Here’s my presentation from the VA EMS Symposium on 11/08/2013.
In case you missed it this week:
Have a great weekend!
This is part II to "37 year old male–CC: Chest Pain". You may wish to review the case.
So, while many of our cases are straightforward, this one is not.
But hey, our patients don't read the textbooks!
First, let's review the chief complaint:
Our 37 year old male had "chest tightness", but complained of lethargy and "chills" for at least a couple of days. While we must take the complaint of chest pain seriously, many of you pointed out that the history did not seem like typical ACS. We can't blow off chest tightness, but the history is no slam dunk.
Here again is the 12 lead ECG:
There is sinus rhythm at a rate of about 83 bpm. Axis is normal. QRS is slightly widened. PRI is normal, and we can debate whether or not there is slight PR segment depression. There is some artifact present. Using the TP segment, there is slight (<1mm) STE in leads II, III, aVF, V5 and V6. If you use the PR segment, which may have some slight depression, you will see a bit more ST elevation. All ST segments are upsloping. Regarding V2-V4, is there any ST elevation? Some will say yes, but there is some wandering of the baseline, and I am not convinced. If there is any, it is a small amount. All ST segments seem to be concave up. There is no reciprocal ST depression. We do not have the computer interpretation/measurements for this ECG.
What do we make of this ECG? Again, as in the history, no slam dunk. I think we can realistically consider three possiblities:
- Early repol
ACS: Was it reasonable for the crew to run this as ACS? I think so. Even if the story sounds a little odd, we can't rule out ACS based on anything here. Does the ECG show STEMI? The constellation of changes we have is not really consistent with the ST elevation of STEMI. Some may point out the inferior ST elevations, but where is the ST depression in aVL? We don't have it, and if it were inferior STEMI we should see it. In fact, there does not seem to be any reciprocal depressions anywhere.
In his most recent post, Dr. Smith writes: "Does inferolateral STEMI also have reciprocal depression in aVL? In my experience, yes. I have yet to see an inferolateral STEMI without some reciprocal depression in aVL, in spite of the lateral ST elevation in V5 and V6".
We can treat for ACS, but I don't think anyone is activating the cath lab based on this ECG.
Pericarditis: The favorite choice in the comments section was pericarditis. The history, especially feeling "sick" with "chills" for a few days opened up the possibility of infection. On the ECG, we have some widespread ST elevations, although not a large amount. There seems to be some slight PR depression, which is why I used the TP segment to measure the STE. The axis is towards lead II but slightly away from aVL, so I think the axis is somewhere between 70-80 degrees. This could be consistent with pericarditis, which is usually towards 60 degrees.
Early Repol: Could this be early repol? With slight concave up ST elevation, it could also be early repol and his normal baseline ECG.
Playing the odds, we can recall that pericarditis is in fact a relatively rare diagnosis.
In his most recent post, Dr. Smith writes that "baseline inferior ST elevation (early repol of the inferior leads) is more common than pericarditis, and if a patient complains of chest pain, and happens to have baseline inferior early repol, they are likely to get a diagnosis of pericarditis if they rule out for ACS".
How do we manage our patient? I don't think we can tell from this one ECG what the issue is. The ECG is non-diagnostic. As I said earlier, I think it is reasonable to treat for ACS. While this case may not scream ACS, we can't rule it out either. It doesn't appear to be STEMI, so I don't think we need to activate the cath lab.
Supportive care is in order, but what I really think would be helpful are serial ECGs. We may see evolutionary changes of ACS or of pericarditis, or we may see no dynamic changes at all. But it would probably give us more insight into his condition.
In the ED, echo and troponins would likely give us the diagnosis.
So how did the crew handle our patient? They opted to activate the cath lab and treat with ASA and NTG. Upon arrival at the cath lab, the cardiology team is split as to what to do before finally deciding on angiogram to rule out any blockages. The cath was clean.
The final diagnosis was "reaction to medication". Apparently he had not been compliant with how to take his regimen of pain meds.
This case was not straightforward, but sometimes these types of cases can be the most interesting. They inspire a lot of great comments and discussions as well. Thanks to all who participated!
This excellent case comes to us from Paramedic Jack Buckle. Thanks Jack!
You and your partner are in the middle of a busy shift, when you are dispatched to 37 year old male complaining of chest pain.
It's almost 2pm, and a balmy 78 degrees.
You arrive to a well kept house and find your patient sitting in his kitchen. He looks pale, but you don't notice any obvious distress.
"How can we help you today?"
"I just haven't felt well for a couple of days. No energy. Chills. And I've been nauseous."
"What made you call 911 today?"
