A Cardiac case

Great reminder of the importance of suspicion.

When taking care of patients with emergency symptoms, whether it is in the ED or in the field, we all start to recognize situations that give you a sense of impending doom. in the ED, the nurse's movements in and out of a room may catch my attention while I am working at my desk, and something tells me I should step into that room sooner rather than later. In pre-hospital cases, sometimes you just know that you are about to have a patient that is going to require your expertise in order to survive. It may be the tone of the dispatcher's voice, or there may be nothing other than your own gut feeling. We have all looked at someone, not knowing their vitals, history or current symptoms and instantly worried that they might die in the next few moments.

The case I had the other day was one of 3-5 patients per shift I see with chest pain. I heard the nurse bring the patient into the room behind me, and I did my work waiting for the ECG to be placed on my desk.I am not sure what caught my attention, but I distinctly remember them getting him into the bed. Then,  there was a delay in getting the EKG in my hands. For some reason, my gut said I needed to see his EKG before I started on another patient.

 Here it is:

He has no chest pain:

Not much to see, is there. So I thought, " Huh, my gut feeling was wrong this time"

When I went in to see him 10 minutes later, he looked uncomfortable and the QRS shape on the monitor looked very concerning.

He said that he was having chest pain again, like what had brought him in from work today. My "spidey sense" sense had told me to pay attention to this patient, and now my suspicions were confirmed.

Here is the EKG when he was having pain:

At this point he was sent to the cardiac cath lab and had a stent put in his right coronary artery.

A few things I will stress related to this case. 

Develop your gut feeling or " Spidey sense". It has really come in handy in the years I have been doing this job. If you listen to your gut, and find out it was inaccurate, learn from it and keep going. My gut feeling is something I have learned to rely on and not ignore it just because it is wrong on occasion.

Gut feelings have saved many a life in EMS. Just recently I was passed a note from an ED MD in town who says an Allina crew saved a patient's life. They had the gut feeling something bad was happening with the patient and insisted she be triaged to a critical room. There were no bad vitals and no significant exam finding. The providers just had a bad feeling. This turned out to be exactly where she needed to be when she nearly bleed to death from an ectopic pregnancy

Next, it is OK to do as many EKGs as you want. Keep trying to get a picture of the STEMI that you think is evolving.

Paul

Kudos

I got this email today and it was clear I needed to get this out to the people who are doing the good work.

Paul,

I just completed my review of 125 more EMS charts for the compression injuries study and I had to send you a note.

 

Allina paramedics (and EMTs) do an absolutely outstanding job of documenting their CA care. After looking at the quality of EMS runs sheets that are completed by other ambulance services, Allina is so superior in this regard that it deserves mention. There are so many useful details that the others just don't bother recording, and ImageTrend was a great choice compared to other tools I see. I am lucky to be trying to do this CA work here, rather than with another service. Whatever you are doing in terms of education around documentation, keep it up.

 

I recognize this sounds like more of a homer comment than something Bert Blyleven would say in a Twins game, but the recognition is important. This person looks at charts from many services in the area, so she has informed viewpoint.

Thank you for the good work you do.

Paul

Heart Block

This was a great case I helped with recently. This is a classic presentation of syncope in an older patient with no medical problems. He just kept passing out when he stood up.

First Point: ALWAYS do a 12 lead when the problem is syncope, and always leave them on the monitor. You never know what you are going to see.

So the EMS crew found him in the above rhythm and correctly identified 3rd degree heart block. He had no symptoms of chest pain. i often think of this happening with an inferior MI, but he did not have the clinical picture.

Point #2: The QRS was wide so they correctly did not try to interpret it for a STEMI.

By ACLS standards, the man is unstable, I guess. He is passing out, he is groggy and has a low BP, but he is not having pain or real dyspnea. This is the first challenge, should you pace him? Pacing means pain, and that means sedation and their goes your ability to use mental status and brain perfusion as a sign of cardiac output. These can get real tricky.

He got atropine, then external pacing and then versed because the mini-taser 80 times a minute gets a little uncomfortable.

