Wednesday, February 27, 2013

ECG Case #4: SOB & Cough x 2wks

70ish yoM presented to our ED & to our cardiology service with the following ECG. The pt has had a "cold" x2wks with cough & SOB, he was seen by his PCP about 1wk ago for same & was given antibiotics that have "not helped much."

The pt was brought in by EMS as he walked up to them complaining of worsening SOB & the fact that he could not get a ride to the ED.

If you were the crew, would you STEMI alert your ED to activate the cath lab? Is this a STEMI? An MI but not necessarily an AMI? If not, what else could be going on?


*** Answer below ***

The following patient sustained a significant anterolateral AMI at some point in the past, most likely within the last couple of weeks. To reference my prior chart from this week, the LAD occlusion would cause this type of distribution.

The old AMI is evidenced by:
1) pronounced deep Q waves in all anterolateral leads
2) poor (virtually non-existent) R wave progression of precordial leads - what does this mean? It means that as you go down from V1-V6, the R wave should progressively get bigger while the S wave gets smaller, with the transition point being somewhere around the V2/V3 or V3/V4 mark. There is none in this ECG, further suggesting an old MI.

Now what about the marked ST elevation with T-wave inversion in anterolateral leads as well as some in inferior leads? How come this is NOT new onset MI? Well given the very deep Q-wave in the said leads would indicate dead, scarred tissue which would be unlikely to reinfarct as it is already dead. The more likely explanation, and another cause of ST elevation, is a ventricular aneurysm.

A ventricular aneurysm is one of the many sequela of an untreated MI. The scarred, dead ventricular wall can no longer contract, yet it still experiences the fluid pressures that the rest of the working ventricle deals with. This weakened area balloons out creating an aneurysm within the ventricular wall, as evidenced by the above image (not mine, ECG was).

This aneurysm rarely ruptures as the scar tissue is elastic and is able to support the stretch; the more deadly complication however is the creation of a stagnant area of blood within the aneurysm that eventually clots... the clot can grow, and then dislodge emboli into the brain or other parts of the body. The brain usually takes the hit first because of the direct, straight off-shoot of the common carotids off the aorta.

The 2nd complication of LV aneurysm are the development of arrhythmia foci that may lead to VT and/or VF. A growing of the aneurysm over time will cause progressive heart failure, and eventual death.

On the ECG the manifestation is usually in the presence of persistent ST elevation with mildly if any elevated troponins. These patients are usually monitored over time, and if growing of the aneurysm is causing significant failure, then reduction surgery may be necessary.

Our patient had just that. The "cold" and SOB symptoms had truly nothing to do with his presentation, and were a red herring in this case. His cold probably was not getting much better given the fact that he was very slowly recovering from his heart attack weeks prior. Remember, a patient with an MI may also have a cold... those things are not mutually exclusive.

We did an echo on our patient which showed marked apical wall motion abnormality with a developing aneurysm and a well defined clot within it. His ejection fraction was currently preserved at ~50% (lucky man so far). He will be anticoagulated and followed closely by our cardiology service.

Learning point from this, the 12-lead looked atrocious at first glance. But if you break it down into components you can tell that this was old stuff... we were looking at an OLD MI, and the unfortunate sequela that can go along with it. Our patient could not recall any episodes of acute onset CP, SOB, syncope or any other worrisome symptoms that could pin point as to when he had his MI... he was just more weak than normal. This is another very important learning point for us... everyone that is elderly (particularly diabetic and/or female) presenting with atypical symptoms that may be mimicking an MI deserves a 12-lead... who knows what you may catch when you least expect it.

I hope this was helpful... as always feel free to share & spread the word. Knowledge in my opinion should be free... who knows one day you may be responding to my side...

Monday, February 25, 2013

Average National EMS Salary

Just a follow up on my earlier post about EMS compensation. $7.25/hr is the minimal wage in the US... this translates to just over $20.7K a year... if you work 40hrs/wk +10hrs/wk overtime.

Now take an average EMT starting salary of ~$9/hr for an EMS only agency (911 only, no non-transport) in my area... this translates into $25.7K a year... just $5K more than minimal wage.

You can see where this gets a little tricky trying to feed a family on $25K a year... and hence why many move on to other things.

Now several of you have "complained" that EMTs should not be compensated any more than the above given the fact that they just "drive people to the hospital"... yup, somebody actually said that... last time I checked my EMT partners do a little bit more than just "drive" for me... but my guess is those are the people that have no need for the above stated salaries.

