 until we stop. We don't stop giving meds.

These are surprising actions for a registered paramedic

I, unfortunately, am sure that it was V-fib on the monitor. For the sake of the scenario, I called it "coarse" just to remove any element of doubt. My best guess as to why atropine was given instead of amio would have to be that they both start with the letter 'A'...

As for multitude of other errors made, I completely agree. They are surprising actions for a registered paramedic to make. But I'd like to provide some reassurance by letting you know that the Medic involved is being held accountable for their actions. It wasn't their first time making terrible treatment errors.

You can't really get in a fistfight over this, and try and wrestle the atropine out of his/her hands, or everyone's getting fired, and the patient's family is getting horribly traumatised...

I'm not sure what my reaction will be if I ever see THAT headline on EMS1.com...Possibly a mix of amusement and sadness.

There is no "outranking" in EMS. You're all responsible for the patient, and will be judged as a group. That being said, as an EMT, you're at less risk than any ALS providers on this call, as this is something out of your scope. Other decisions, particularly the problem of a partner wanting to do a refusal on a patient with potential ACS symptoms will put your job at jeopardy as well, even if a paramedic is there. In this situation where an ALS med error was made, you're less likely to get disciplined.

Of course, the point here isn't to not get disciplined -- it's to do the right thing for the patient.

I couldn't agree more. Unfortunately though, I know a few people who think that if it's not their PCR, it's not their problem. But I'm glad to see that you're one of the medic's who encourages a team approach to treatment and patient advocacy.

Thank you for your response! And merry Christmas!

I don't buy into the adage that "EMT's save medics" or any of that bull. I am happy to carry my Medic's bags and learn all I can in the process. I do believe that each member of the team is exactly that, a member of the team. As such I say what I am thinking because I am very aware that everyone misses things, gets distracted, and has a bad night. Even medics.

I don't have any problem with contributing to our patient having the best outcome possible. This is usually not a problem with my partner because I try to turn everything into a teaching/learning moment. If I am wrong in my contribution I learn from it. If I am wright well...you get the picture. Only once have I kept my mouth shut when I should have spoken. I lived to regret it.

I can safely say that I learn more from my mistakes than I do otherwise. That being said, it took me a few too many times flapping my gums when I shouldn't be before I learned to shut my mouth when I should. Unfortunately, I've also made the mistake of being quiet when I should have spoken, and regret it. And thus my quest for the perfect balance began!

Sometimes, you just have to teach your medic how to be a grown up, and if you can't do that, then sometimes you have to report them and allow others to force the maturing process. It's truly not easy being smarter than you're supposed to be when a lower level of care...And I mean that sincerely...

I really like how you put that!

I wonder if the medic thought the EMT was asking which he wanted, as if the EMT hadn't heard him. A quick sentence with what's wrong and what should be given might work. "Do you mean Amiodarone for his vfib?"

Maybe you're right; the problem with being shy about a treatment disagreement is that it leaves a lot of room for misinterpretation.

I, unfortunately, have been on both extremes of the spectrum, in that I've been too quiet on some occasions, while being overly assertive on others. If you're too quiet, you don't seem confident in your suggestions. But if you're too loud, people just think you're being obnoxious and try to ignore you. I guess it's a skill that develops over time...

I don't know exactly how I would have handled that situation but I do know I would have pushed my partner more than that. I have to go home and sleep at night. Knowing I could have done more would kill me.

Honestly, that was a pivotal point in my career when I figured that out; whatever I do or do not do, I have to live with my actions in the end. I'd rather be able to sleep at night than worry about an ego. The problem is that I need to remember that lesson all of the time.

I'd like to clear the air here and state that I was not the EMT-A on this call. I am friends with the EMT though, and since this call I have had similar instances where people who outrank me have made decisions that I felt would negatively impact my patient, and have been faced with the challenge of confronting the matter either on-scene or after the call.

I felt this scenario was black-and-white enough to keep the focus clear; when is it inappropriate to challenge the medic in charge, and at what point does the risk to the patient outweigh the risk of losing the confidence of the family or seeming unprofessional in the public eye?