"Well, to be honest, I started having some chest tightness today and I got really scared."
His discomfort, 6/10, is poorly localized and non-radiating. He describes it as "intermittent". It started when he was at rest, and began about 2 hours prior to calling 911.
After talking with your patient, you understand that he suffers from depression stemming from a rugby accident that left him with a severely painful back condition.
In fact, he has previously undergone L5-S1 fusion surgery. He takes several pain meds for this chronic condition.
Although he states that during a recent hospital stay (related to back pain) he had to be on the cardiac monitor (he doesn't know why), he denies any history of cardiac problems, and no allergies.
- Pulse: 78 regular
- BP: 141/90
- RR: 20, unlabored
- SpO2: 99% on high flow O2
- Skin: pale, cool and dry
You acquire the following 12 lead ECG:
You are 14 minutes from the community hospital, and 22 minutes from the nearest PCI center.
YOU MAKE THE CALL:
What do you think is going on with this guy?
Where should you take him?
How should you treat him?
"For heaven's sake man, treat the patient not the monitor!"
Ahh, the angry cries appear every time we post a difficult case with a challenging ECG or treatment decision..
The attitude seems intractable, despite our best efforts.
Over a year ago, I wrote "Treat the Patient not the Monitor?", and not much has changed since!
So, I got to thinking. Where did this come from anyway? What were the intentions of the originators of "treat the patient not the monitor"?
In search of answers, I visited treatthepatientnotthemonitor.com, but surprisingly found nothing.
I am left only with my theories and opinions.
Back in the day, decades ago, I'm sure all of this wasn't an issue:
Pulse-ox? Portable cardiac monitor? I don't think so!
However, as the advent of portable medical devices made its way to EMS, educators and skeptics alike told cautionary tales about not treating "the monitor"– just look at your patient!
There are the classic examples we are all familiar with :
You put the pulse-ox on the patient with good color and no signs of respiratory distress and it reads 88%.
HE NEEDS O2 STAT! Well, of course not, because we treat patients not monitors!
Because measuring blood glucose is considered a "vital sign", you check it on an A/O patient (come on, you know some of you do it) and it reads 62.
HE NEEDS DEXTROSE STAT! Well, again, not so fast, because we are treating patients not monitors!
It is a good lesson, right? We do not treat numbers on a machine, we treat living breathing patients, and sometimes we just don't know what to do with the numbers.
By the way, cardiologists are having somewhat of a similar issue with high sensitive troponins. Because they are so sensitive, more patients without acute ischemic heart disease are showing positive readings, and now it is not clear what to do with all of them.
In Treat the Patient Not the Monitor -Part I, Rogue Medic writes that citing these words is "dangerous in the wrong setting". I couldn't agree more.
What exactly is the wrong setting? What is the right setting for that matter?
For starters, it comes back to our patient assessments. Can we assess a patient without the help of technology? Of course we can.
Will that assessment be as thorough and accurate as it could be? Well, maybe not!
Our technology is a key part of our assessment. If used in the correct setting, it adds information that we might not have been able to obtain otherwise.
The key word, though is "Context".
We should have a reason to use whatever technology we are using. In the setting of an AMS patient, getting a blood glucose reading makes sense to me. It is the proper context. If a patient is short of breath, pulse pulse-oximetry, or even better, capnography makes sense to me. If a cardiac etiology is the suspected cause of a patient's presentation, the monitor makes sense.
What does not make sense to me is the blind usage of this technology on every patient. I know it is done. I know people can make good arguments for that, but it doesn't work for me.
Here's why. Without the proper context, I feel like i might not know what to do with the results.
As I mentioned earlier, many medics routinely obtain blood glucose readings on every patient as a "vital sign".
My dilemma is this: Do I have a clinical reason to obtain this information? Will it alter the way I treat my patient?
Does he have a CVA or hypoglycemia? Of course, I'll check the BGL. But check it on everyone?
If i do this, what happens when I get a reading of 62 on an alert and oriented patient?
I have two choices:
Option 1: I treat the number and give my patient glucose. Well, I'm not going to do that, because my patient is not altered and doesn't need it.
So I go for Option 2: I simply ignore the number. Write is off as an "erroneous".
The problem is, If I am not going to use the reading I obtained, why am I getting it in the first place?
I don't use pulse-oximetry on everyone, and I don't routinely obtain a 12 lead on every patient encounter either for the same reasons.
I realize that right now, many of you are thinking, "see, even HE treats the patient and not the monitor!"
This is where i differ.
It all comes back to context. Clinical judgment means using all available information to assess the patient and find out what is going on. Of course, that does not mean blindly following the monitor, but it certainly does not mean ignoring it.