So he presents groggy, twitching every .75 seconds and yet his pulse was 24. So the pacing was not effective at the time.

Please send me a note if you have ever felt like you successfully managed a patient with an external pacer. My experience is that you have to crank the energy way up just to capture the heart. And I define capture as feeling a pulse with each twitch, not just a change in appearance on the monitor. In order to get the energy that high, you HAVE to sedate them and I really think you have just complicated the whole picture.

My choice of management was to intubate him immediately so we could remove the patches from his hairy back.

Seriously, I chose not to pace him, watched his HR of 24 and asked him 300 times if he was still with us while waiting for the cath lab to be ready to put in a pacemaker.

And he did fine. My point is this. The decision making around pacing for bradycardia can be very challenging. I do not think that pacing is a great, successful therapy for bradycardia. It has it's own problems. Like the need for sedation and trying to determine if the pacing is really helping. So, follow your protocol, but be willing to critically think about your decision to pace and if you are really helping the patient.

Paul

Back to Blogging

Sorry about the lapse in recent posts. Sometimes I can't decide if I should post something just to post something or if I should hold out for riveting subject matter.

 

Prepare for riveting subject matter...

 

Our care goal for the year is going really well. All of the Allina Health EMS staff have changed their documentation patterns and I am very pleased to say that things are looking good.

 

The priority is good patient care, recognizing those patients that truly are at risk of having something bad happen to them and being as careful with them as you can.

 

When we launched this, we all talked about the increase in calls to MDs for medical control clearance. Well, for the month of May the care goal generated 31 calls to an MD for medical direction. If Lisa looks at calls that were made unrelated to care goal data, there were 14 that month. I am glad to say this care goal is not generating an overwhelming number of calls for medical control. I have not had any negative feedback from hospitals regarding this at all.

 

Now, we are seeing a number of cases where there should have been a call. So there is room for improvement. Interestingly, these are very often because the patient has persistently abnormal vital signs. Remember that there is a number range for HR and RR that the patient must fall into to be signed without a call to the MD. There is only one call related to alcohol where an MD call was not made and should have been.

 

You are doing a good job, thanks.

Paul

Documentation Request

I am going to use this communication medium as an opportunity to convey a request.

Nearly every call we go on involves a first responder of some sort. Some of those agencies have committed to providing an advanced level of care for the patients in their community. They are initiating care before we arrive, commonly administering medications under the medical direction of AH-EMS. We support those EMR services that want to do more, like the medications, with some stipulations around education and training.

For the most part, the only medications that the EMR services are doing are the ones outlined in the Minnesota state rule regarding "variances". The rule is for BLS ambulances services and allows them to provide glucagon, epinephrine via auto-injector, sub-lingual nitroglycerin and albuterol via nebulizer. The rule does not mention EMR services, but we use follow the letter of the rule for consistency when initiating the plans with the EMR services.

For clarification, there are no variances relating to procedures. I commonly hear people refer to an IV variance or a King airway variance. There is no rule in the legislature about those procedures. It comes down to whether or not the EMS medical director wants the group to do it. Of course, the responsible medical director would ensure proper training and review of cases.

This brings me to my main point. Two years ago, AH-EMS received a grant to study the effects of the care provided by our EMR groups. We specifically chose to evaluate the care provided by two of our groups doing advanced cares. Allina Health has a very talented group in the research consulting unit who was able to tie together the AH-EMS patient report with that of the EMR services we chose to study. They were able to link about 80% of the calls in the time period chosen. That equals about 10,000 calls where we have both the EMR report and the AH-EMS report for the same person. From a data perspective, this is great. the 20% gets lost in things like misspelled names, cancels of either party, etc.


What did we find?
That is the point of the research and it is not done yet, so you'll have to wait.

BUT, we did find out that everyone documents in a different way. Some people put EMR procedures under the activities tab, and then put "done by FR" in the comments, or just leave it under their own name with no comments. This makes it look like AH-EMS did the King,  for example, when it was the EMR who did it. This means that our data has a giant conflict because 2 groups are claiming the procedure and we can't be sure who did it.


