13 year old female CC: Syncope – Discussion

This is the discussion for 13 year old female CC: Syncope.

You may wish to go back and familiarize yourself with the details.

The short of it is that on a very hot and humid day a 13 year old female passed out after looking at her sister's scraped knee. She had passed out at the sight of blood before.

The parents were not the ones who contacted 9-1-1 and they were not interested in having the patient transported to the hospital by ambulance.

However, the family history was very concerning as the father's brother died (many years ago) at age 16 from a "seizure disorder." 

Prudently, the treating paramedics obtained consent for an exam and obtained a 12-lead ECG.

I had posed the following questions:

  • Why did the paramedics ask questions about the family history?
  • Why did the paramedics perform a 12-lead ECG?
  • Do you see anything that would suggest this patient is at-risk of anything life-threatening?
  • Is it okay for the parents to refuse transport to the emergency department?

Paramedics asked about the family history because early, unexplained deaths in the family could suggest some kind of inhereted disorder like Prolonged QT Syndrome, Wolff Parkinson White Syndrome, Brugada Syndrome or Hypertrophic Cardiomyopathy.

The fact that the father's brother died at age 16 is important (and would be even if the patient hadn't experienced a syncopal eposide).

Paramedics performed a 12-lead ECG because they knew the parents did not want their daughter transported to the hospital but they saw it as an opportunity to screen the patient for these disorders.

Now, some of you may think this kind of screening is dangerous or poses liability to the paramedics or EMS system because the paramedics haven't been formally trained in how to detect these abnormalities.

However, there's one easy rule you can follow to make sure you always do the right thing in EMS.

Treat every patient like a member of your own family.

A member that you like (preferrably).

I think we all understand (or at least I hope we all understand) that paramedics are not board certified emergency physicians, let alone pediatric cardiologists or electrophysiologists.

So, part of the risk of refusing care for any patient is that a paramedic's assessment is not equivalent to a qualified physician's assessment (complete with all the diagnostic tests they have at their disposal).

Let's break down these abnormalities one at a time.

  • Is the QT/QTc prolonged? No. 
  • Are there delta waves suggestive of WPW? No.
  • Is there a Brugada pattern? No.
  • Is it suspicious for HOCM? It's close to meeting the voltage criteria for LVH (for adults) in the precordial leads. But no.

If you saw the recent case on Burned-Out Medic's blog then you know the most difficult ECG-diagnosis in all of medicine is "Normal ECG"! 

However, one of the really cool things about Web 2.0 and blogging is "peer sourcing" and I do my best to make sure I'm giving out correct information.

So, I had this ECG reviewed by two people I respect a whole heck of a lot.

The first is Stephen Smith, M.D. from Dr. Smith's ECG Blog. Here's what he had to say.

It looks pretty normal to me. I get a QTc of 460 at most, not dangerous. Also, the history strongly suggests vasovagal.

Then, when specifically questioned about the voltage in the precordial leads:

I did notice that there is more voltage than usual, and thought about HOCM, but it is certainly not highly suggestive of it. And the patient was not exercising when this happened, and she had a classic vasovagal from looking at blood. I wouldn’t worry about it. On the other hand, if you sent her to the right ED (like ours) we would do a bedside ultrasound to look for LVH and septal hypertrophy. If you sent her to one that doesn’t do that, she would be sent home without any further workup (most likely) or possibly be admitted, and possibly get a formal echo at some point. It’s just playing the odds, and the odds of this kid having something bad are not zero, but they are very low.

I also had the case reviewed by Mark P. of the Electrophysiology Fellow blog. Here's what he had to say.

The ECG is normal. History is classic for vasovagal. The dead 16 year old necessitates followup for the extended family in any case (ECG as a first procedure). But there is no danger in this young girl not going to hospital. Reading the comments, almost all of the ECG changes noted by people are related to her age.

As a closing thought, some paramedics are quick to say that ECG transmission means that an EMS system doesn't trust its paramedics, and over and over again I've suggested that simply isn't true. There is nothing wrong with getting a second (or third) set of critical eyes on a 12-lead ECG, especially when the stakes are high (as they are for a possible STEMI patient).

There's no shame in transmitting an ECG like this to the hospital to get a second opinion (or even a first opinion if, like so many other paramedics, you have never been trained to look for prolonged QT, WPW, Brugada or HOCM). Discussing this case with Medical Control (as suggested by Ken Grauer, M.D. in the comments) is a great idea!

