The other day I heard a story of an ED doctor geting angry at the paramedics who had brought in a cardiac arrest who the medics had had gotten pulses back on in the field. The doctor was angry because after he had done a 12-lead on the patient in the ED, he'd discovered the patient was a STEMI. He was furious that the medics hadn't done a 12-lead on the way in and discovered this themselves.
My initial reaction was what is he crazy? In 16 years as a medic I have never done a single 12-lead on any cardiac arrest I have rescusitated. Why not? Working as a single medic most of the time I am pretty busy with post-rescisitation care. That's my easy excuse, but I have done a number of rescusitations with other medics, and I have to say it has never occured to me to do a 12-lead. We are still usually too busy (shaking each other's hands), bagging the patient, hanging dopamine drips, etc, and remaining vigilant to losing pulses.
So, it is with great interest, I read the following article:EMS 12-leads after ROSC.
The bottom line for me in the article is a good number of these patient's are going to have ECGs showing a STEMI. It seems reasonable. There are probably many systems doing this routinely.
If possible, I will definately try to do one the next time I have a ROSC.
And I'll be curious if that knowledge will change the way the patient will be initially treated when I bring the patient in.
Tuesday, February 24, 2009
Sunday, February 15, 2009
Something to Ponder
I have been working at my clinical coordinator job for over six months now, and while I miss being on the ambulance during my desk job days (I still do 40 hours a week in 3 nondesk job days as a field medic), I am enjoying some aspects of the job -- particularly the patient follow up and the data collection. (I remain at times distraught over the QI – torn between having to second guess medics and upholding certain standards of care and documentation).
I did not realize when I interviewed for the job that part of my duties included being the trauma data collector, and when I had it explained to me, I was not happy about. I have however, come to appreciate the insights this duty has given me.
As the trauma data collector, it is my job, per the data collection section of the Connecticut Trauma Regulations to input information from prehospital run forms, the ER records and the in house records for all admitted trauma patients at the hospital. Trauma, in Connecticut is defined as, “a wound or injury to the body caused by accident, violence, shock, or pressure, excluding poisoning, drug overdose, smoke inhalation, and drowning.”
To identify the patients, I sort through the ED data base to identify admitted patients with trauma diagnoses. I then open up each record and record information like time in the ED, procedures done, vitals, etc. If the prehospital run form has been scanned into the record, I can capture that information as well. Later I go down to medical records and pour through the charts to discover what procedures the patients had, how long they were in the hospital and what their outcomes were.
Since I work for a smaller, non trauma center hospital, the amount of information I enter is much less than it would be for a trauma center. At the end of the year, the information is sent off to the state, which collects and complies it.
The trauma patients who come to our hospital are predominately elderly and predominately the victims of low falls. (Major traumas in the area go to one of two trauma centers). I have been curious to read about other state’s trauma registries, and to discover that many exclude hip fractures from their registry. I guess there is a debate between surgeons on the issue. Some say a hip fracture is trauma, others that it is merely the end of a natural aging process. The bone becomes brittle and breaks almost of its own. Whether or not hip fractures are included can widely alter a state or hospital’s statistics.
As I may have mentioned before, I have been keeping a separate data base on hip fractures to record pain scales and time to analgesia both prehospitally and in the ED. Prehospitally, over a four month period, we received 39 hip fractures from EMS, only 4 (10%) of whom received prehospital analgesia. 87% needed analgesia in the ED. Part of the reason the prehospital number was so low is many of the area services utilize paramedic intercepts and medics in many cases are not even dispatched to the hip fracture calls. On the other hand, often a medic ambulance is sent and the medic ends up driving while the basic techs. Maybe unknown to the medic, but the basic is recording 9/10 and 10/10 pain scales for many of these patients, which is certainly a QI red flag.
I recently asked the state trauma data collector to try to ferret out the statewide stats on pain management, and the statistics were somewhat difficult for him to get from the collected data and are of somewhat uncertain reliability, but enlightening nonetheless.
There were 34,260 traumas patients admitted (admitted, died in ED or transferred to another acute hospital) to Connecticut hospitals between 2005 and 2007.
1,260 of these trauma patients received prehospital pain or sedation meds. (3.6%)
5,288 trauma patients had ICD-9 codes for hip fractures.
267 of these hip fracture patients received prehospital pain and sedation meds.(5%)
The problem is some hospitals evidently didn’t enter hip fractures, some prehospital run forms are missing, some patients, with no prehospital run form found, have prehospital meds listed from the ED records. Much depends on the quality of the data entry person and the quality of the records. The true number could be higher, but it is unlikely to be high enough to escape the “you have to be kidding me is this anyway to treat our elderly number!”
