Pediatric Cardiac Complacency – A Case Study for EMS

It’s interesting how personal experiences and professional biases can affect a clinician’s personal style of providing patient care. I’d wager that it happens to us all in some subtle and some not-so-subtle ways.

One of the things I’ve noticed about my own style of personal practice is that I’m very sensitive to screening for and catching acute coronary syndromes and coronary ischemia. I run a lot of 12-lead EKGs and scrutinize them closely, perhaps even too closely. I’ve noticed that it causes me to catch little things in the squiggles that may only be academic in nature and do not necessarily affect the care I provide.

I’m not saying that this is necessarily a bad thing, because I would consider myself to be very thorough overall in my patient assessments in most areas, but I tend to see things in EKGs that my colleagues and peers don’t. It’s negligible whether or not my sensitivity to mild EKG abnormalities makes me a better paramedic or not, but it’s there and I watch myself for it to make sure I am not overly biased to cardiac issues over other possible diagnoses.

I tend to run these a lot is what I'm saying.

I tend to run these a lot is what I’m saying.

 

I can attribute my possible oversensitivity with EKG reading to a number of things, including being steeped in a service that emphasized cardiac care, but also because of a patient I had early on in my career when I was a new little medic-let working in an ER.

I remember this vividly, all these many years later. It was early Christmas day by only about a half-hour past midnight and I was working as the triage medic in a small, free-standing emergency room. A 19 year-old male patient walked into the ER waiting room with his mother. We were very slow that night, and he was going to be one of our only patients so far that shift. He was complaining of chest pain, and his mother had become concerned enough to bring him in to be seen.

A 19yo with chest pain? Ok, let’s not hurry here. Am I right?

The triage exam was pretty unremarkable. I checked him over while the clerk entered him into the computer. The pain had been going on for a couple of hours, he had been sick lately, but I didn’t find any life threats. Ho hum, no big deal. Kids don’t have big problems when their chests hurt and I was steeped in the superstition that this couldn’t be any kind of life threat. As I remember, the kid had no history of trauma, no cough with hemoptypsis (coughing up blood), no signs of a Pulmonary Embolism, and nothing else that concerned me. I took his vitals and put him in a minor exam room.

After that, I grabbed some of the sugar cookies that one of the nurses had brought in and stood in my usual spot at the desk to shoot the breeze with my coworkers. Merry Christmas to all.

Imagine my surprise, as a young and inexperienced medic, when the nurse grabbed the doctor quickly and had me get a 12-lead EKG. Turns out the kid had some massive ST elevation that was even visible on his lead II monitor rhythm. We moved him into the resuscitation room and worked him up for cardiac ischemia. His diagnosis was acute pericarditis and he ended up going to the ICU as I recall.

Mark a black mark for complacency on my permanent record for that one. That under-triage and complacent disregard for a good assessment caused me to miss a potentially serious condition on a kid who was sicker than my assessment bias allowed me to believe at the time. It’s a good thing that this happened to me early in my career in a setting where my mistake was easily caught and corrected by more experienced providers. It taught me a good lesson that I’ve not forgotten.

You should remember this lesson too: Don’t let yourself become biased in your patient assessments. Patients can be as sick as they darn well please and it’s your job to fully assess them and make a proper professional, clinical judgment. The patient has no responsibility to conform to your personal biases, to any statistics about disease prevalence, or to any semblance of conditions you think they may or may not be able to have. Complete a full assessment of every patient, every time.

I thought about this case this morning after reading a case study on Dr. Smith’s ECG blog, which is an exceptionally good resource for learning about cardiac care. It regards the same type of scenario that happened to me all that many years ago. You should read it too. It’s better to learn this type of lesson via reading words on a screen than it is to learn it the hard way through missing something with an actual patient.

A 16yo Girl has Syncope While Playing Basketball Dr. Smith’s ECG Blog

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Interested in learning more about Pericarditis for EMS providers? Read “Pericarditis for EMS – A Short and Sweet Case Review.” You can also learn about how to increase your sensitivity in assessing patients with chest pain by remembering to “Call PAPPA for Chest Pain – A helpful Mnemonic for Paramedics and EMTs”

  • Mike Smertka

    I think this is a very good post. To just offer an assessment tip, it is best to consider the epidemiology of life threats in various populations. While it is almost inconceivable a teenager is having an MI secondary to arteriosclerotic clot formation, especially early teens show/have their first presentation of genetic heart defects, and as pointed out here, infections. (especially secondary to drug use, which may be causing its own cardiac abnormalities.)In the realm of critical care, BS is a diagnosis of exclusion.

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Chris Kaiser aka "Ckemtp"

I am a paramedic trying to advance the idea that the Emergency Medical Services can be made into the profession that we all want it, need it, and know it deserves to be.
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