If you had a 13 year old daughter, sister or niece, how would you want the case to be handled by EMS?

29 Comments

  • Troy says:

    If you believe transmission of ECG’s means that your system doesn’t trust the paramedics, your a fool. This is not the profession to have an ego in, especially one that compromises patient care. Most paramedics have BASIC knowledge of ECG recognition, and those who have more knowledge still should not worry about another pair of eyes looking at it. Some ER physicians are far more versed in interpretation, look at Dr. Smith for example. Plus from a liability standpoint, two sets of eyes reading the 12 lead are better than one.

  • BenjaminTx says:

    I’ve been a paramedic for about six months, and I’m one of the medics that have a “basic” knowledge of ECGs. My service has relatively advanced protocos, but we generally only transmit 12-Leads to activate the cath lab. That’s just our SOP.
    I follow this blog closely, and I hope to be able to interpret 12-Leads like the people that post on here in the future.

  • CA Realtor says:

    OK, So I have been out of the EMS gig for about 18 months now so excuse me if I am a bit rusty. I was EXTREMELY proactive on selling people to go to the hospital (which is probably why Ive made a halfway decent realtor). I didnt care what the chief complaint was (obviously the scraped toe was slapped on the head and given a bandaid) but nearly everything went. I understand that bed delay sucks, hospital sandwiches are dry, and the baby cans of soda barely quench a thirst, but guess what… YOU ARE OUT OF THE SYSTEM! There will always be another ambulance to take someone to the hospital. Get the whole "Im going to miss the big one" mentality out of your head. If you are assigned a call, complete it.. Quit AMA-ing people. Besides, do you REALLY want the liability if you are wrong?

  • Scooter says:

    I'm in paramedic school now, and we've definitely focused on the prolonged GT, WPW, Brugada, and HOCM. I've noticed that myself and many other classmates have been able to read ECG's in a more detailed manor than several of the nurses in the ER and other parts of the hospital. Also, I agree with the comment above about this profession not being one to have an ego in. I may be new in the field, but one thing heavily stressed is the quality of patient care. There is nothing wrong with another set of eyes to review the ECG if anything is questionable or just simply for another opinion. 

  • CA Realtor – The treating paramedics in this case did their best to persuade the parents to have the patient transported to the hospital and did a good (and thorough) job of explaining the risk of refusing care. What I see in this case is due dilligence; not laziness. The kind of paramedics you describe wouldn't have bothered with a 12-lead ECG (and then we'd have nothing to talk about). But I share your sentiments about taking people to the hospital. That's our job! What I find particulary distasteful are paramedics who have turned patient refusals into an art form! They plant doubts into the minds of people who called 9-1-1 with every intention of going to the hospital. I agree wholeheartedly that they are dangerous and I would retire them out of EMS tomorrow if I had the ability to do so. Thanks for the comment! 

  • Scooter – Wow! Where do you go to paramedic school? 

  • ToddB says:

    circa 1997: arrived on scene to find a relativey new paramedic explaing to an 80 y/o with CP that there was probably nothing wrong with them, the machine (an LP 11) looks at 12 views of their heart, and (giving the ECG to the pt) stated, "See, it says Normal ECG….so the machine even knows theres nothing wrong with you."  That's (sadly) honing your refusal skills. Rank was pulled and she was transported. He didn't last long in the system….thankfully. 

  • brugada medic says:

    As a long qt patient of the Brugada variety (and an 18 year medic) let’s keep in mind that many long qt patients do not present with EKG changes. My Brugada pattern comes and goes, much to the chagrin of my EP; simply because there is no reason discovered yet why it dies so. Long qt diagnoses are new, with Brugadas only being discovered a decade ago and still quite rare. Any 13 year old who passes out is going to get a complete looksie by me and a stern warning to Mom and Dad. Even autonomic dysfunction disorder can be dangerous (sensitive vagal system). I was diagnosed by a 12 lead before and after I ate. How can we say with certainty its not long qt without a more complete workup? Which is why no paramedic should be even considering long qt as a differential diagnosis. It’d just not that simple…we just completed the first phase of an ekg study and while paramedic are great at seeing whether or not a 12 lead is abnormal; less than 20% could tell me what it was. We need to focus on recognizing the hoofbeats and finding the horses!

