12 lead and oxygen

[CBEMT]

crotchity:

http://www.cardiosource.com/cjrpicks/CJRPick.asp?cjrID=4555

Full document: http://circ.ahajournals.org/cgi/content/full/118/10/1066

[VentMedic]

VENT,

I am going to disagree with you, I am JUST as familiar with ground EMS as I am with FLIGHT, I actually did work the ground in DETROIT no less.......Does NOT get any worse than detroit, trust me....

I have many friends who work ground all over the country, and the majority have protocols for retevase, and actually do use it.......I never said ALL cath labs would activate, I said, the ones with which I have experience both in Michigan, Arizona, Utah, Colorado, Oregon, Ohio, New Hampshire,etc....... will >90% of the time activate based on field 12 lead. I have personally delivered MANY patients both ground and air straight to the cath lab and bypassed the ER.....

You keep using California and Florida as your primary ammunition in all of your comments, You could NOT pick any two worse states for crappy EMS services and education standards.

Please remember, I also spent 11 years in Europe, so I am EXTREMELY familiar with what goes on all over the world...

Respectfully,

JW

John,

You have made many blanket statements about a lot of services in a lot of states and you might be surprised to know that there are services in those states that do not even have ALS in some areas and others may not all have 12-lead capability. While FL may not be perfect, it does provide ALS to all residents and there are some excellent EMS agencies in that state. You might also remember who did some of the first thrombolytic studies for EMS in the 1980s.

Post some of the protocols from those services you are familar with so we can see if their recipe states O2 or 12-lead first. Also post whether they transmit the 12-lead to either the ED physician or Cardiologist for viewing prior to arrival. Bypassing the ED can be done but...did one of the other 2 two physicians make the call? We get a lot of CP patients in the EDs everday and even with EKG changes not all will go directly to the cath lab. Some will be directed to bypass the ED and some will come in to the ED for more monitoring and tests. Hell there might even be a patient will NO ECGs changes that gets sent straight to the cath lab. Each patient can be different so blanket statements for one treatment to fit all is not a good way to do medicine...except for some EMS agencies.

[DwayneEMTP]

I can tell you for a fact that the hospitals in Colorado Springs and Pueblo will all activate on my word alone, despite a negative 12 lead. Though my protocols demand a 'clean' 12 lead if possible before activation.

But, should I activate based on s/s alone, which I've done once, there had friggin' well better be justification when I hit the doors.

So, not sure where you've worked Crotchity, but here 12 leads combined with a medics impression and assessment carry some weight.

Dwayne

[Jwade]

John,

You have made many blanket statements about a lot of services in a lot of states and you might be surprised to know that there are services in those states that do not even have ALS in some areas and others may not all have 12-lead capability. While FL may not be perfect, it does provide ALS to all residents and there are some excellent EMS agencies in that state. You might also remember who did some of the first thrombolytic studies for EMS in the 1980s.

Post some of the protocols from those services you are familar with so we can see if their recipe states O2 or 12-lead first. Also post whether they transmit the 12-lead to either the ED physician or Cardiologist for viewing prior to arrival. Bypassing the ED can be done but...did one of the other 2 two physicians make the call? We get a lot of CP patients in the EDs everday and even with EKG changes not all will go directly to the cath lab. Some will be directed to bypass the ED and some will come in to the ED for more monitoring and tests. Hell there might even be a patient will NO ECGs changes that gets sent straight to the cath lab. Each patient can be different so blanket statements for one treatment to fit all is not a good way to do medicine...except for some EMS agencies.

Vent,

Yes, I have made blanket statements, I have the experience and education to make those statements, and while I certainly agree with your above statements about ALS et al.....I think you might be a tad biased based on your experience in Florida and California. Each of us see things through different filters, and therefore express opinions based on those filters instead of looking at the bigger picture. I have spent way too much time in marital counseling to learn all that stuff, so I try to put forth majority opinions based on what I know to be factual. One cannot argue the fact that I spent 11 years in Europe and have done countless flights to Europe and Middle East, Japan, Australia, Israel, to have a big picture perspective at what is going on in world medicine.

I will be in New Hampshire visiting my best friend this weekend, I will get a copy of his protocols and post them for you when I get back. I will also dig out my protocols from Detroit, and send a few other emails out requesting hard copies.

Again, I answered the OP based on his limited info scenario, in which I would not arbitrarily stick a NRB @ 15l on that person. I have done this many times throughout my career, and not once has any ER, Cardiac Surgeon, or Medical Director ever questioned me on the process.

I realize that every patient is different, but, I have been fortunate to work in some progressive EMS( minus ARIZONA), HEMS companies and forward thinking hospitals, which has influenced my decision making process. To each their own however....