I'm posing this question in the form of a scenario. It's based on real events, but obviously I had to change some details to protect various people's privacy.

You are an EMT-A working with an EMT-Paramedic. You're relatively new to the service you're working with, and the medic is someone who's been around for quite a while. You're working in a rural community with limited resources, and it's been yet another slow tour for you and your partner, who together form the only ALS crew in the region. You are called to back up a BLS ambulance responding for a 30 year old female, 9-echo (Cardiac arrest, CPR in progress). Collapse was witnessed, and compressions were performed by family for approximately 9 minutes prior the BLS crew's arrival, at which point the monitor was attached, V-Fib was recognized, and one shock was delivered. V-fib continued, and compressions resumed, and that's when you and your "ALS" partner showed up.

Being an EMT-A, you recognize that the Paramedic is calling the shots now and assume a supportive role. Good quality CPR and ventilation is maintained, IV's are established, and coarse V-fib continues despite one round of Epi and another defibrillation attempt. It's been about 20 minutes since collapse, and the family is standing nearby watching you attempt to revive their wife/mother, and they are increasingly distraught by the events unfolding.

It is at this point where things start to unravel.

Your paramedic partner looks at the coarse, obvious V-Fib showing on the monitor, and requests you to draw up Atropine...

"Do you mean Amiodarone?", you ask quietly.

He retorts with a glare, and absolutely insists that Atropine be drawn. This is an easy task to accomplish, as the Atropine you carry is in a preload syringe. You reluctantly pass it to the medic, who proceeds to push the drug slowly into the patient.

Fibrillation persists.

5 minutes later another dose of Atropine is given. No change.

A little over 30 minutes into the arrest and the third shock is delivered, at which point the patient goes into asystole. Upon seeing this, the medic determines that no further medications are to be given, and that transport should be initiated to the closest facility (about 30 minutes away). Compressions are continued, but no further electrical activity is restored enroute, and all measures are ceased shortly after arrival at the care center.

So my question to you is this; being the EMT-A in this scenario, at which point do you interject and voice your concerns over blatantly poor decisions and errors made by your "superior" who's running the call? Bare in mind the setting of this scenario, and the fact that all communication on scene can be easily overheard by the patients family. Do you say anything on scene? Do you address the matter afterwards, or in private? Or do you just assume that your partner knows something that you don't, and move on.

And what do you do in other situations when a partner that "outranks" you makes a Tx decision on scene that you absolutely disagree with (morally or clinically)?

I'd really appreciate your thoughts on this...

Very cool indeed!

There used to be more of these time-lapse hearts on youtube. I can't find them any more!

If you find some more, please share.

I consider myself very fortunate to not have to deal with these calls very often in the region I work in. I feel for you; it seems like it's weighing down on you pretty hard.

I think you've done the right thing so far by opening up to peers (even if just anonymously). You'll get lots of opinions, lots of advice, and lots of Monday Morning quarterbacks, but I have a feeling you're going to get the most benefit from simply typing the whole thing out and organizing your thoughts.

In the end you've just got to do what will help you get to sleep at night. Follow your gut, and good luck.

Hah! That's actually pretty clever. It takes a while to get to the point, but adding comedy, violence, and zombies to CPR instruction will only aid in the educational process.

If they could only combine it somehow with "So You Think You Can Dance" or "Lady Gaga", there wouldn't be a person alive who didn't know how to rock CPR....

Hello!

I'm Jay, I'm an EMT-A/Primary Care Paramedic in western Canada, and have been for a little over 2 years now. I just stumbled upon this website, and really enjoyed the scenario forum, and thought it seemed like something I'd enjoy partaking in!

I am passionate about everything EMS related, but I have a particular love for cardiology and ECG's, and I'll probably be submitting a few ECG's from my collection once I'm familiar with how things work in this forum.

I'm excited to get involved in the discussions, and to hopefully learn a thing or two to make me a better practitioner.