  • brugada medic – Arrhythmias come and go, too, but we still look for them on the cardiac monitor. No test is 100% sensitive and 100% specific. There are no certainties in medicine, but if the parents are going to refuse transport, why not look for ECG abnormalities considered high-risk? Your point is well taken that we can't give anyone a clean bill of health, and I'm all about recognizing horses, but every once in a while a zebra makes hoof beats. I completely disagree with you that prolonged QT-syndrome should not even be a part of the differential diagnosis. With your history I'm surprised to hear you say that. When forming a differential diagnosis I subscribe to Ray Fowler, M.D.'s method of saying, "I think it's w, it could be x, it's probably not y, and it's definitely not z." I think prolonged QT in a syncope patient is a very important 'x'. It's so easy to look at the QT/QTc. Why wouldn't you do it?

  • Andrew says:

    On the similar page as scooter, in central NY our nurses are often our first line if we have questions but I've noticed that they do not always have the knowledge of 12 leads that we would expect.  In one recent case I had an ER RN tell me that my 12 lead was useless because the patient has a Bundle Branch Block.  When I proceeded to explain that I felt it helped as I didn't see any concordant ST elevation she replied "I don't know what that is." I never hesitate to bring my 12 lead to a doctor at the ER desk and ask them about it, I have transmitted several just for consult and think its a great tool. You'll always have the MD's and RN's that just wish you had left well enough alone, but then you'll always have the medics who never would have evaluated this patient in the first place.

  • Christopher says:

    Tom, I dunno where Scooter is from but we certainly covered Long QT and HCOM in my class. We didn't do Brugada, but we were taught R-wave progression and appropriate ST-T-wave changes throughout the precordium and likely would have caught BrS as, "this is out of place and looks bad."

  • Insanity doing the same thing and expecting a different result says:

    First not evaluating a patient with a complaint is called negligence.  If a paramedic does not evaluate this patient then they need to get off a truck.  Second, 12 leads should never be used by paramedics as a screening tool.  The only people qualified to do this are physicians, PA's, and NP's.  Last time I checked I have only met one paramedic who fits any of those afore mentioned positions.  EMS has become a field that is more concerned in the idea that lets see who can get the coolest toys.  EMS needs to go back to a common sense approach.  I have been a paramedic for 11 years and in ems for 14.  I have always approached patient care in a logical manner.  I remember that I am a technician, trained to practice skills honed by experience.  I am not a clinician who spent 3 years in graduate school, completed an internship, residency and now practices medicine.  We are not allowed to practice medicine.  We follow a list of protocols or standing orders.  We cannot make a decision outside of these parameters without contacting a physician first.  If we do we are practicing medicine without a license.  Last time I checked that got you a vacation with a lot of other men, in a poorly furnished room.  The medics should have told the parents the patient had a syncopal episode, which may have been caused by the sight of blood, but could also be caused by an undelying condition that cannot be diagnosed by a paramedic.  I worked for a service that used Dr. Fowler as thier medical director.  He pushes the use of a 12 lead by paramedics.  He would like for paramedics to diagnose cardiac conditions and treat the condition.  He never wrote a protocol that allowed us to do this.  We treated all cardiac chest pain with O2, ASA, NTG and diesel fuel.  I for one do not want to be responsible for diagnosing any patient.  We need to get the illusion out of our heads that we are more than stretcher jockeys.  We do not have an opinion, we do not give advice and should leave the diagnoses with the Physician in charge at the receiving facility.  Let us not forget that most MI's are diagnosed with blood work and a physicians gut reaction.  Why do physicians treat acid reflux with a GI cocktail and not a trip to the cath lab.  The cath lab might come, but only with a 12 lead with acute changes or blood work that shows elevated cardiac enzymes.  Lets get back to reality and do what we are supposed to do.

  • Of course we screen patients. Every time we perform a 12-lead ECG we're screening the patient for acute STEMI. In fact the primary use of the 12-lead ECG is to screen broad, symptomatic emergency department populations for cardiac ischemia. By extension, EMS performs them in the field. However, sometimes patients don't wish to be transported to the hospital, and it's the treating paramedic's job to explain the risk of refusing care. Part of that risk is influenced by our history taking, the vital signs, the physical exam, and diagnostic tests like a BGL and the 12-lead ECG. Screening a patient for cardiac ischemia is not practicing medicine without a license. It's responsible care. The standard is the "reasonable and prudent paramedic." By your definition telling a patient they need to be seen in the emergency department is practicing medicine without a license because we're offering an opinion about a medical condition. I disagree with using a 12-lead ECG as a tool to convince a patient not to go to the hospital but that's not what happened in this case. Had the paramedics caught a case of LQTS, WPW, HOCM or Brugada they would be deserving of our praise. The ED physician, PA, or NP is not in the field. Paramedics are and we have to do the best we can within our scope of practice. I have no quarrel with contacting a physician when appropriate but I see no reason why we shouldn't be educated as to the potentially life-threatening abnormalities on the 12-lead ECG. Whether that's a run of VT, acute STEMI, or Brugada, what does it matter? It's a tool to help understand what's happening with our patient. Nothing more and nothing less.