Speaking of QI, I just read an article where a research project was done where medics were paid $100 if they met certain QI objectives. In this study, with the promise of seeing cold hard cash, 100% of medics were in compliance with their “appropriate treatment of patients with traumatic hip pain” guidelines. The bottom line of the study was money talks more than a simple “Job Well done!”
That’s something to ponder.
Pay-for-Performance Incentives Might Improve Compliance
I did not realize when I interviewed for the job that part of my duties included being the trauma data collector, and when I had it explained to me, I was not happy about. I have however, come to appreciate the insights this duty has given me.
As the trauma data collector, it is my job, per the data collection section of the Connecticut Trauma Regulations to input information from prehospital run forms, the ER records and the in house records for all admitted trauma patients at the hospital. Trauma, in Connecticut is defined as, “a wound or injury to the body caused by accident, violence, shock, or pressure, excluding poisoning, drug overdose, smoke inhalation, and drowning.”
To identify the patients, I sort through the ED data base to identify admitted patients with trauma diagnoses. I then open up each record and record information like time in the ED, procedures done, vitals, etc. If the prehospital run form has been scanned into the record, I can capture that information as well. Later I go down to medical records and pour through the charts to discover what procedures the patients had, how long they were in the hospital and what their outcomes were.
Since I work for a smaller, non trauma center hospital, the amount of information I enter is much less than it would be for a trauma center. At the end of the year, the information is sent off to the state, which collects and complies it.
The trauma patients who come to our hospital are predominately elderly and predominately the victims of low falls. (Major traumas in the area go to one of two trauma centers). I have been curious to read about other state’s trauma registries, and to discover that many exclude hip fractures from their registry. I guess there is a debate between surgeons on the issue. Some say a hip fracture is trauma, others that it is merely the end of a natural aging process. The bone becomes brittle and breaks almost of its own. Whether or not hip fractures are included can widely alter a state or hospital’s statistics.
As I may have mentioned before, I have been keeping a separate data base on hip fractures to record pain scales and time to analgesia both prehospitally and in the ED. Prehospitally, over a four month period, we received 39 hip fractures from EMS, only 4 (10%) of whom received prehospital analgesia. 87% needed analgesia in the ED. Part of the reason the prehospital number was so low is many of the area services utilize paramedic intercepts and medics in many cases are not even dispatched to the hip fracture calls. On the other hand, often a medic ambulance is sent and the medic ends up driving while the basic techs. Maybe unknown to the medic, but the basic is recording 9/10 and 10/10 pain scales for many of these patients, which is certainly a QI red flag.
I recently asked the state trauma data collector to try to ferret out the statewide stats on pain management, and the statistics were somewhat difficult for him to get from the collected data and are of somewhat uncertain reliability, but enlightening nonetheless.
There were 34,260 traumas patients admitted (admitted, died in ED or transferred to another acute hospital) to Connecticut hospitals between 2005 and 2007.
1,260 of these trauma patients received prehospital pain or sedation meds. (3.6%)
5,288 trauma patients had ICD-9 codes for hip fractures.
267 of these hip fracture patients received prehospital pain and sedation meds.(5%)
The problem is some hospitals evidently didn’t enter hip fractures, some prehospital run forms are missing, some patients, with no prehospital run form found, have prehospital meds listed from the ED records. Much depends on the quality of the data entry person and the quality of the records. The true number could be higher, but it is unlikely to be high enough to escape the “you have to be kidding me is this anyway to treat our elderly number!”
Speaking of QI, I just read an article where a research project was done where medics were paid $100 if they met certain QI objectives. In this study, with the promise of seeing cold hard cash, 100% of medics were in compliance with their “appropriate treatment of patients with traumatic hip pain” guidelines. The bottom line of the study was money talks more than a simple “Job Well done!”
That’s something to ponder.
Pay-for-Performance Incentives Might Improve Compliance
Saturday, February 07, 2009
STEMI Interpretation
I've been spending a great deal of time at my clinical coordinator job looking at STEMI cases, as well as putting together educational material.
When we take a class in STEMI recognition, the ECGs, once you know how to read them, are all pretty clear cut. You can flash the 12-leads on the screen and a well- taught class will call out in unision "Inferior, Anterior, Anterior, Inferior, Lateral," etc. You get tricky and you throw in the ST imposters, but they catch on. "Left Bundle, Right Bundle, LVH, Inferior, Anterior, Left Bundle," etc.
