Win big on the strip

Time sensitive metrics are receiving increasing attention and scrutiny in Baltimore County and EMS jurisdictions throughout the country.  It is expected that we will detect STEMIs immediately, transmit a 12-lead ECG to the hospital within minutes of arrival at the patient's side, and deliver the patient to a cardiac intervention center priority 1 all while getting an IV established and completing a host of other tasks while going down bumpy roads backwards at high rates of speed.  Then there is the 'Golden Hour' of trauma care, the 3.5 hour 'window' for tPA in ischemic stroke, time to first shock for VF/VT arrests, and the list goes on.  There is so much to do and so little time to do it.  But we do.  And we love it.

In the rush to perform all of these tasks and utilize all of the technology floating out of the hospitals into our medic units (12-lead ECGs, video laryngoscopes, EZ IO drills, capnography, etc), we have to remember what is at the center of all of this excitement . . . .  the PATIENT.  

As many of you know, I have an enormously bushy squirrel tail.  I was driving home one night up 83N after a long shift in the ICU.  EMS 1, Engine 17, IV 395, and Medic 475 were dispatched for a medical box aboard an MTA bus in the Timonium area as I approached the Timonium Road exist on 83N.  Unable to resist the urge, I switched to central and called enroute.  EMS 1 beat me to the scene and was already in the bus assessing the patient when I arrived.  What I witnessed next was something I see less and less of these days.  EMS 1 was kneeling over the patient in the center isle of the bus, talking to the patient, and examining the patient.  He was NOT immediately hooking the patient up to the cardiac monitor, placing an Spo2 probe on his finger, or peeling back a shirt sleeve to look for an IV.  He was actually examining the patient - looking, listening, palpating - human contact.

So I'm as guilty as the rest of you.  When a patient gets rushed into my ICU from the general medical or surgical floor crashing and burning, I grab my glidescope and ultrasound and get suited up to insert lines and tubes all while the nurses attach the patient to an array of bedside monitors.  The exam often gets squeezed between necessary procedures and a detailed examination often gets pushed back until well after the patient has been stabilized.  Sometimes priorities like the need to establish an airway get in the way - but more often than not - the ABCs are OK and we can actually leave the monitor and pulse oximeter alone for a minute, talk to the patient, examine the patient, and use the oldest tool in EMS - our hands.

Bottom line - technology is great. It saves lives, it makes our job more interesting, and often gives us important information to guide care and to aid with making clinical decisions.   But we need to pause, put our hands back on our patients and get back to fundamentals - we need to revisit the lost art of the physical examination.  I'm not even going to get into the kumbaya side of the reassurance and compassion of a human touch - I will leave that training to you and your DO (or not). 

I recently conducted a case review in the Western Battalion that I would like to share with all of our providers.  A medic unit was dispatched in the early afternoon for reports of a 67-year-old woman with trouble breathing.  The crew arrived to find the women seated upright, in mild distress, with complaints of recent vomiting and feeling dizzy.  The patient also reported having syncope a few days prior - the cause of which was not known.  The patient denied chest pain, shortness of breath, and abdominal pain.  The GCS was 15.  Initial VS were BP 98/70, HR 110/min, RR 22/min, Spo2 96% on room air.  Finger stick glucose was 223 mg/dL.  The care plan read like so many of our emeds reports do: "O2, IV LR, monitor".  No medications were listed on the emeds report and a brief medical history including "gastric reflux, lupus, chronic fatigue, and syncope" were listed.  The patient was bolused 500 cc LR enroute to the hospital.  The crew reported that enroute to the hospital the patient felt better, skin color improved, and the patient became more alert.

Here is the 12-lead ECG that was obtained:

How do you think this ECG was interpreted?  How did you interpret it?  If you're not sure what the rhythm is - is there anything else you can do to aid in interpretation?  How might simple physical examination skills aid in making the diagnosis?

The patient was transported priority 2 to the ER and transferred to hospital staff without incident.  Review of the emeds report and ECG by the DO a few days after the incident resulted in this case being brought to my attention for review with the provider.

Where did this seasoned ALS provider go wrong?  Aside from the "O2, IV, monitor" and LR bolus - should anything else have been done for this patient?  

How could a basic EMT with only their hands have saved this ALS provider and helped clinch the diagnosis?

I look forward to your comments and will post the conclusion to this case shortly.

CONCLUSIONS:

1. Quick glance at this 12-lead ECG might lead the provider to think they are looking at a normal sinus rhythm with low voltage and an occasional PVC.  The P-waves do indeed march out at a rate of about 90/min.  However, none of these P-waves are followed by QRS complexes.  The QRS complexes that do appear do not communicate with the P-waves.  Thus, this is complete (3rd degree) heart block.

2. Usually a 12-lead ECG will give you much more information than a simple rhythm strip.  However, in this case, a longer rhythm strip would have probably made it easier for the provider to see the QRS complexes marching out independent of the P-waves.  Simply looking at a continuous lead display (i.e. lead II) on the LP15 is less ideal than printing out a 10-15 second strip.

3. Never underestimate the importance of the basics.  Always take your patient's pulse manually.  As some of you astutely pointed out - actually palpating the patient's pulse should have clinched the diagnosis of complete heart block (as only the profoundly bradycardic ventricular beats should have generated a palpable radial pulse).  It is unlikely but remotely possible that the regularly occuring atrial activity might have generated a faint carotid pulsation.

4. Pacing/debrillation pads should have been applied to the patient's chest so that transcutaneous pacing could be initiated immediately had the patient become hemodynamically unstable.

5. While atropine often does not work in complete heart block, 2013 protocols state that it may be considered after medical consultation for Mobitz type II AV block or 3rd degree (complete) AV block.