Respectfully,

Jw

[DwayneEMTP]

I can't believe that we are having this discussion, a patient c/o of chest pain should receive an immediate assessment along with cardiac monitoring, oxygen, aspirin unless contraindicated, a 12 lead ECG, IV access, labs should be drawn if you are allowed to do so & a pre-hospital checklist/screening should be completed. You might also want to consider giving nitro & pain medication like morphine prn as tolerated!

Yeah man, we get that, but did you get that the discussion surrounds the order in which these things should be done? Also, most people learned to regurgitate that sequence of events their first week of medic school. Why do these things? Why in that order? Should they be done differently?

Can you actually answer/justify your answer to the question from the original post?

And why can't you believe that we're having this discussion? Obviously it's gone on for pages, so there must be something to say, right?

Also, if you really want to impress then provide the science that shows Nitro and Morphine are beneficial to your pt.

Dwayne

Edited for clarification of a phrase. No contextual changes.

Edited December 2, 2009 by DwayneEMTP

[Kaisu]

arbitrarily stick a NRB @ 15l on that person

Did I miss it in the original posting about 15lpm via NRR? I never intended to imply that I would put hurricane force O2 on the patient. With no symptoms of SOB, they would get 2/3 LPM via NC... and yes, before anything else.

[Jwade]

Did I miss it in the original posting about 15lpm via NRR? I never intended to imply that I would put hurricane force O2 on the patient. With no symptoms of SOB, they would get 2/3 LPM via NC... and yes, before anything else.

Kaisu,

Hey girl, NO, this was NOT intended as a rebuttal to anything you implied. I simply stated this because, from my experience, this is what I see being done time and time again. This was not a personal reference in the least..:-)

Where in Havasu are you working? I am coming out that direction after the first of the year to do some teaching.

Respectfully,

JW

[kevkei]

You guys are kidding right ?

No, I'm dead serious.

You would withold treatment that could help for a diagnostic test that is worthless in the field ?

Yes I would and routinely do. You (and others) are making assumptions, I said withold the treatment (O2) until a baseline 12 lead is established and proven to be clear and readable (no artifact, intererence, etc). Once that is done, continue on with standard of care. O2 as appropriate, IV, ASA, Nitro, Morphine, etc.

The diagnostic test is the standard of care in nearly our whole Province as is early physician intervention (consultation) to triage to either PTCI (proimity, availability of cath lab, which cath lab, etc) or prehospital thrombolysis (tNk) , if warranted. This followed with Plavix and Enoxaparin (low molecular weight heparin).

I'm sorry, but this is one of the few definitive times where you do actually treat the monitor (12 lead/15 lead) with more importance than the patient.

And tniuqs, the Wellens discussion comes from a Cardiologist and 2 residents at UAH. Not specifically O2 alone, but our global treatment for cardiac ischemia (MONA if you will) has evidenced many occasions resolution of 12 lead indicators but our early 12 lead establishes evidence of the pathology. Hence why Cardiology loves EMS 12 leads.

[kevkei]

Post some of the protocols from those services you are familar with so we can see if their recipe states O2 or 12-lead first. Also post whether they transmit the 12-lead to either the ED physician or Cardiologist for viewing prior to arrival. Bypassing the ED can be done but...did one of the other 2 two physicians make the call?

I know it wasn't directed my way, but here is a link, the pdf was too large. Vital Heart Response - Dr. Robert Welsh

Here is our worksheet (protocol if you will). Read the 8th section from the top "Oxygen to keep SpO2 ≥92%" If the order is to indicate sequence of events (nothing specified as such), 12/15 lead occurs prior to O2, ASA, IV, Nitro (IV before nitro and after 12 lead? )

VHR Worksheet1.pdf

[Kiwiology]

Yes, in my humble opinion, the 12Lead in the field is useless unless you carry thrombolytics on your truck, and use them.

I say the 12 lead prehospitally is of benefit by allowing diversion to PCI capable facilities, prehospital thrombolysis and identification of things you just can't get with Lead II like bundle branch and fasicular blocks, LVH etc

Can also allow for more appropriate triage - you roll up to ED with a little old lady who was complaining of chest pain but now has none thanks to the GTN and morphine as well as no ECG changes so she'll probably end up in the hallway, have a cardiac arrest an hour later and croak out; but, if I whip out a 12 lead showing bad-ass ST changes, well, maybe she'll go for an angiogram straight away.

This study from Los Angeles none the less supports lower door to needle time in PCI; .... in Los Angeles for frick sake, where Paramedics rely on machine interpretation of 12 lead ECG to active STEMI facilities; ..... gah!