I do not personally think that either I or you are "above" the rest of the society, however I do feel that a public service profession such as ours needs to be compensated appropriately. It is quite sad that our society values flipping burgers as equivalent to being EMT in terms of compensation... although on second thought, fast food chains do offer way BETTER benefits than does an average EMS agency.

Again I apologize for my rant/soapbox... but earlier comments in regards to us in EMS already being compensated appropriately... just struck a nerve with me... part of the reason for why I went further in my career is because I could barely feed myself, have money left over to go on vacation, pay my school loans or have anything really left over from my paycheck on my paramedic salary... let alone try & feed a family on it. 

Part 2:

Parting thoughts in response to all the Facebook messages about the above post.

This will be my last discussion on this topic for a while... maybe forever... but my question is:

Is the underlying issue here is that we are willing to pay nothing to EMT's with 110hrs of training as you guys put it... or is that we are entrusting our lives in someone with only 110hrs of training? 

Personally I'm not sure of any other profession other than public service, military and medicine where experience that you get on the job is quite honestly priceless. I would rather take a seasoned EMT as my partner over any brand spanking new or cocky know-it all paramedic any day.

Yet, this EMT with just "110 hrs" of instruction that I entrust to do pretty much everything gets paid the same as someone flipping burgers... so again my point is...

Are we ok paying someone with 110hrs of training $9/hr knowing that they will be the ones showing up on our worst day....


Is it that we are ok with someone showing up at our doorstep on our worst day that only has 110hrs of training & hence is why we pay them $9/hr...?

In summary, you guys made a very good summary of our profession... we as a society find it acceptable to entrust the life of our kids... our parents... our grandparents... and an assortment of other friends & family in someone with only "110 hrs" of training... and since those "professionals" have such limited training, we as a society pay them accordingly for their "level" of training... aka just above minimum wage... sigh...

Sunday, February 24, 2013

12-lead ECG AMI Summary Chart

Here is a little creation of mine. Feel free to share, steal, print, and use at your convenience... just give me credit ;) 

This is in my opinion is about as condensed of a summary of a 12-lead description as it can get. I took bits and pieces from a couple of lectures, books, and instructors, and put them into this chart. So if you have been struggling with recognizing exactly what each lead looks at in a 12-lead, and what kinds of pts present with each AMI, then this should help.

In this chart, I presented to you the location of the AMI, the leads associated with it, artery occluded, the most common presentation that goes along with it, and lastly the most common leads to see the reciprocal changes. If you are able to recognize everything on this chart & commit it to memory... if by looking at a 12-lead given to you, the entire heart comes alive... well then my friend, you would have achieved more 12-lead AMI recognition then the majority of the medical profession.

Remember this chart describes the majority of our patients, there will ALWAYS be variation, sometimes significant, in some patients... so use this as a guide, NOT as a RULE. Diabetic patients may have NO symptoms... a lateral AMI may have significant symptoms, and not always be subtle... etc.

Don't forget about the other causes of ST elevation that may mimic an AMI... if something is not making sense, it probably is not.

Hope this helps!

*For: paramedic students, nursing students, medical school students.

Wednesday, February 20, 2013

Quick Cardiology Review: ECG progression in an AMI

There seems to be a lot of confusion among students, nurses, paramedics and even doctors as to exactly what is the correct sequence of ECG changes that happen in an evolving AMI. 

Below I will list the CORRECT progression that you need to be aware of when seeing a patient that you suspect may have an ACS:

1) Hyper acute T-waves (peaked T-waves) - are always the first ECG findings found in a coronary occlusion.
Don't forget other causes of peaked T-waves such as hyperK+, benign early repol, among others.

2) Inverted T-waves - follow the hyper acute T-waves, and occur within 2-3min of occlusion.

3) ST segment DEPRESSION (indicating ischemia)- begins within 10-20min of occlusion.

4) Pseudonormalizaiton of the ST segment - occurs within 20min to hours... so what does that mean????

This means that before ST segment actually elevates (i.e. the classic evidence of AMI), the ST segment must rise PAST the isolectric line... past the baseline before it elevates... it means that you could be having an Acute MI, and your ECG looks absolutely NORMAL!!!!

This is why it is EXTREMELY crucial to do serial ECGs/12-leads every 10-20 min to CATCH the actual AMI if your initial 12-lead was normal and/or was showing non-specific stuff.

5) ST-segment elevation follows indicating now injury... dying cardiac myocytes!!!

