12 lead and oxygen

[tniuqs]

'Jwade'

Well, <55 & >35 on the age! I don't give out personal info on a public forum. OLD ENOUGH to know what the hell I am talking about!

Were your REMT-P certs recognized in the country's you have mentioned ?

Interesting reply, oddly your name your degrees, your married to a Gas Passer, your lecturing agenda and once you stayed in a holiday in.

2002 - 2010 That would equal 8 years +/- a month or two. > than the 5 years you quoted in your earlier post.

I thought the # of years was 11 in Europe (maybe I am wrong) so what operation in "medivac" were you employed by in Europe, on the "gas guzzling" Falcon 40/50 or the "flying cigar tube" Lear series or C-130 or were you doing repat's on commercial airliners ?

Just wondering is all, perhaps we have some friends in common ?

Germany to be exact, Are you familiar with Medicine at the University of Heidelberg?

Ah Germany those folks make a FINE beer!

Ever been to Siberia or Kazakhstan or the gem called Sakhalin Island ?

cheers

Edited December 2, 2009 by tniuqs

[Paramagic14]

This is great, this is why this forum is so amazing. Something so "basic" if you will causes so much debate. I know one person was less than thrilled about the OP being so open ended BUT I did that on purpose to see where things would go. Another person wanted to know where this came from and it simply just came from a discussion I had with a fellow paramedic. We each had opposing sides to the matter.

My stance on this issue is I personally wait until the 12 lead is finished with a clean baseline as long as the pt is NOT in any respiratory distress. My opinion, like some others, is that you want to get the earliest possible picture of the heart prior to any interventions/meds and oxygen is technically a med. Then if you do any subsequent 12 leads OS or En Route you can observe ANY changes that occured... BUT like I said I would NOT withold ANY Tx from a pt that is needed. If the Pt is not in any respiratory distress than in my humble opinion I believe you cant wait the extra 25 seconds to get a 12 lead... ANd yes, that is what you have your partners OS for. They could be setting everything up while the 12 lead is being completed that way it is ready to go. Also, no 15lpm via NRB was not specified, I was actually meaning any sort of oxygen at all. I also beleive this is where not being a cookbook medic and thinking "outside the box" comes into play.

Now, if any of you would like I could post a couple different Chest Pain scenarios with their OPQRST SAMPLE, pertinant neg's and etc and we could all post our opinions or we could continue this great open ended debate.

Respectfully,

Paramagic14.

[tniuqs]

With the Kind Permission of Paramagic in PM:

Lets put some Meat on the Bones of the this scenario and make it less open ended and theorums proposed ?

You have a pt c/o chest pain. pt denies sob and there is no evidence of an increased work of breathing. pt speaks in full sentences. My question is: if the pt is not in any obvious respiratory distress, do you wait to put the pt on oxygen until the 12 lead is finished.

Same Criteria as above, with a twist or 2 ....

Start time 10:00 hours MST (winter conditions)response to scene 20 minutes.

Patient is located at 6000 ft asl. (remote area 1.5 hour transport time to closest rural facility)

NO HEMS available due weather, Closest Cath Lab 3 hours from rural facility and is 3 hours and FW only)

Total time of Transport (all going well 6 hours transport to urban facility with Angio capabilities)

Age 55 y/o Male

Wt 82 kg, Ht 6 ft.

PMHX: of Asthma (not on routine RX)

Meds: ASA 325 mgs today for H.A. maybe he had too many beers evening prior.(Pt States)

Onset of "very mild" CP discomfort, uncertain as time of onset (poor historian as to event)

Associated c/o a sore left shoulder, mild SOB upon exertion.

Colour unremarkable, Warm, No diaphorisis.

Pulse Oximeter not available.

Pulse 88 regular.

RR= 20 not labored.

BP = Not taken ... I can't find the gauge says the First Responder, your partner is an EMR.

Initially only 3 lead available (there is a 12 lead available if requested)

Lets Start with the scenario as if one does not have all the bells and whistles and build on that.

Comments Questions Advice ?

Edited December 2, 2009 by tniuqs

[letmesleep]

"12 Leads are worthless"

"12 Leads save lives"

"SPo2 should be....."

“My protocols say this"

"My protocols say that"

Come on, you are all very intelligent people, right? Treat your pt, not your monitor. If the pt is in no real or immediate distress then use your brain about o2 v. 12 Lead. If your pt is gasping for their last breath.....we may need some o2 at the minimum, but use the skills (education or experience) you have. I stopped reading after page 3 because I couldn't take it any more. Even with thrombolytic therapy available on a truck, are you not going to move forward with good old MONA?

TREAT YOUR PT!

[mobey]

Looks like we may have a BBB. Need a 12 lead to know for sure though. In the following order please.

12 lead

O2 @ 5lt Nasal cannula.

Listen to air entry.

When last seen a Dr?

Excersize?

Career?

Smoker?

Drinks last night... OK. Does he drink everyday?

Street drugs?

Family Hx?

[tniuqs]

LOL 'mobey' you lurker you, you just love this stuff

Well Looks like we may have a BBB. Need a 12 lead to know for sure though. In the following order please.

As you wish:

Well electrodes for the 12, damn things all dryed out, getting the jelly out to reactivate them ... but 12 lead is on the way

Is this Left or Right ? and your not concerned about ST ?

BBB in face of possible MI .... is it and Query back at you whats outcomes L vs R ?

12 lead

Patient says he had one done a year or 2 ago (routine medical) ... his MD said something about well thats normal as they get.

O2 @ 5lt Nasal cannula.

Patient says what the hell for ... I don't need this you just want to make money off me!

Listen to air entry.

Air Entry acceptable in all fields noted minor creps/ crackles RLL, does not clear with cough.

