Right Ventricle? ECGs....

[captainstandup]

It really depends on whether the patient is right or left dominant in terms of coronary perfusion and absent a previous cath the waters are a bit muddy regarding the specific vessel. If for no other reason than a heightened degree of caution regarding increased incidence of catastrophic decrease in blood pressure associated with nitrate admin and RVI, I feel a V-4R should be standard in all chest pain patients. While I'm on the subject, please ensure students understand the need to initiate a minimum of two IV lines, three if possible, for anyone with suspected AMI. This will help expedite the patients "time to balloon inflation" time, should they go to the cath lab. It will also provide a backup should the patient require "fluid resuscitation" or multiple meds / drips.

I applaud the fact that you are EDUCATING your students instead of teaching them. It sure is a shame your friend had to loose muscle due to an incompetent physician.

[fiznat]

...please ensure students understand the need to initiate a minimum of two IV lines, three if possible, for anyone with suspected AMI. This will help expedite the patients "time to balloon inflation" time, should they go to the cath lab.

Just to clarify, this may not be the case in every system. I know there are a lot of hospitals that will immediately pull prehospital lines and start their own (usually in that order, and sometimes to the patient's detriment) based on "infection" rates purportedly caused by poor EMS IV technique. 3 lines may be overkill if this is even remotely the case. ...Also, if you are going to do that many lines, the provider should be sure that at least one of them is #18 or larger, and nicely patent so that a clean draw can be made from it for a type + cross. Meh. I dont work at a hospital though so who knows what the REAL delays are in getting these patients upstairs. Is it really IV starts, or perhaps something else?

[ERDoc]

Fiznat, I have to agree 3 lines are probably a little overkill. It is not the IV access that slows down door to balloon time. There are other factors that limit the rate much more than IVs. Capt, I would have to disagree with you that V4R should be the standard of care. If you see changes on your normal EKG that raise suspicion for a right sided infarct then a right sided EKG should be done. As with everything else in medicine, there should be an indication for doing something.

[captainstandup]

OK three lines may be overkill, but two are a minimum. I'll agree there are a myriad of additional factors that impede efficient door to balloon time. The unfortunate reality is that hospitals are notorious for carrying forth their doctrine of heart or brain care and offer charts, graphs, a dump truck load of data allegedly supporting their plan and of course a new mnemonic to christen the new program.

Unfortunately its entirely symbolism over substance. Physicians exercise their autonomy and either choose to participate in the various initiatives or not. It's very difficult to get them all on the same page and they essentially answer to no-one.

Although not directly related to this thread, an example of what I am speaking of is diagnostic cath labs. These things are on every corner it seems. Patients, who already tend to minimize the severity of their situation, are easily deluded into believing a diagnostic heart cath is all they will need. Unfortunately, for a significant number this is not true. Once it's determined the patient has significant disease requiring at minimum stent or even CABG surgery, EMS or Critical Care Transport must then transfer the patient, sometimes many miles, to definitive care. This is no small issue by the way. Among the many risks associated with transfer are: Life threatening hemorrhage, air embolism, increased risk of clot formation and pulmonary embolism, and not to mention traffic accidents. If the patient has a swan-ganz in place the risk of catheter migration and spontaneous wedge are real possibilities.

It is my opinion that diagnostic cath labs are at minimum unethical and probably should be considered criminal neglect, since the patient would have clearly been better served within an interventional lab with appropriate CVOR supporting services.

Like Dennis Miller says "thats my opinion, but hey I could be wrong"

[akroeze]

Fiznat, I have to agree 3 lines are probably a little overkill. It is not the IV access that slows down door to balloon time. There are other factors that limit the rate much more than IVs. Capt, I would have to disagree with you that V4R should be the standard of care. If you see changes on your normal EKG that raise suspicion for a right sided infarct then a right sided EKG should be done. As with everything else in medicine, there should be an indication for doing something.

Ok, I'll bite on this one. Could one not say that by definition suspected ACS is an indication for a 15-lead ECG? I mean, if we're going to take a look at the heart why not look at the entire thing instead of just a piece of it? Especially when it takes almost no extra time or cost but has significant benefit?

[ERDoc]

Ok, I'll bite on this one. Could one not say that by definition suspected ACS is an indication for a 15-lead ECG? I mean, if we're going to take a look at the heart why not look at the entire thing instead of just a piece of it? Especially when it takes almost no extra time or cost but has significant benefit?

Because you can see evidence or right sided injury in a 12-lead. If you see any evidence then proceed with the V4R.

[akroeze]

Is it possible to have RVI with no evidence on the 12-lead?

[ERDoc]

Is it possible to have RVI with no evidence on the 12-lead?

Not that I am aware of, but I guess anything could happen. As with any other MI you will have reciprocal changes that will be evident on a 12 lead.

[captainstandup]

I agree with doc, I have never heard of an MI that cant be seen in some manner by the 12 lead. Even old tissue damage usually results in some changes, albeit subtle in some cases. But hey, I never say never in health care and I certainly have a great deal more to learn.

[akroeze]

Ok, I concede the point.