So, here is the solution.

I ask that all of you document any EMR medications or procedures in the Prior Aid slider in the At Scene tab. That is what it is for, and we can search it with reports and know exactly who did what. We cannot search comment fields for things like " done by Bloomington PD".

So, I encourage you to change how you document EMR interventions. I know that there may be cases where it is not perfect for telling the story. But, look at what we have now. We have people using numerous ways to document the EMR care and if we are going to keep track of their work, review the cases and research it, it needs to be done in a uniform way. So let's use the Prior Aid slider in the At Scene tab.

In the name of research, I thank you.

How good is Allina Health EMS?

Hello,

I've been thinking about how we can make things easier on our staff at the airport, this may be a start.

I have just returned from a trip where I got a chance to learn about the EMS system in Great Britain. Interestingly, I found that they have many of the same challenges that we do. They are trying to improve their outcomes of cardiac arrest and are looking at the best way to do that. They are trying to develop processes to reduce the number of non-emergent ambulance responses and alternatives to taking everyone to the hospital. They have standard national protocols that are the minimum standard for all ambulance services. That means that they have a uniform set of medications and equipment.

There are national clinical performance goals that they take very seriously. At the end of the year, if it looks like they are going to miss the required marks, they cancel all meetings and send everyone into the field to work on the goals.  The medical directors are directly responsible for these goals and have to answer for them.

Their goals include response times, care of stroke victims and of patients with STEMI.

Their goals also include survival of cardiac arrest.
For reference, the Allina Health EMS  survival to hospital discharge rate is 14.4%. This is better than the average of Hennepin County, Minnesota or the US.

In Great Britain, the number is 7.5%.

You should be very proud of what you do.


Ultimately, I learned we have a very good EMS system. While we can lean from others about how to tackle some of the challenges in front of us, we do things very well.

Interesting Case

One of the reasons I went into Emergency Medicine is that on every shift, there is the potential for an interesting case. I suspect there are many people in Emergency Medicine and Emergency Medical Services who are of the same opinion. We all tolerate the mundane cases, the repetition of influenza cases in January and the long nights with no patients. You do all of this knowing there that there is still part of this job that gets your attention when you see something that you didn't expect, or haven't seen very often.

Look at the image above as I give you the details of this case.

This is a young person who came in saying he fell on the steps in the past few days and has vomiting and abdominal pain. Part of the reason he fell was that he was drinking, but he and his partner assure me that he had not overdone it and that his symptoms were not from a hangover.
He has normal vitals, but was very uncomfortable. I did a bedside ultrasound and saw no free fluid i.e blood, so I started into by speech about pain and muscle contusions and how unlikely it is that there is anything wrong internally.
Blunt trauma to the abdomen can cause damage to wither the spleen or liver, most commonly. The term used is spleen laceration or liver laceration, but they are more like fractures or bruises. With blunt trauma, that is the injury you worry about, unless the mechanism is atypical, like a handlebar to the abdomen or if someone throws a shoe at you. But "Who throws a shoe? Honestly."

When you have a focal impact to your abdomen, you can bruise your bowel which will cause pain. Then, once the bowel swells, you will stop passing food and you start to vomit. That process can take up to 48 hours and that did not fit really well in the case I am presenting here.

I kept looking at the patient and decided he was in to much pain to send home without formal imaging, hence the CT scan image you see above. What is outlined in green is the patient's pancreas and it is broken in half. This is rare, painful and has the potential for many long term complications. The treatment is placing a stent in the pancreatic duct using upper endoscopy. You do this because you don't want the pancreatic enzymes that normally digest food leaking into your abdomen and wreaking havoc on your abdominal organs.

An unusual case that is worth bringing up because it is easy to let your guard down when you hear a mechanism that so often leads to no significant injury. I even make jokes about how I see people who fall on the stairs everyday, yet I still brave the steps in my house.

Extra credit: Send me note and tell me what is represented by the dark area I have identified with an orange circle.

Paul