Category Archives: Basics

12-lead placement is simple, so why do so many people fuck it up?

I see incorrect lead placements all the time, especially precordial leads. I see this in prehopsital settings. I see this at the EDs. Some days, it seems like no one on Earth knows how to do it correctly.

The other day, some idiot medic had the gall to tell me that my placement of V1 was too high. I ran my fingers down the normal-sized patient’s ribs, counting out 4 intercostal spaces along his sternum, just to make a point. This idiot removed all the leads and put them on incorrectly anyway, without any evidence he physically touched and counted any intercostal spaces.

I don’t understand it. There are not many different ways to do it. Entire diagrams of lead placement are printed in protocols and textbooks, in color, in black and white, superimposed on ribcages, described in detail – you just have to follow it. Endless pages of images of proper lead placement are searchable on Google if one simply bothered. In fact, for this post, it took me HOURS on Google just to find 3 or 4 images of incorrect precordial lead placement.

So what the fuck? Why can’t people put these leads on right?

Limb leads go on limbs. Not the torso.

Precordial leads go like this:

OBHG Education Subcommittee
OBHG Education Subcommittee

Another view:

Wikipedia/Mikael Häggström
Wikipedia/Mikael Häggström

This image shows why we do precordial leads a certain way:

precord_view

Another image:

EKG_leads
Wikipedia/Npatchett

Another one:

fab1b553147852918fac8ea5423017ed

One more:

07-ECG-Anatomy-LITFL

Therefore, with axis in mind, this is absolute bullshit:

pleadp

So is this:

AP Photo File/Thomas Kienzle
AP Photo File/Thomas Kienzle

As is this:

ems12lead.com
ems12lead.com

Or this:

ECGAcademy.com
ECGAcademy.com

Further reading:

Another example of how NOT to park

I know it’s just a commercial, but still, that is a completely nonsensical park job. PD too. I’ve already covered this before in a previous post, so I’m not going to repeat myself.

Basics #4: Keep calm and drive on

The absolute majority of people and their families do not want to see responding crews freaking out. Other than too much TV and movies, I never understood where some of our co-workers get the idea that it’s OK to be yelling and screaming at other personnel on a call. Imagine you called 911 and now the people who are supposed to take care of your problem are now running around with their panties in a wad.

WRONG.

Instead, I truly think you should be at a point where your outward tranquility should occasionally get you a complaint or two that you don’t care or you aren’t concerned. Like one particularly incompetent engine company who was angry that I told them to “calm the fuck down” on a simple evisceration. Take a lesson from my episode: It’s almost impossible to get an excited crew to “calm the fuck down.”

You really shouldn’t care. At least during the call. You make MUCH better decisions when you are objective and your mind is not clouded by emotion.

“Your head fell off? Yeah, yeah, I understand that, but please stop screaming at me. And you got your insurance card on you?”

And then after that, whoever is driving needs to remember to DRIVE CALMLY so stuff can get done in the back of the ambulance.

I’m certainly not saying you shouldn’t care or experience some emotions after the call. You should, because it’s good for your mental health. But during the call, it can be very bad for your license.

Basics #3: People lie

People lie. All the time. Even if you haven’t watched House, by now you must realize that everybody lies.

People lie. But cars don’t. This is why we walk all sides and look at damage.

Neither do symptoms. Objective stuff you can see and touch. That’s right – put your hands on patients and actually examine them. It’s the O in SOAP.

Be smart about what to believe.

It’s bright out here

If I hear another provider tell me that a patient has “pinpoint pupils” when we’re standing on the street in broad daylight, perhaps under the sun, as if it’s something really important that I missed, I just may lose it and gouge someone’s eyes out.

We’ll see if they’re pinpoint too after they’re separated from the brain.

An example of how NOT to park

I’m noticing a jump in new people not knowing how to park rigs on scene, and this is more important than ever as fewer and fewer civilians pay attention to their driving with the introduction of each new smartphone.

