By Miguel

"This is why people fail exams and/or lose their certifications"

Rule #1: BLS before ALS.

Rule #2: Treat your patient not the monitor.

Rule #3: An ‘excellent’ EMT = a ‘good’ medic.

Rule #4: Protocols are guidelines, not set in stone.

Rule #5: Refrain from getting tunnel vision.

Never forget:

1) ABC DEFG (airway, breathing, circulation, disabilities, extremities, full vitals, GO).

2) IPASSO (inspect, palpate, auscultate, stabilize, seal, O2).

3) OPQRSTI (onset, provocations, quality, radiation, severity, time, interventions).

4) SAMPLE (signs/symptoms, allergies, medications, past hx, last intake, events).

5) Pertinent questions regarding call: ex: weight, LMP, PARA, Gravada, drug consumption, Etoh, smoking, etc.

* Head to toe assessment *

** approximately 40 questions before you begin ALS, unless the call is obvious **

Rookie Mistakes:

#1 Uses monitor for everything.

#2 Every call becomes ALS.

#3 Every chest pain is cardiac.

#4 Every patient gets an IV.

** don’t go by what the EMT’s tell you **

***Become a Clinician***

Been a while since we did cardiology so I wanted to do a quick review on the normal deflections you should expect to find in each lead of an EKG

Limb Leads

Lead I – Looks across top of heart with positive electrode at left arm – so QRS complexes are upright but not that tall

Lead II – Follows normal electrical axis of heart, top right to bottom left . All complexes should be upright and tall.

Lead III – Looks from top left towards bottom left – at this angle P waves may be inverted but QRS should be upright (more than in lead I)

Lead aVR – Positive on right arm, so everything negatively deflected

Lead aVL – Positive on left arm – similar to Lead I but this lead looks down AND to the right so QRS are upright but very small

Lead aVF – Positive at left leg, looking at bottom of heart. Electricity is coming right at this lead so QRS should be upright and prominent.

 

Chest Leads

Leads V1-V6 – R wave starts very small and S wave is prominent. As the leads progress the R wave is more prominent and S wave is gone in V6. This is known as R wave progression.

  P Wave

P wave should be upright in Leads I and II as well as V3-V6

P wave always inverted in aVR

P wave usually upright in aVF and V3 but occasionally biphasic or flat

P wave is variable in leads III,  aVL, V1 and V2 (upright, inverted, biphasic)

Inverted P wave in II, III and aVF and upight in aVR is diagnostic for a Junctional or low ectopic atrial rythm.

Most people say that your best view of the P wave is in Lead II – others say V1. The truth is that every patient is different, find the best one on your patients EKG and study that one well.

 

See this page for some quick review and this page

NYC 911 System – Sat night 21:00 – 09:00

I had two "good" calls on Sat night

16 y/o female, pedestrian struck by a cab. Unconscious with agonal respirations. Paddles applied shows sinus tach at 174 but no palpable carotid or radial (PEA?). CPR performed for approx two minutes and faint pulses felt. We arrived same time as BLS, we were on scene for under 5 and had her in Belleview in about 12 minutes from going on scene. Attempted to intubate but unable due to blood and vomit (preceptor). Our brief exam revealed a flail chest (could I have done that with cpr?), distended abdomen, bruising to tib/fibs and ankles. I was asked to bag the patient in the ER so I got to observe them put in two chest tubes as well as the rest of the trauma team workup. (Got to watch an abdominal ultrasound with a Sonosite Titan) She was off to OR within 20 minutes of our arrival. Checked back later and her biggest problem seems to be an ICP of 35 and a probable Diffuse Axonal Injury. Not good, even if she makes it…

2nd call dispatched at 02:50 for an unconscious lying by his car. Talk while enroute was of a probable intox or OD. Arrive on scene at parking garage and told that vehicle was seen driving in at around 02:00 and he was found lying next to the open drivers door of his still running vehicle at around 02:40.

As we ran up the ramp we could see an elderly male lying on the floor looking everything like an arrest, as we got closer though we could hear loud snoring respirations. Assessment reveals HR 48 regular, respirations of 24, GCS 3, Pupils fixed and dilated, no obvious trauma. Loaded him into bus and worked out the differentials. Dilated pupils and Tachypnea – Not an opiate OD, Glucose at 79 so not likely that either. BP at 220+ with fixed and dilated pupils – likely a massive CVA. (We did not have time to do a 12 lead EKG)

I asked if I could intubate, I was told that I have one try. He was breathing so everything was moving and I didn’t get a good visual but tried to aim for where I thought it was but I didn’t push it far enough in. I wanted a second shot but we were at the hospital and he didn’t let me (I consoled myself later when I saw the resident take 10 minutes and a bougie to get it done)

At Belleview again they worked up a stroke code and Dr Chung literally forced us to stick around for the results of the CT. He spent quite some time with us going over the pedestrian struck patient’s CT and then again when the results of the second CT came back. Massive intracranial bleed – ventricles entirely filled with blood – also not good for this guy. If any of you meet this Dr just hang on to him, he really treated us like part of the team and explained and showed everything.

Other than that we had 1 Anxiety, 1 A fib (who vomited all over me) and 1 severe chest pain (probable gall stone per ED staff) Wind chills under 0 degrees F all night.

Good stuff