Atypical AMI's

[AnthonyM83]

I was considering some more obscure, difficult, historical, or EMS system related topics until I found out we were presenting to our classmates.

Since, I can't count the number of times I've been handed off a chest pain patient because the "the 12-lead came back no STEMI", I figured a chance to educate would be useful to new people going to the field. Ideally, they'd retain at least the main point of the presentation, if not the details, and maybe even share it with their future medic parts at the FD's.

SO, coming to you guys.

Anyone have any specific suggestions or resources or cases on the topic?

I want to have a certain number peer-reviewed journal articles for the paper, but can use many other sources, too.

Case studies and anecdotal experiences can be worked into my presentation.

I'm good with the basic research stuff, but if you guys have any gems, please let me know.

Some topics I'd like to touch on:

-Diabetics

-Elderly

-Young patients (pediatric MI's, congenital conditions, etc)

-12-lead efficacy

-Field assessments beyond what's taught in basic medic courses

-Specific combinations of past medical history that puts patients at risk (other than generic cardiovascular history and atherosclerosis), maybe?

[cynical_as_hell]

I dont know how much I will be to you means how Im just an emt, but lets give it a try.

I have heard from the medics that I work with that 12 leads in the field can be beneficial, however, sometimes when somebody has a heart attack, you won't see a change on the monitor for up to 12 hours later. My understanding is that they could be having one right in front of you but when you put them on the monitor, they may still be showing a sinus rhythm.

In my area we dont do 12 leads in the field. The biggest reason is because everytime we bring in a cardiac patient and show the E.R. our strips, they just crumble them up and throw them away then do their own. And when asked why they do that, they reply with "We don't trust your monitors."

In regards to diabetics, im certain I don't have anything useful. I'm reminded of a call though where the patient had a glucose level of 1400. Maybe in being able to teach in this area, bring up how a patient with a significantly high glucose level can present. My patient was obviously altered, would go in and out of consciousness, was slightly combative at times, had a fever, and was shaking like she was cold. Maybe touch on the fact that sometimes when you get an error read on the glucose monitor, their sugar levels may be too high or too low for the monitor to be able to pick it up.

The elderly is kind of a fun topic and make for great patients because when you speak of the elderly, you are essentially referring to a group of patients that grew up not having the 911 system. One thing I have noticed with this particular group is that when they call 911, they usually truly need you. Also with this group, they should have called sooner than they did, but didn't want to bother anyone or thought they could take care of whatever the problem is by themselves. The elderly in the nursing homes will sometimes complain of something minor just to get out of that place.

And I have to touch on the pediatric section. One very valuable piece of information that everyone needs to know is that even pediatrics can have high blood pressure. Allow me to use myself as an example: When i was 13 I was getting a physical for a sport I wanted to play in. I was sent over to the er for evaluation because the dr was not certain about my blood pressure reading. When I got there and the hospital did their eval, they discovered that my bp was 200/184. They were stunned because as everyone knows, that is not normal by any means for a healthy 13 year old. After further researching, record pulling, and testing, the doctors discovered that my hypertension is secondary to a chronic kidney disease that I have. They discovered that I have one kidney that is the size of an infant's, and the other kidney is twice the size of an adults. The biggest mystery in all of this is that I had no signs or symptoms of having high blood pressure. So when taking a blood pressure on a pediatric, pump the cuff up to the same level that you would do with an adult.

I dont know if any of this will be helpful to you, but good luck on your paper and let us know how you did....

[CBEMT]

In my area we dont do 12 leads in the field. The biggest reason is because everytime we bring in a cardiac patient and show the E.R. our strips, they just crumble them up and throw them away then do their own. And when asked why they do that, they reply with "We don't trust your monitors."

In effect, saying "We don't trust YOU." I'd recommend finding out why that is.

I'm also wondering if hospital administration and risk management are aware their staff is operating in complete contravention to AHA guidelines and best practices.

[AnthonyM83]

I would imagine every ER has to do their own ECG at the hospital, just like every trauma center does their own head-to-toe assessment, on top of yours. Having your EKG come up negative doesn't rule much out, but having it come up positive is more likely to rule things in. Our local ER's always redo the ECG's, but in case something has changed or something was missed, but a STEMI in the field would direct us to a cath lab hospital and activate the cath team.

Thanks for the notes on the other topics. I'm trying to relate each subpopulation to AMI presentations. I like your pediatric HTN story. while I don't really think kids with c/o CP are having an AMI, it irks me when a legitimate assessment isn't even done on them because they're just 12 or just even just 25. I think it goes back to that screening for zebras, but treating like horses thing.

[cynical_as_hell]

In effect, saying "We don't trust YOU." I'd recommend finding out why that is.

I'm also wondering if hospital administration and risk management are aware their staff is operating in complete contravention to AHA guidelines and best practices.

First off, its "We don't trust your monitor" If you're going to reply to something, make sure you get it right and not twist it around. Trusting us and trusting our monitors are two different things. Secondly, our medical director has us providing substandard care to begin with out in the field and the hospital does nothing about it. My understanding however is that this is about to change now that the medical director works for our ambulance company as our personal medical director and our company wont allow us to provide care that is not up to standard.

AnthonyM83:

Im glad I could be of some help to you. Good luck and hope you find what you are looking for.

[CBEMT]

First off, its "We don't trust your monitor" If you're going to reply to something, make sure you get it right and not twist it around.

I twisted nothing. I suggested that what they say to your face and what they think could possibly be two different things.

Don't be so sensitive. I didn't say they had a GOOD reason to be that way.

[AnthonyM83]

I have a good amount of articles, but starting to write now, so thought I'd bump this just to see if anything new pops up:

I'm researching atypical myocardial infarctions for a presentation. Just wanted to drop by and see if anyone had noteworthy resources or source recommendations. I'd like to include diabetics, females, young patients, non-STEMI, the very old, and other conditions which might mask the typical crushing chest pain radiating to left arm/jaw with ST elevation.

The goal would be to educate and help medics in decision-making when deciding if patients should be transported ALS or BLS level (in systems where both automatically respond to the scene). My main source is pubmed and my textbook, but any specific articles or sources that stand out would be helpful.

[tskstorm]

http://eurheartj.oxfordjournals.org/cgi/reprint/27/21/2607

http://clinical.diabetesjournals.org/content/20/2/101.full

http://jic.sagepub.com/cgi/content/abstract/2/1/25

[mobey]

Anthony: Although I have no further info for you, I would love to see your paper once you complete it.

PM me if you are interested and I will trade you for my paper entitled "Cardiovascular disease pathology and management"

[VentMedic]

In my area we dont do 12 leads in the field. The biggest reason is because everytime we bring in a cardiac patient and show the E.R. our strips, they just crumble them up and throw them away then do their own. And when asked why they do that, they reply with "We don't trust your monitors."

Have you seen them do this in front of you?

Why aren't you attaching these to the hard copy of your report as part of the patient record?

Do you do your own 12-lead EKG interpretation or do you take the machine's word?

It is sometimes very difficult to get a good EKG in the back of a truck with artifact and other factors that can interfere with tracing. This has been a problem with some EMS agencies that rely on the machine and are calling in a lot of false STEMI alerts.

Now, back to the topic.

http://scholar.google.com/

Since this has been a major topic on news and talk shows, it might be good to know what they are telling the public.

Five ways to get ambulance workers to take you seriously

http://www.cnn.com/2009/HEALTH/01/21/ep.91...cnnSTCText?iref

Panic Attack or Heart Attack? http://www.womensheart.org/content/HeartDisease/panic_attack_or_heart_attack.asp

Edited May 21, 2009 by VentMedic