With each passing day, it feels like there is a greater and greater chance of getting hit by a passing vehicle, especially when we’re parked on scene. This is not even considering all those times civilian drivers don’t have the sense to slow down and give the scene a wide berth. I’m sure you all remember too vividly those instances when you actually felt the draft from their passing vehicles.

As for our own drivers’ parking decisions, I don’t know if this is a training issue or a common-sense issue or both, since every scene requires flexibility and some know-how in order to position the rigs as safely as possible. At the same time, the general rules are pretty much the same – don’t reverse if you don’t have to, protect working areas, etc.

Twice the other day, 2 different drivers did the following, exactly the same way:

Instead of parking on the wrong (oncoming) side of the street, in front of the scene, where everyone was obviously out front, and where the fire crew has deliberately left space for the ambulance with a blocking position, both drivers drove past the scene while staring straight at the scene but not recognizing the sensible spot, made a 3-point turn in the intersection without (as explicitly required by policy at every agency on Earth*) a backer (who by the way, on foot, would have been in a very dangerous situation), came nose-to-nose with the fire engine – blocking both the engine’s egress and the ambulance’s egress, meaning one of which had to reverse unnecessarily – leaving the rear patient doors and the very vulnerable act of lifting the gurney exposed to cross-traffic.

Please try to make it harder for the civilians to hit us.

*If you know about an agency that doesn’t have such a policy, I’d love to hear about it. Whether the policy is followed every single time is an entirely different matter and doesn’t interest me much. This is pretty much consistent with how I approach workplace backing situations: I’m happy to back you anywhere, anytime, even in the rain, and I won’t rat you out if you refuse my offer, but you had better not fucking hit anything or I will kill you just for the paperwork you cause me.

A quick note on writing PCRs

Some time ago I wrote a post about writing PCRs and even included an example. Now, I read a lot of PCRs, like a couple of hundred each quarter, for reviews, and in one of those moments when you’re daydreaming and having random thoughts, I realized I forgot to mention my biggest source of annoyance.

Let’s take a look at this:

This was a 25-year-old male who was found on the couch of a rather tidy residence with his head up his ass. He otherwise appeared to be in no apparent distress, had a strong odor resembling ETOH on his breath, and c/o that his “pussy hurt.” He was polite and cooperative, but was a poor historian and did not provide much useful detail regarding his complaint despite crew’s multiple attempts to elicit such information. He denied any vaginal trauma/bleeding/spotting/discharge or dysuria. He denied any other pain/complaint or history of similar events. He admitted to ingesting ETOH and using “a lot of meth” over the past 24 hours. No obvious abnormalities noted in his genital area. Physical exam otherwise unremarkable. Pt was instructed, sternly, to pull his head out of his ass and “quit being a little bitch.” He was then instructed to walk to the ambulance, which he did with a steady gait and no apparent difficulty. Pt was transported without incident, and he rested quietly and comfortably on the gurney. Pt care was transferred to ED staff without incident.

Let’s see if we can make it better:

This was a 25-year-old male who was found on the couch of a rather tidy residence with his head up his ass. He otherwise appeared to be in no apparent distress, had a strong odor resembling ETOH on his breath, and c/o that his “pussy hurt.”

He was polite and cooperative, but was a poor historian and did not provide much useful detail regarding his complaint despite crew’s multiple attempts to elicit such information. He denied any vaginal trauma/bleeding/spotting/discharge or dysuria. He denied any other pain/complaint or history of similar events.

He admitted to ingesting ETOH and using “a lot of meth” over the past 24 hours.

No obvious abnormalities noted in his genital area. Physical exam otherwise unremarkable.

Pt was instructed, sternly, to pull his head out of his ass and “quit being a little bitch.” He was then instructed to walk to the ambulance, which he did with a steady gait and no apparent difficulty.

Pt was transported without incident, and he rested quietly and comfortably on the gurney.

Pt care was transferred to ED staff without incident.

Yes, PARAGRAPHS!!! Use them!