The problem is when you get back on the street not all 12-leads are so cut and dried. I'm been sort of lucky lately in that I've had some idiot-proof STEMIs. Take this one for instance:
Or this one:
In what is becomming one of my favorite expressions regarding STEMIs. "Not Subtle."
Unfortunately, many of the real world 12-leads can be classified as very subtle. I've seen 12-leads that I wouldn't call STEMIs that turned out to be, and some I would call STEMIs that turned out to have negative cardiac enzeyemes and clear arties.
The other day I came across a new study just published in the American Journal of Cardiology. Differentiating ST elevation myocardial infarction and nonischemic causes of ST elevation by analyzing the presenting electrocardiogram in the February 2009 issue.
Here's what it was about. They recruited 15 experienced cardiologists from across the world and gave them each 116 ECGs that had ST elevation of some sort or another whether it was a true STEMI or imposters like LVH or early repolarization and asked them, assuming the generaic patient had chest pain, to decide whether or not they should be sent to the cath lab or not based on the ECG. And if they were not going to send them to the cath lab, they had to check one of 8 reasons why not.
Of the 116 only 8 were STEMIs based on the patient's final charts. The rest were nonishemic ST elevations.
The cardiologists recommended from 7.8% to 33% of the patients go to the cath lab with an average of 19% being sent. And when it came to assigning reasons the researchers found a wide varience in the cardiologists' interpreations of the same ECGs.
The study includes 5 sample ECGs where the reader can make their pick and then read how the cardiologists saw it.
Only 5 of 15 called this one correctly. (Answer to follow)
The study's bottom line:
This study’s findings reflect the diagnostic limitations encountered by cardiologists when the ECG is used as the sole diagnostic tool for STEMI. If experienced readers, using the current criteria and guidelines, cannot accurately and consistently distinguish between STEMI and NISTE, less-experienced readers cannot be expected to do so.
So take heart, paramedics, we aren't expected to be seers. Just do the best you can to identify what you can. Cast a wide net when you do your 12-leads. Do serial 12-leads. One that is not obvious can soon grow into a not subtle one. Call the obvious ones, and bring attention to the possible ones. Evaluate based on patient presentation and ECG.
When we take a class in STEMI recognition, the ECGs, once you know how to read them, are all pretty clear cut. You can flash the 12-leads on the screen and a well- taught class will call out in unision "Inferior, Anterior, Anterior, Inferior, Lateral," etc. You get tricky and you throw in the ST imposters, but they catch on. "Left Bundle, Right Bundle, LVH, Inferior, Anterior, Left Bundle," etc.
The problem is when you get back on the street not all 12-leads are so cut and dried. I'm been sort of lucky lately in that I've had some idiot-proof STEMIs. Take this one for instance:
Or this one:
In what is becomming one of my favorite expressions regarding STEMIs. "Not Subtle."
Unfortunately, many of the real world 12-leads can be classified as very subtle. I've seen 12-leads that I wouldn't call STEMIs that turned out to be, and some I would call STEMIs that turned out to have negative cardiac enzeyemes and clear arties.
The other day I came across a new study just published in the American Journal of Cardiology. Differentiating ST elevation myocardial infarction and nonischemic causes of ST elevation by analyzing the presenting electrocardiogram in the February 2009 issue.
Here's what it was about. They recruited 15 experienced cardiologists from across the world and gave them each 116 ECGs that had ST elevation of some sort or another whether it was a true STEMI or imposters like LVH or early repolarization and asked them, assuming the generaic patient had chest pain, to decide whether or not they should be sent to the cath lab or not based on the ECG. And if they were not going to send them to the cath lab, they had to check one of 8 reasons why not.
Of the 116 only 8 were STEMIs based on the patient's final charts. The rest were nonishemic ST elevations.
The cardiologists recommended from 7.8% to 33% of the patients go to the cath lab with an average of 19% being sent. And when it came to assigning reasons the researchers found a wide varience in the cardiologists' interpreations of the same ECGs.
The study includes 5 sample ECGs where the reader can make their pick and then read how the cardiologists saw it.
Only 5 of 15 called this one correctly. (Answer to follow)
The study's bottom line:
This study’s findings reflect the diagnostic limitations encountered by cardiologists when the ECG is used as the sole diagnostic tool for STEMI. If experienced readers, using the current criteria and guidelines, cannot accurately and consistently distinguish between STEMI and NISTE, less-experienced readers cannot be expected to do so.
