I meant to get this out earlier in the week, but work responsibilities and a couple of other things delayed it until today.
So, I mentioned a couple of things that I see in case reviews that I irk me. Well, the part about moving hypotensive patients inappropriately more than irks me. It’s a practice that clearly has the potential to harm a patient. The BGL check is more irksome than anything else, but it makes me wonder what some paramedics are thinking. Or even if.
So, on to part 2 of things I read.
I read a lot of reports where the patient had either a limb lead EKG or a 12 lead EKG and I can’t figure out what the clinical indication was. I first have to explain that when I was trained and educated there was no such thing as a 12 lead EKG in the field. Paramedics just didn’t to them.
At the time a lot of physicians felt, and some still do that a paramedic can’t interpret a 12 lead EKG. Most can, some can’t. I also have to editorialize about the accuracy of the computer based interpretation of 12 leads. It’s not good. I’m not alone in that opinion as a physician I know who runs a one day intense 12 lead class shares the same opinion.
His advice is to look at the computer interpretation, but over read that with your own assessment. Given the choice, I wouldn’t turn on the computer interpretation, but I think that from a risk management perspective that train has left the station.
Even after we started doing 12 lead EKGs in the field, very often I would only do limb leads first and then if the patient clinical impression indicated that a 12 lead was indicated, I’d perform one. I wouldn’t do one just because I happened to have a patient of a certain age.
Some complaints require a 12 lead EKG. The older the patient, the more inclined I’d be to do a 12 lead. An older patient, let’s say 50 older, who presented with syncope, chest pain, or dyspnea would automatically get a 12 lead. We had a lot of education regarding “Anginal Equivalency” and how often a patient having a cardiac event didn’t present with the traditional mid sternal chest pain.
On the other hand, an 18 year old male who is having an anxiety reaction and feels “nervous” very likely isn’t going to be a cardiac patient.
Nor is the person who was just shot in the chest. Yet, I’ve read reports where the medic delayed getting a patient to a trauma center to do a 12 lead EKG. I’d always ask them what they were looking for. “Because the hospital wants one.” is not an acceptable answer.
My practice, and the practice of just about every medic I worked with was to reserve EKG monitoring for trauma patients to the ones that I expected to intubate during transport. Not once did a doctor say anything to me because I brought a patient into a trauma room without an EKG strip.
Today’s cardiac monitors do far more than monitor EKG rhythms, perform 12 leads, pace, and defibrillate. In addition to Oxygen saturation, they can read Carbon Monoxide (it’s an option), and Carbon Dioxide and of course provide often inaccurate blood pressures. One of my former co workers sometimes derisively referred to our cardiac machine as the “Symptom Checker.” He was a bit on the sarcastic side, if you didn’t guess.
Still, he had a point. Which brings me to my point. Some paramedics over rely on the readings from these very expensive machines and don’t perform their own clinical evaluation.
A few years ago I did a presentation for BLS providers on using ALS assessment skills at the BLS level. Everything I told them could be done without a cardiac monitor. In fact, the only pieces of equipment that they would need were a stethoscope, BP cuff, and glucometer.
What that assessment required was looking at, touching, listening to, and on occasion smelling the odors emanating from the patient. If you do that as a provider at any level you’ll discover that the “Symptom Checker” is an aid, but not replacement for examining your patient.
Henry J.L. Marriott MD in the Eighth Edition of Practical Electrocardiography wrote,
“The electrocardiogram should be considered confirmatory clinical impression, and should not supersede it. If the patient is suspected clinically of having sustained a myocardia infarction, he should be treated accordingly even if his tracing is completely normal.”
The Eight Edition was published in 1988 and has been superseded by the Thirteenth Edition. I should probably pick up a copy, but it’s not an inexpensive book. It is a good teaching tool, though. I also don’t know of anything that would negate his statement. EKGs are still essentially the same although the technology for acquiring them has improved.
Put another way “Treat the patient not the monitor.” Yes, that’s an EMS cliche, although I think of it an axiom. If a patient looks sick, they are sick and should be treated as such.
A good paramedic can walk into a room, look at a patient, and know that they are sick. He or she may not know what is wrong, but they know that something is wrong. The History of Present Illness (HPI) and Physical Exam (PE) will likely help determine what treatments need to be done immediately and which hospital to go to.
The bottom line is that there is no guarantee that the cardiac monitor/symptom checker is going to magically diagnose the patient for you. It’s poor form to over rely on technology instead of knowing what you are doing.
If a patient has symptoms consistent with Acute Coronary Syndrome, then treat them as if they have Acute Coronary Syndrome.
The last thing I’ll mention today is Intravenous skills. I first will note that the patient population that EMS is seeing seems to have aged considerably over the last eight years. Then again, so have I.
Older people often have fragile veins do to a combination of underlying medical problems, the changes to both skin and vascular structure as we age, and often medications that patient are taking.
It’s no great sin to “miss” an IV. I certainly missed more than my share over my years in the field. Just don’t make excuses. About 90% of the reports I read where a medic misses an IV blames it on “poor vasculature.” This is alien to me as I never felt the need to justify a missed IV.
To a down stream reader, be it a doctor, nurse, QI reviewer, or anyone else, it looks like the provider is making an excuse for missing an IV. It also looks like the provider is blaming the patients veins for being fragile.
I laugh, but not in mirth, more in the line of derisive laughter when I see that. Our guidelines don’t allow us to make editorial comments on writing style, so I can’t put a comment in the auditing notes.
Speaking of which, we don’t audit for spelling, syntax, or grammar. If we did, it would take an hour to do each audit.
That said, in the context of professionalizing EMS by improving education if it were up to me I’d require entry level English and Math classes before would be paramedics to go on to the Anatomy and Physiology portion of school.
That’s Part 2 of this. I think I will do a Part 3 just on respiratory assessment. It’s a key skill that should be fundamental, but is lacking at both the ALS and BLS levels from what I read.