No wheeze, No coarse Rhonchi.

When last seen a Dr?

For Drivers Medical about 2 years ago ... why ask's the patient is something wrong ? hell I could loose my licence !

Excersize?

Mild SOB when walking in snow at 6000 ft.

Career?

Consultant Type ... has an attitude.

Smoker?

PMHX 22 pack years .. has tried to quit many times.

Drinks last night... OK. Does he drink everyday?

Just on days off ... moderate drinker, note gets a bit agitated with this question.

Street drugs?

Smoked Pot in 70s and 80s ... Who didn't he states.

Family Hx?

Just lost his 84 year old Mother yea some heart problems .. says Damn hospital killed her,

Father to CA when he was young man.

Siblings unremarkable.

Grandparents died at 96 and 94 y/o

OH EMR finds his gauge ... BP 138/98 (auscultated)

Also states I forgot about it, only "got" asthma 14 years ago was in Hospital BAD DOUBLE Pneumonia, they gave me this biotics stuff and steroids ... it sucked.

Edited December 3, 2009 by tniuqs

[mobey]

I feel like I know this pt .... wierd.

We could always do a 9 lead....... But I'll wait for the jelly Wide QRS yeah, but I'm looking through a filter or two with the 3 lead. Of course if it is new onset (Which it sounds like it is re: drivers medical) it can be indicitave of MI.

When did he take that ASA?

Any allergies?

OK... I need to know a little more about the pain.

What was he doing when it started?

anything aggrivate it? deep resp? palp? etc...

0-10 rating?

Start an I.V.

I am considering a Nitro trial. But I'll stop and let someone else play too.

I will be explaining all procedures to this patient, and asking only pertanant direct questions since he seems a little annoyed with my presents. I will also let him know we do not charge by the treatment here..... he will get the same bill with or without O2.

Edited December 3, 2009 by mobey

[Jwade]

Were your REMT-P certs recognized in the country's you have mentioned ?

Interesting reply, oddly your name your degrees, your married to a Gas Passer, your lecturing agenda and once you stayed in a holiday in.

I thought the # of years was 11 in Europe (maybe I am wrong) so what operation in "medivac" were you employed by in Europe, on the "gas guzzling" Falcon 40/50 or the "flying cigar tube" Lear series or C-130 or were you doing repat's on commercial airliners ?

Just wondering is all, perhaps we have some friends in common ?

Ah Germany those folks make a FINE beer!

Ever been to Siberia or Kazakhstan or the gem called Sakhalin Island ?

cheers

1. Yes and No

2. I don't understand the statement.

3. You are misunderstanding what Vent and I are speaking about. 8 years is the time HVA has been using 12 leads as opposed to her " About 5 year quote for Michigan"

4. All of the above minus the C-130, with the addition of a Hawker, G-4, G-5!

5. Drop me a PM, we could have some friends in common for sure.

6. Bitburg, Weisbaden, Landstuhl, Ramstein, Took an american out of a Tel-Aviv Hospital a few years back when all of the suicide bombers were blowing crap up on the streets...Made for an interesting ambo ride under military escort, and even more interesting security search at Ben-Gurion Airport. Those guys don't F around!

7. To your scenario questions, DO we have Retevase available to use?

Respectfully,

JW

[kevkei]

I know there are semantics and generalities in your statement, but you should always treat the patient before you treat the equipment. When I started out, we did not have glucometers, pulse oximeters, or 12 Lead, and it amazes me to see how many Paramedics trust the equipment over patient presentation, history, and signs and symptoms. The first thing I did for any new Paramedic on my truck was to take all of that equipment away, so that he had to assess the patient first.

crotch, I completely agree, I've never suggested not treating your patient. That said, when you have the tools available to you, you need to use them to treat the patient based on quantitative data otherwise you are going the 'coma coctail route'. Like any tool, if used properly, it increases and/or narrows sensitivity and specificity.

What do you do with a patient with no chest pain or anginal equivalents but you have a 12 lead that screams of LCX infarction? Do you treat the patient? My position is and has simply been, do a quick 12 lead before doing anything else to intervene, then continue on with the rest of your treatment.

I still see there hasn't been any response to the protocol I posted earlier, good, bad or indifferent.

LOL 'mobey' you lurker you, you just love this stuff

Well Looks like we may have a BBB. Need a 12 lead to know for sure though. In the following order please.

As you wish:

Well electrodes for the 12, damn things all dryed out, getting the jelly out to reactivate them ... but 12 lead is on the way

Is this Left or Right ? and your not concerned about ST ?

BBB in face of possible MI .... is it and Query back at you whats outcomes L vs R ?

I'm going with RBBB, but not entirely until a 12 lead. In RBBB, I would be concerned with elevation. In LBBB not so due to early repolarization and is an infarct imposter. What I would be concerned about in LBBB is new vs old. New onset, could be treated as conventional infarct pattern. I'd hold off on Retevase though.

Generally, LBBB has a better outcome than RBBB. RBBB (the right bundle of His) is more delecate and more sensitive to progression to a complete heart block. Hemiblock, fascicular block. 1st degree, second I, II, 3rd (complete)...

I'd be looking at the long haul, and best get going. I'd be preparing for atropine, inotropes and/or pacing down the road.

Oh, and due to to elevation, I'd probably look at going to an NRB, partial pressures and all.

- O2, IV, continuous monitoring, serial 12 leads, I'm happy with the ASA but could go with another 160mg PO due to transport time (unknown ECASA?). I'd like to see a 12 lead to, which would have been done before anything else

[mobey]

Oh BTW...

Since we have such long transport times I ASSume we were diligent enough to call TNTDiagnostics and round up some bedside troponin kits eh??