The reason "Treat the patient not the monitor" does not apply to the cardiac monitor is that used properly, it can give us information that we could not otherwise obtain. You can not look at a patient and determine whether or not he is having a STEMI.
Do we still examine our patients? Hands on, getting a feel for the pulse, their skin condition? Of course we do. But there is so much more to assess.
The fact is, there is no other surrogate for the monitor. We can not "look at our patients" and have an idea of what the monitor will reveal. That is quite different from blood glucose, NIBP, pulse pulse-oximetry, etc where there will be signs and symptoms of what those "monitors" will show.
The cardiac monitor? You just won't know until you apply it.
You might feel a slow regular pulse, but you don't know if it is Sinus Brady, Mobitz 1, or complete heart block.
That rapid pulse you palpated? Is it VT, AVNRT or A-Flutter?
Is there a STEMI, sending them straight to the cath lab?
Is that Brugada in your syncope patient?
Maybe it's WPW or ARVD!
To be blunt, in many cases you simply can't diagnose (yes we do that) your cardiac patient correctly without the monitor:
There are limitations to the cardiac monitor. They need to be troubleshooted like every other piece of technology. Part of our job is to be able to diagnose problems with the monitor, and not be led astray.
In "Reversals", Peter Canning writes about a case where the arm leads were put on reversed, and the rhythm looked like VT.
"The only thing going for me is that he doesn't look like he is about to die. I did not expect to see a rhythm like this. I look at it closer…I have the left and right arms mixed up. That'll do it."
If what you see on the monitor is totally out of left field, you have be a critical thinker and ask whether something could be wrong with the data. It happens some times. Leads are switched, cables break. That's part of clinical judgment, and our responsibility when using technology. You've got to have your "Spidey Sense" working at all times.
The limitations, however, do not overshadow the fact that we are supposed to figure out what is going on with our patients, and the cardiac monitor can play a crucial role in doing that.
I looked at many of the posts by Dr. Smith of Dr. Smith's ECG Blog looking for cases of "treat the patient not the monitor". Guess what I found? He actually uses the information on the monitor!
Dr. Mattu recently had his 100th video case presentation at his video blog. 100 videos? Why in heavens name would he do that when he could have just 1!
"This week, we have a very difficult case… squiggles here, some blipity-blips there… Oh hell with it, just look at your patient!"
That would be one short video series! In all seriousness, they present tough cases. Difficult ECGs. Why aren't they saying "Treat the patient not the monitor?
We (all of us) don't always like to hear it, but every time we throw our hands up and say "treat the patient not the monitor", it has more to do with our limitations than those of the monitor. It means, "help, I can't figure this thing out, so I'll just treat the patient until we get to the hospital".
That's what we do when we can't figure out what is going on. All of us.
Just know what it means when you do that. There was something on the monitor that you couldn't interpret. It is an opportunity to learn. That's what ems12lead.com is here for, and what other ECG blogs are here for as well.
"Treat the patient and the monitor".
Remember, it's all about the context!
As always, your comments are welcome!
This excellent case comes to us from our friends in the UK. The author wishes to remain anonymous, but we thank him for his contribution.
It is about 8am on a gorgeous Wednesday morning, when your Paramedic unit is dispatched to a 49 year old male, "chest pain".
You arrive at the bungalow of a summer resort and are greeted by an elderly couple.
"They don't look too bad", you think, but you are not that lucky.
"Our son has been complaining of chest pain and vomiting for a couple of days".
You are led back to a room where you find your 49 year old patient lying in bed.
His parents say they found him like this and called 911. They tell you he seemed ok when he went to bed last night.
Your patient is lying supine in bed, responds to verbal stimuli only, and it is difficult for you to make sense of his answers.
You note that he appears anxious and uncomfortable, with dried vomit on his shirt.
His airway seems clear, but his respirations seem quick and a bit shallow, although clear bilaterally. You put him on a non-rebreather.
The rest of the vitals are as follows:
- Pulse: 85 and regular
- RR: 27, shallow
- BP: 86/62
- Pupils: equal and reactive
- Skin: cool and slightly diaphoretic
While he is not adequately answering your questions, you are able to determine from his parents that he is an insulin dependent diabetic. You are unable to determine any other past medical history, medications, or allergies.
You check his blood glucose while your partner puts him on the monitor. The BGL reads "High".
Here is the 12 lead:
You are 15 minutes from the local community hospital, and 30 minutes to the PCI center by ground. Air transport to PCI is a possibility.
What's your differential diagnosis?
What does the ECG show?
What do you want to do about it?