  • Troy says:

    [Edited for civility. Thanks, Tom B.] By your own deduction, a patient should be taken by taxi and not ambulance. If you don’t want to actually diagnose or be “responsible for someone” maybe you should be out of the field. That’s just poor patient care.

  • Insanity doing the same thing and expecting a different result says:

    Tom ischemia is a diagnosis.  Ischemia can be diagnosed cereberal or cardiac, if you don't believe me look up the diagnosis code.  Telling a patient they need to go to the hospital is not practicing medicine if it comes after or before you might have an underlying medical problem I am not qualified to diagnose.  Are you qualified to diagnose WPW, LQTS, or Brugada.  Have you seen enough of these rhythms to make an accurate assessment of the rhythm.  I work on an ambulance and in a urgent care practice with PA's, DO's and MD's.  Often these "Clinicians" consult with each other to make an accurate diagnoses.  Do you need a 12 lead to explain the risk of refusing.  It might help but what happened when we didn't have them.  We explained the risks in the context of their symptoms.  What standard is the "reasonable and prudent paramedic".  I have never heard of this standard.  I have never heard anyone I know talk about this standard.  Scope of practice of paramedics is limited.  Scope of practice is limited because we have people who fit into three catergories.  There are those who think they are more than they are.  These people stay on scene way too long and delay care.  The second are those that think no one needs to go to the hospital and try to talk the patient out of going.  These are the medics no one wants to work with and never want to have treating them or their family.  The third is the type who assess the situation, advise the patient of what needs to happen and transports to the hospital treating en route to the ER.  Which type are you?
     

  • I've always been a "get the show on the road" paramedic. I minimize on-scene times and usually do my treatment en route unless there is a compelling reason to "stay and play" (stabilize on scene). I despise paramedics who don't want to do their job and take patients to the hospital. Thanks for asking. As for the "reasonable and prudent paramedic" you might want to consult any EMS attorney.

  • Troy says:

    So “insanity”, v-fib is a diagnosis. Do you treat that with epi, amiodarone, and defibrillation? Can you not diagnose v-fib? Paramedics diagnose every day. And yes, I CAN AND WILL diagnose a STEMI, treat it accordingly, and activate the cath lab. I guess I’m an overachiever like that. As far as LQTS, WPW, and Brugada, prehospital 12 lead can be essential for diagnosis. My docs and I have a very good working relationship and they trust my opinion. I know I’m not the higher level of care, but diagnosis and treatment in the prehospital can be the difference between life and death for my patients. I don’t like to stay and play very often unless I have to but the 75 seconds it takes to run a 12-lead is one of the times I will. That can be 20 minutes worth of myocardial death.

  • Brandon O says:

    Thanks for this case, Tom. I go back and forth on the idea of screening for congenital cardiac abnormalities as a role for EMS and this was a good reminder.
    As a general rule, and although not necessarily pertinent here (I would not freak if that patient had not been transported), I do feel that the purpose of these "above, beyond, and ever-deeper" assessment subtleties is mainly for potential refusals. Okay, it's true that you can catch the Brugada or you can miss the Brugada and it may be a moot point as long as it eventually gets caught by the doc in the white coat. But what if the patient is considering not visiting the doc in the white coat?
    I suppose this is a non-issue if you push for absolutely 100% transports. But I find this ethically questionably as well.

  • Brandon O says:

    Sorry, just to add to my previous… in an ideal world I would like for field personnel to see "visiting the emergency department" as a type of TREATMENT, just like a diltiazem push or strapping on a CPAP. It has certain indications and benefits, but it also has adverse effects, and you should weigh the risks against the costs. It costs money. It takes time. It's generally very unpleasant. It carries the possibility of nosocomial infection and iatrogenic harm. How to weigh these risks will vary by the patient, which is why the patient needs to make the decision, but — and this is a big but — the patient does not have the training to fully understand their medical situation. I try to think, "what would *I* want to do if I were the patient?", meaning I would have the patient's circumstances and interests, but my own training and knowledge. Any sane person would lean strongly towards the side of playing it safe, but that doesn't mean the costs of transport should be totally ignored.
     