6) Q-waves - occur within hours to days... they are the sequela of an MI... q-waves indicate a scar... dead myocytes :(

Remember the teaching point being: if you have a high clinical suspicion for a cardiac event, always do SERIAL 12-leads as you may actually catch the evolving MI... do a 12-lead when you first get to the patient... click analyze again while enroute to the ED... and one more time when you get there. Time is muscle... and one day you may save someone that otherwise would have been shoved towards the back of the triage area just by pressing the analyze button on your 12-lead just one more time.

Hope this helps to many of you that asked me for this explanation or were confused from the get-go.

**I will post a more full review of this topic with actual ECGs soon on my actual blog

Monday, February 18, 2013

Seizure ECG.

This was my pt that went into an active generalized tonic-clonic (aka grand-mal) seizure while attached to the monitor. I was able to catch the last bit of the full seizure and him coming out of it... as you can see in the first couple of frames he is still actively seizing while the last 3 frames, the muscle contractions become less frequent, but still evident every couple of seconds (right about the time my versed started working I'm guessing).

Learning point from this?
1) If you see rhythmic interference on your ECG (like in the last 2 frames), there's a good chance your pt is seizing.
2) If this pt was paralyzed from RSI, you would not have seen this ECG manifestation... their ECG would have been totally normal looking, but their brain is still seizing.


Sunday, February 10, 2013

MED MATH... A tutorial.

MED MATH: From a paramedic student fan... a quick tutorial by working through a problem... if you are a paramedic, nursing, or doctor student and have had trouble getting med math under control, then you may consider looking through this... I understand it is long, just take your time, print this out for ease of reading, or just look at parts of it... whatever works.

So here goes, gonna give it a shot... but be advised I am writing this at 0030 on a Fri night after having a glass of wine, so if I made some basic mistakes... my bad, I'm human too :) 

PROBLEM: You are at a rural hospital with a 85lb woman who is suffering from chest pain and SOB. The MD has ordered NTG drip @ 15mcg/min. The bottle concentration is: 100mg NTG/250mL.

The questions are as follows:
a. What is the pt's weight in Kg (no rounding)?
b. Using 60 gtt tubing, the pt should receive how many drops per minute?
c. How many mL/hour should she receive?
d. How many mg of NTG will the pt receive in the one hour?

***Disclaimer: the following piece requires you to have a basic understanding of med math & basic units***

So when I break down med math, I try to make it as easy as freaking possible. Let's start with the 1st rule of med math... lbs to kg conversion... many of you probably already knows this, and if you don't, then LEARN it. The easiest way to make the conversion... take the lbs, divide them by 2, and subtract 10% from the remainder to get the kgs... say whauuttt??

Here is an example from above:
85 lbs divide that by 2... how the heck do you expect me to do that on 85 lbs??? You would ask... well I don't, round that jank either up or down whichever way is easier to make it an even number... so in this case I'll round up to 86lbs.

So.... 86 lbs/2 = 43... subtract 10% from 43, which in this case would be 4.3... but again, make math easy... what's easier 43-4 = 39 kgs or ~40kgs ..... or 43-4.3 = 38.7kgs... yea, I'll go with the 40kgs.

86lbs/2 = 43 - 10% = 43 - 4 = ~~40kg

Now I understand that the above says "no rounding," but in real life as you are flying down the interstate hitting every freaking pothole, and your patient just got a pulse back, and you have 22 seconds before he codes again... I don't really give a shiza about rounding.... so real life = don't care about rounding... fake life (as in on tests) sure do the full thing & use 38.7kgs.

So anyways now you have 40kg patient to mess with... how do we answer Part B, C & D???

Again make it as easy as possible... I personally like to make everything into a 10 or 100 or 1000... cause it twirks my brain trying to figure out the concentration by taking 100mg/250cc, and how exactly that translates into the drug concentration per cc. Now this is how I do it, and you can do it this way, or not, or do parts of this, whatever floats your boat.

100mg of Nitro is to be put into 250cc bag... so technically if you take 4 bags of 250cc and make it an even 1000cc bag of saline... you would need four 100mg nitro vials... right? you following me??? If you are not, then stop, and take a breather.

If you follow that reasoning:
100mg of Nitro put into a 250cc bag is the SAME thing as putting 400mg (4vialsx100mg) into a 1000cc bag.

That gives us a concentration of:
400mg/1000cc or 0.4mg/1cc or 400mcg/1cc (if you don't know how to convert mg to mcg, then look that jank up, again I'm assuming that you have a basic understanding of units here, if you don't no worries, just look it up.