So take heart, paramedics, we aren't expected to be seers. Just do the best you can to identify what you can. Cast a wide net when you do your 12-leads. Do serial 12-leads. One that is not obvious can soon grow into a not subtle one. Call the obvious ones, and bring attention to the possible ones. Evaluate based on patient presentation and ECG.
Dust
Cardiac arrest. Old frail man in his 80's in a hospital bed. Wife was talking to him, and then after awhile noticed he had stopped talking back, not that he ever said much in the first place. We put him down on the floor. He was warm and limber, but asystole in three leads. I intubated him while an officer did CPR. The initial ETCO2 was 40, which encouraged me that we could save him, but it steadily plummeted down to 5.
I looked at the officer doing CPR and was surprised to see his hand was off center and he wasn't doing very good compressions. "Get right on the sternum," I said. "Hard, fast and deep." I wanted to get the ETCO2 number back up in a decent range. The better the CPR, the higher the ETCO2. It stayed at 5. He was barely pushing at all.
"No, like this," I said.
I put my hand on the sternum and pushed hard.
With that awful crunching sound, my hand seemed to go break right through the man's chest. It was like the sternum broke completely off from all the ribs and sank right down on top of his heart.
The officer looked at me with a knowing sadness.
My bad, I said silently.
***
Working at my other job as clinical coordinator at a local hospital, I have been tracking prehospital cardiac arrests and cardiac arrest saves. The saves, like the literature says, are almost all witnessed arrests with a presenting rhythm of vfib, who get early CPR and early defib. And the patients are almost all in the 50s and 60s. 80-year-olds in asystole with unknown down time do not come back. Sure you might get a pulse and a pressure for awhile, but they don't open their eyes and see the world again. They don't walk out of the hospital and back to the arms of their loved ones.
And for all the emphasis on the new CPR, pushing hard, fast and deep, some of these frail old bodies, you just can't do CPR on. There is no bend in their bodies, only break, as with pressure, their bones turn to dust.
***
We finished out our twenty minutes with no change in the flatline and the ETCO2 registering only 3. I called the hospital and got permission to cease. Before we stopped, I had the family members gather around and say their goodbyes. He was an old man who had been sick and had been expected to die, but he was greatly loved by his wife and daughters and grandchildren and great grandchildren. We took out the ET tube and removed the IV and peeled off the electrodes and defib patch, and picked his old body up off the floor and set him back into bed. We covered him with a sheet up to his neck, and closed his eyelids, and gently lifted his head to place a pillow underneath it.
I looked at the officer doing CPR and was surprised to see his hand was off center and he wasn't doing very good compressions. "Get right on the sternum," I said. "Hard, fast and deep." I wanted to get the ETCO2 number back up in a decent range. The better the CPR, the higher the ETCO2. It stayed at 5. He was barely pushing at all.
"No, like this," I said.
I put my hand on the sternum and pushed hard.
With that awful crunching sound, my hand seemed to go break right through the man's chest. It was like the sternum broke completely off from all the ribs and sank right down on top of his heart.
The officer looked at me with a knowing sadness.
My bad, I said silently.
***
Working at my other job as clinical coordinator at a local hospital, I have been tracking prehospital cardiac arrests and cardiac arrest saves. The saves, like the literature says, are almost all witnessed arrests with a presenting rhythm of vfib, who get early CPR and early defib. And the patients are almost all in the 50s and 60s. 80-year-olds in asystole with unknown down time do not come back. Sure you might get a pulse and a pressure for awhile, but they don't open their eyes and see the world again. They don't walk out of the hospital and back to the arms of their loved ones.
And for all the emphasis on the new CPR, pushing hard, fast and deep, some of these frail old bodies, you just can't do CPR on. There is no bend in their bodies, only break, as with pressure, their bones turn to dust.
***
We finished out our twenty minutes with no change in the flatline and the ETCO2 registering only 3. I called the hospital and got permission to cease. Before we stopped, I had the family members gather around and say their goodbyes. He was an old man who had been sick and had been expected to die, but he was greatly loved by his wife and daughters and grandchildren and great grandchildren. We took out the ET tube and removed the IV and peeled off the electrodes and defib patch, and picked his old body up off the floor and set him back into bed. We covered him with a sheet up to his neck, and closed his eyelids, and gently lifted his head to place a pillow underneath it.
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