    But this is all certainly a very difficult and potentially dangerous line to walk, especially when "the good of the patient" may have to yield to considerations like policy and liability.

  • ToddB says:

    @insanity-

    1. To refer to EMS personnel as stretcher jockeys is akin to calling us ambulance drivers; or calling an animal control officer a “dog catcher”. I’m amazed to hear that from anyone in EMS.

    2. “We do not have an opinion”? I’ll be glad to reference you to a mid 70s episode of “Emergency!” where a physician told Johnny and Roy that the pt was in Vtach and gave orders to cardiovert. They read sinus bradycardia and switched frequencies to contact a secondary ED – and saved the pt’s life.. They had an opinion 35+ years ago….and the show was pretty accurate for it’s time period. Having an opinion is the only thing that sets us apart from monkeys.

    3. The reasonably prudent EMT (or paramedic) should have been covered on the second or third night of EMT class (basic class). Perhaps you were absent that night or had a poor instructor. Not your fault…..happens to the best of us.

    4. Your blind respect for MDs, PAs, and NPs is misplaced. I see the typical urgent care or family practice MD (PA, NP, etc) floating through ACLS or PALS every week. Most of them have no clue about emergency cardiovascular care and can’t even read a 3 lead EKG. I usually end up teaching a basic EKG course just to get them through. Anyone posting here that teaches ACLS or PALS knows exactly what I’m talking about. Ever responded to an urgent care and found a doc calm, cool, and collected running a code?

    ** side note- ED docs and competent practitioners are exceptions to above

    5. I cannot believe you have the experience you state, but only know 1 paramedic that has gone on to be a doc or mid-level practitioner. I know several (unfortunately I’m not one of them).

    Having said that, you are certainly entitled to your opinion. I can repect the fact that you are willing to put it in writing. Good luck…

  • Insanity doing the same thing and expecting a different result says says:

    I find it very interesting when someone who states an opinion that many have thought about but few truly voice catches so much backlash.  ToddB i'm not offended by someone calling me an ambulance driver.  I do not have blind respect for MD's, PA's or NP's.  The providers minus one at the urgent care center where I work, have all worked in Emergency Medicine.  One of the PA's worked for a cardiologist for 6 years.  I think he know a little bit about reading an EKG.  We don't have an opinion.  If you followed an order from a doc that was wrong then you would knowingly harm a patient.  Having an opinion and following a standard of care are two different things.  We treat based on a standard of care.  If a patient c/o respiratory distress, has a history of copd or asthma, has bilateral wheezing, most if not all would treat with breathing tx's, steroids, cpap and any other treatment allowed by the protocols, standing orders or online medical control.  You can form an opinion of the cause of the patients illness, but that opinion is not what establishes your treatment plan.  Your treatment plan is started based on experience, protocols and what you have been taught.  You can call it a diagnoses if it makes you feel better.  I choose not to.  No one calls 911 for paramedics opinion on what is wrong with them.  If we give our opinion we are offering medical advice.  I'm not sure how long you have been a paramedic ToddB, but when I took national registry I had to use a pencil to take the test.  You state that ED docs are an exception.  I would agree with you if you said some ED docs were, but not all.  I don't really care if you believe how much experience you have, but I do appreciate that you agree that we all have a right to voice our opinions. 
     
    Troy have you ever treated WPW, brugada, or any other similar cardiac condition.  V-fib is not a diagnoses.  V-fib is a treatable cardiac rhythm.  A diagnoses is something healthcare facilities, ems services, fire departments, doctor offices etc. can treat and bill for.  The actuall diagnosis for v-fib would probably be cardiac arrest, an MI or any number of diseases or disorders.  No physician, hospital or ems service has ever diagnosed someone with v-fib.  A medical examiner does not ever list the cause of death as v-fib, asystole, v-tach or any other ecg rhythm.  By the way the cause of death is also a diagnoses.