Since concentration of 100mg/250cc is the same as 400mg/1000cc, this means that you have a concentration of 400mcg/1cc for either way you do it, whether it be 100mg/250cc or 400mg/1000cc, it is STILL 0.4mg/1cc or 400mcg/1cc

So for EVERY 1cc that drips into a patient, they will be getting 400mcg (or 0.4mg) of Nitro... the equivalent of a sublingual...

The doc ordered the rate to be at 15mcg/min... how the hell do we do that? Well think about it, if you have a 60ggt set... this means that 60 drops of the IV make 1cc, for our scenario we now know that our 1cc has 400mcg of Nitro:
60ggt = 1cc = 400mcg.... but we only need to give 15mcg... so here is when math gets a bit harder. Our goal is now to figure out exactly how many drops equal 15mcg, when we know that 60 drops = 400mcg.

By that reasoning:
400mcg/60ggt... why are we doing it this way? well it would be useful to know how many mcg are in EACH drop...
Now you can use a calculator or you can just do it the old fashioned way... or you can just break the fractions down... 3 ways of doing it:
1) Calculator
2) Old fashioned paper & pen
3) Break the fractions apart... I'll show you #3, as the other two ways you should already know (if you don't, buy a calculator OR review Chapter 2 in your 4th grade math textbook)

Break fractions:
400/60 same as 40/6 same as 20/3 same as ~7/1 or ~7mcg/1drop... this means that you would need to give just a little bit over 2 drops to get you to 15mcg/min.

So our answer is ~2 drops from your 60 drop set per minute! Now that's near about impossible to do with precision manually, unless you have an IV Pump.... but it's a fake scenario so we'll play along.

To answer Part C: if you are giving 2 drops/min, then it goes without saying that you give 120drops/hr (60min x 2 drops =120)... 120 drops = 2cc/hr (or 2ml/hr)

To answer Pard D: if you know you gave 2cc of nitro at 400mcg/cc... then the patient got 800mcg of nitro in 1hr (400mcg x 2cc in the 1hr)

This is a crap load of information, and some of it may be rambling on my part... again my bad, I'm tired & wined up... try printing this out or using a different medication & working a similar problem through using this method. I hope this helped.

Friday, February 1, 2013

It's the little things.

Received an email from an old crew member of mine in regards to a call that was run by my crew a long time ago (preceded me by about 2yrs)... but nonetheless was run by my friends & colleagues so worth mentioning.

The call was for 3yo girl that was a near drowning at a local pool 15 years ago... when they arrived on scene the child was already out of the pool, crying & inconsolable by neither family nor friends. She was transported to the local peds ER for observation but continued crying her heart out during the trip. One of the EMTs pulled out a teddy bear (that we standardly carried in our trucks) and gave it to the girl... who immediately cuddled it & stopped crying. The only treatment that she received... was the teddy bear. Minimal vital signs, nothing else...

Fast-forward to this week, and my friend says that he ran into the father of this "child" (they've been colleagues for some time), and asked how his now college aged daughter is doing... to which the father replied... that she has slept with this teddy bear that my EMS crew gave her every night ever since... and when she packed off to go away to college that it was the FIRST item that she packed.

Many of us get into this "EMS" business to drive fast, play with sirens & flashy lights, "save" some lives, etc... however, the reality of the matter is that we rarely get to "save" lives... the calls where we literally pull somebody out of the brink of death are few and far between... the calls where a firefighter pulls a screaming child from a burning building is even rarer... what is more common are the little things... it is the fact that we make a difference unbeknownst to us... we put an invisible dent... a permanent scratch into people's lives... we affect them in some shape or form... we rarely truly "save" them. Our gift is the fact that we are oftentimes the first people to be there for someone's worst day... no one calls us because they are having a good day... what we fail to realize is that many a times we "save" them just by showing up... just by caring.

Whether it be holding the hand of a crying mother whose baby just had a simple febrile seizure... giving a neb treatment to an asthmatic & watching the veil of breathlessness slowly pull away... doing "everything" to save a cardiac arrest that never had the chance of making it for "family's sake"... just showing up at the right time to inadvertently intervene in a young man's near suicide... or just giving a teddy bear to a crying child. These are our calls. These are our saves. This is when we show up... and this is what we do. Never underestimate the impact that you make every time your foot steps through a door of someone's house... every time you show up on scene of a call that on the surface may never have needed an EMS in the first place...

No matter what facet of medicine I have been over my last 13 years, I can count on only two hands the number of patients out of the thousands that I've seen that were genuinely pulled away from death by me....... but I have no idea how many of my teddy bears made a difference... I hope all of them.