Nitro paste is NOT an emergency medicine drug – The Evidence
I have no idea why, but many paramedics clamor for including nitroglycerin paste in their drug bag. Baffles me. True, you don’t need to break the seal of the CPAP to give it, and you don’t need to use an IV. But this medication hardly belongs in the emergency department, let alone a 21st-century EMS rig.
Before I get to the most recent evidence, I first want to highlight this perspective about why prehospital use of paste doesn’t make sense.
Rant!
First off, let me ask: In what other medical emergency, where a patient is diaphoretic, ghost-white, and tachy-crazy, do we apply an ointment – stat!
Stat!
And why not? B...
Source: EMS 12-Lead - July 22, 2015 Category: Cardiology Authors: Brooks Walsh MD Tags: Dogmalysis Pharmacology Source Type: research
30 Day Challenge
Today is July 11 and I have not had a drink in 30 days.
Some of you may know that my mother suffers from advanced dementia and requires round-the-clock care. She is on hospice and I have been out on FMLA leave helping with her care (which is why I missed SMACC in Chicago).
This time away from work has allowed me to do some soul searching about life. Life is hard. Working in the emergency services is hard. Being a caregiver is hard. Being a good husband and father is hard.
I was drinking a lot. My mother goes to bed between 3:30 and 4:00 p.m. and my Dad and I would sit down at the kitchen table and enjoy a honey whiskey an...
Source: EMS 12-Lead - July 11, 2015 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized 30 Day Challenge Source Type: research
Computer misses it, but the medic catches it.
True fact: I failed out/dropped out of grad school in mathematics. But despite having little enthusiasm for topology or complex analysis, nothing drives me more nuts than people who say stuff like “I’m not good at math – just not a math person, I guess.” This attitude is not just incorrect, it’s harmful. Most mathematics is quite straight-forward, if you practice and study conscientiously. Same with ECGs.
Stratford EMS was called for a (quite) elderly woman who wasn’t feeling well. And of course, she lived on the 5th floor of a building with narrow, twisting stairs. Nonetheless, the paramedic Jay and his crew h...
Source: EMS 12-Lead - July 9, 2015 Category: Cardiology Authors: Brooks Walsh MD Tags: Uncategorized Source Type: research
Conclusion to 59 Year Old Male: Unwell
Conclusion
So what happened? The patient obviously got his rate controlled as stabilization (see Fig. 11) and then went for emergent cardiac catheterization where an ostial LAD lesion was identified and removed with suction thrombectomy. Although he now has a residual decreased EF (approx. 35%) and congestive heart failure, he has survived several years since his near-fatal MI and maintains a decent prognosis for the time-being.
For more discussion on the actual management of this case look forward to Part 2 of our conclusion next week. (Source: EMS 12-Lead)
Source: EMS 12-Lead - July 4, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Conclusion Vince DiGiulio Source Type: research
59 Year Old Male: Unwell
It’s the middle of the afternoon when you are dispatched to the residence of a 59 year old male with a chief complaint of general illness.
When you arrive on scene you encounter a middle-aged man in obvious distressed lying on a couch. He is pale, gray, diaphoretic, and drowsy. He states that he has felt drained for the past 8 hrs; unable to catch his breath or get up off the couch with a heavy sensation in his chest. 30 minutes prior to your arrival he vomited and felt like he was going to pass-out so he decided to call 911.
His radial pulse is faint, rapid, and irregular while his skin cold and moist.
HR – 1...
Source: EMS 12-Lead - June 29, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Vince DiGiulio Source Type: research
How to be successful at IV therapy – some advice for paramedic students
Image credit: Wikimedia Commons
In a recent thread at EMT Life a paramedic student wrote:
Just entering my 2nd semester of paramedic school. So far I’ve found the coursework to be the easiest part. Instead of being stressed over tests I’m stressed over IV’s. 170 sticks in overall my % sucks. Granted most of those were just “oh I wonder if that vein could be hit with this gauge” attempts to find what could and couldn’t be done. Now that I’m on the truck I know what veins are my go to. Still struggling mentally with it but over the last 45 sticks my % is approx. 75% first attempt suc...
Source: EMS 12-Lead - June 23, 2015 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized Source Type: research
DNRs, Falsifying Official Documents, and Compelling Reasons
Image credit: Billie Ward – Creative Commons
I originally posted this on my personal Facebook page but there appears to be a lot of interest so I decided to post it here also.
The Staten Island Advance newspaper reported on May 22, 2015:
Two FDNY paramedics are accused of lying about administering aid to a dying 71-year-old Dongan Hills man — aid they didn’t provide because they sympathized with the patient’s wife, who didn’t want him to be revived but couldn’t find his “do not resuscitate” paperwork, sources familiar with the case said.
I’m not excusing the falsificat...
Source: EMS 12-Lead - June 1, 2015 Category: Cardiology Authors: Tom Bouthillet Tags: administration-leadership Do Not Resuscitate DRN Source Type: research
What If We’re Wrong? Prehospital ECG Interpretation
Conclusions
After sorting through that huge pile of information, let’s start drawing some conclusions. Here’s the big three I’ve gathered from the above studies.
Computers are specific but not very sensitive when it comes to recognizing STEMI. When they say it’s a STEMI it usually is, but they also miss a lot of them. Their performance can be improved by ensuring good-quality tracings with mimimal artifact and no “Data quality precludes interpretation” message, but there is still a ceiling to their abilities.