  • VinceD says:

    Buckle up kiddies…
    I will gladly continue to diagnose patients with STEMI, acute pulmonary edema, asthma exacerbation, or Brugada Syndrome. Just the same, if I cannot find a specific cause for a patient’s symptoms (the majority of the time), I will give them the diagnosis of chest pain, abdominal pain, difficulty breathing, or headache. That is because a diagnosis is not a billing code, but rather a medical provider's best impression of the processes affecting a patient; construed from the history of present illness, physical exam, and the results of whatever testing is deemed necessary based the former two. Based off of this information, the prehospital provider is capable of initiating interventions and arranging for the next step in the patient’s care. This is the same exact thing emergency physicians do every single day and it forms whole basis for modern emergency care. If we are capable of giving a definitive answer like STEMI (and I know many readers of this site are, y'all rock), that is great, but if we can only state that the patient has "chest pain," that still falls within the realm of a diagnosis because (and this is the important part), we have given the patient a label and will now venture down a course of treatment and decision making based off of that.
    Emergency care is not about finding a definitive answer for every single patient; it is about risk stratifying and figuring out the next step and who needs to be called. It is the job of in-patient physicians to form a large differential diagnosis and then try to whittle it down to the most elegant answer; however, if emergency physicians and prehospital providers can also draw specific conclusions about a patient while performing the emergency evaluation, then that is all-the-better.
    For us, “chest pain” without STEMI involves a focused physical exam, testing with a 12-lead ECG and pulse oximetry, possibly treatment with aspirin, oxygen, and nitro, and transfer to a facility capable of providing further workup. Once at the ED, the “chest pain” patient will receive serial troponin draws, a chest x-ray, ECGs, a higher level of physical exam and HPI, and possibly discharge to follow up with the patient’s primary care provider in 1 to 3 days. Both of these processes followed the exact outline and utilized the exact same diagnosis of chest pain, they were just performed by different people. They also came to the exact same conclusion: “Yes, you are experiencing discomfort in your chest; no, we do not know what is causing it; yes you should continue along the medical care continuum for further evaluation.” Just as easily, a prehospital diagnosis of “chest pain” can evolve to “acute coronary syndrome” in the emergency department as more history is gathered, and later change to “acute myocardial infarction” upon admission to the hospital and further testing. Both the original label for the patient’s condition along with the emergency physician’s were acceptable diagnoses, they just weren’t the final diagnosis. Still, they were (let’s hear the word one more time…) diagnoses none-the-less.

    Now I am not saying any of us are licensed medical practitioners like emergency physicians or capable of the same level of decision making, but just like them we must assess patients, performs tests, provide treatments, and decide what the next step in a patient’s medical care will be. Call it what you like, but that’s making a diagnosis to me.

  • Christopher says:

    If by screening tool you mean using a 12-Lead ECG to rule OUT a condition and let someone refuse, then no, most Paramedics are neither trained to do so nor given the latitude in scope of practice.
     
    If by screening tool you mean using a 12-Lead ECG to rule IN conditions and begin a course of treatment based on a working diagnosis, then yes, most all Paramedics are trained to do so and are given the latitude in scope of practice.
     
    Otherwise I'm just not seeing what is the big deal here.

  • Troy says:

    @Insanity,

    I have diagnosed WPW before. Started him on a procainamide drip after he sent into SVT, controlled it with that, gave the report to the doctor of “previously undiagnosed WPW” and got an attaboy from the doc. I even diagnosed a APE the other day, heparinized her, and gave report to the doc as “Acute Pulmonary Embolus.” That’s the fun part about having a system where you work together as a team for the diagnosis and where most docs respect their paramedics. And I believe 12 leads are not a tool to “rule out” and help a AMA signature. But having a man who has “indigestion” and doesn’t want to go to the hospital, a 12 lead could definitely “rule in” a “diagnosis” of “acute inferiolateral MI” 😛

  • Insanity is doing the same thing and expecting a different result says:

    It great that you work in a system Troy that gives you the latitiude to treat patients.  My whole argument with 12 leads is that many patients diagnose with a 12 lead do not have signifcant ecg change.  The diagnosis comes with further testing.  If you have a patient with indigestion and a normal 12 lead, what is you next step.  My point has been all along that the 12 lead should not be the reason you transport.  The fact that the man has a c/o chest pain should.

  • Troy says:

    A 12 lead can be a vital tool, but whether you have one or not, you treat the patient.

  • Egotastic says:

    You guys crack me up!  Me me me, I I I, me me me.  Experience experience experience.  You you you. Didn't some one state above some where some thing about egos? 

  • James says:

    Hey, what about a secundium atrial septal defect? There is RAD, the beginings of an IRBBB and even Crochetage sign!

    Certainly explains the syncope.

    Just a thought.

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