Prehospital providers are more sensitive but often less specific than computer...
Source: EMS 12-Lead - June 1, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: What If We're Wrong? Vince DiGiulio Source Type: research
Snapshot Case: What Happened?
Snapshot cases are tracings where we do not have good patient follow-up—or sometimes even clinical information—but still feel there are points worth discussing.
This is a patient who required emergent cardioversion for unstable rapid atrial fibrillation.
What happened?
Tracing shared by Rob McDonald, and emergency department nurse in Queensland, Australia. (Source: EMS 12-Lead)
Source: EMS 12-Lead - May 26, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Snapshot Vince DiGiulio Source Type: research
Proficiency vs Deficiency… The Art Of Electrocardiography
Understanding the different types of assessments, assessment tools, and findings acquired from these assessments, are all part of proper patient care in both acute and chronic emergency medicine management, in every realm of the term “PATIENT CARE”. One of the most important tools, in both the prehospital setting and long term care, is the 12 lead ECG, which just like any other tool, requires attention to detail, probably even more so than other tools. We have to know when to use it, why to use it, and be able to recognize the information given to use through its use.
ECG INTERPRETATION IS MORE THAN A SKILL,...
Source: EMS 12-Lead - May 22, 2015 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg Source Type: research
Proficiency vs Deficiency… The Art Of Electrocardiography Analysis
Conclusion to 1st case:
This patient was admitted to the cardiovascular unit, awaiting pacemaker placement.
Another example of why we should not solely rely on the computerized ECG interpretation:
There is a sinus rhythm with LVH, physiologic Leftward axis (aVF is the isoelectric lead perpendicular to Lead I) at approximately -10 degrees. No primary (ischemic) ST-T changes with normal R wave progression and QT prolongation.
The computerized ECG interpretation is “SINUS TACHYCARDIA WITH 2nd DEGREE AV BLOCK 2:1 AV CONDUCTION”
Does this mean that we will give Atropine or stand by pacing for the 2nd ...
Source: EMS 12-Lead - May 22, 2015 Category: Cardiology Authors: Ivan Rios Tags: 12 lead ecg Source Type: research
Transcutaneous Pacing Success!!! Part 2
This is the second half of a two-part case presentation examining transcutaneous pacing. If you didn’t see yesterday’s post I highly suggest checking out Part 1 before continuing, but if you hate learning I suppose you can start here.
Yesterday we examined a series of tracings that depicted transcutaneous pacing (TCP) in all its stages: initiation, false-capture, intermittent capture, successful capture, and finally, spontaneous resolution of the bradycardia that necessitated pacing in the first place. It was a whirlwind!
Intermittent capture with the Lifepak 12 set at 150 mA and 80 bpm.
As we mentioned in that...
Source: EMS 12-Lead - March 20, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Transcutaneous Pacing Vince DiGiulio Source Type: research
Transcutaneous Pacing Success!!! Part 1
Anyone trained in transcutaneous pacing (TCP) needs to be able to identify the rhythm below instantly.
Successful transcutaneous pacing?
It shows a patient being transcutaneously paced at 80 bpm and 125 mA on a LifePak 12 [the strip is labelled 130 mA but that refers to a point just past the end of the paper, I promise].
Well, actually, it shows attempted pacing. Despite the generous current being delivered there is no evidence of successful electrical capture. Without electrical capture there cannot be mechanical capture, so the patient’s pulse at the moment is actually 10 bpm.
Here are the patient’s two nativ...
Source: EMS 12-Lead - March 19, 2015 Category: Cardiology Authors: Vince DiGiulio Tags: Cases Transcutaneous Pacing Vince DiGiulio Source Type: research
Revolutionizing Pediatric Resuscitation, JEMS Games Finals, and a Very Serious Topic #EMSToday2015
Friday, February 27
Okay, I admit it. I’m 43 years old and I can’t party like I used to. I needed a little help yesterday morning after ZOLL SHOCKFEST. But, I had an important meeting to attend with three amazing women who keep the trains running on time at EMS Today 2015 – MaryBeth DeWitt (@dewittmarybeth), Deborah Murray, and Amanda Brumby. It was really nice to put faces to names and share thoughts and observations about education, event planning, and social media. A.J. is incredibly fortunate to have these capable, professional women working behind the scenes to make EMS Today 2015 a success!
Exhibit...
Source: EMS 12-Lead - February 28, 2015 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized EMS Today 2015 Source Type: research
Meetings, Great Classes, and Celebration! #EMSToday2015
Thursday, February 26
My day started early (these blog posts don’t write themselves you know!) and then I was off to my first ever JEMS Editorial Board meeting. As the “new guy” I had resolved not to cause too much trouble. A.J. Heightman (@AJHeightman) was suffering a bit of laryngitis which gave everyone good-natured laugh at A.J.’s expense.
Everyone around the room gave a short introduction and spoke the things they were passionate about (or interested in) regarding EMS and then about the things they were concerned about. It was interesting to hear some of the common themes.
Passionate about:...
Source: EMS 12-Lead - February 27, 2015 Category: Cardiology Authors: Tom Bouthillet Tags: Uncategorized EMS Today 2015 Source Type: research
