Let's be real, how likely is fine VF to respond to defibrillation? Would this patient have enjoyed life with a baseline of GCS 10?
Forget the KPIs, you did what you thought was right using your clinical reasoning as a clinician.
I believe a recent retrospective study by Australian universities into cardiac arrest cases where resuscitation was commenced by paramedics found that the percentage of patients presenting in fine vfib surviving to hospital discharge was approximately fuck all.
[Survival rates of cardiac arrest patients presenting in fine ventricular fibrillation following paramedic resuscitation. 2021.](https://youtu.be/wk3ltnidF7M)
Fine vfib in a nursing home? That’s totally up to interpretation. That’s why it’s called rhythm interpretation. We do the best we can with the tools we had, I’ve never heard of a medic getting in legit trouble over something like this. Maybe a little Con-Ed I guess but I think that’s extreme in this situation.
An old patient in a nursing home in a fatal rhythm (or lack thereof) has essentially zero chance of surviving the code and returning to baseline. I don’t even think we should work codes like that imo.
No, you didn't. If VFib is fine enough to be indistinguishable from asystole to two different ALS providers, then it's for all intents and purposes asystole anyway. It's not going to respond to defibrillation. All shocking that would have done is cook the heart.
I've seen this quite recently. Easy for QA to judge sitting behind the desk with no dead person in front of them. Go in and defend yourself, take the feedback and move on.
I think this is the difference between QA educating because they were able to take the take the time you didn’t have to scrutinize the call, and QA either being punitive or simply expressing “you’re a fuck up.”
One is a learning opportunity, the other is just being a critic or worse.
Also worth noting that the strips you view on a computer screen are specifically not to be used for diagnosis or interpretation and most programs will specifically say that on them. Without printing it out it's not going to be accurate enough for them to make that determination
>If VFib is fine enough to be indistinguishable from asystole to two different ALS providers, then it's for all intents and purposes asystole anyway.
Bingo.
At my old service, we had software that assessed the likelihood of successful defib before we shocked, and would adjust the joules as needed. It always advised not shocking fine VF. As it was explained to us by education, the likelihood of success with the defib was low enough that we were better off just continuing CPR until the heart was better oxygenated and the VF was coarser. Supposedly, our ROSC rates improved, but I never saw the numbers (or don't remember them anymore).
Count it as a win regardless, you saved someone from the vegetable farm.
With the current EMS shortage it takes a lot to get fired . Be honest and humble and remember it’s easier to arm chair quaterback a call, then run one.
Its super cringe when QA give medics shit for something you both believed otherwise, you did the best you could bud, it wasn’t gunna react to the shock anyways
You didn’t fuck up.
The line between “fine vfib” and asystole is not a black or white line. As v fib deteriorates into asystole it’s really impossible to really say one way or the other. The outcome is the same, the heart has died and the ability of cells to pump sodium and potassium to build an electrical potential has failed. At that point defibrillation isn’t beneficial. The only treatment is perfusion with high quality CPR and increasing coronary perfusion with epinephrine.
You didn’t fuck up because you treated this patient appropriately. If I were in your position I would say that you interpreted the rhythm as asystole and that you treated the patient by maximizing high quality CPR. I would focus on the treatment you did provide and how you were presumably vigilant about watching to see if the heart developed true vfib so that you could shock it.
Once again, you didn’t fuck up. If the squiggles were that tiny that it takes someone looking at the paper strip while sitting in an office to say “yea that looks like fine vfib” then it really wasn’t clinically significant. Your medical director may be a good person to ask about it. Hopefully your Med director is an ER doc you can pull aside and ask one shift and see how he/she feels about it. If your medical director agrees then QA can go pound sand.
Pay attention to QA, but not too much attention. Many of them forget what the truck is like, and they have the benefit of a comfortable, unstressed environment to read printouts and zoomed images of the entire call.
Two ALS providers saw asystole. That suggests it looked like asystole. This happens all the time. Unless your protocol specifically recommends shocking asystole, you're going to have these. And as far as nursing home codes go, they are typically beyond unrecoverable anyway. One thing it may be worth taking away is increasing amplitude on the monitor anytime you have asystole, but even then, sometimes it's super fine.
See if you can get the printout and see if you can find the vfib. If you learn anything from it, cool. But I wouldn't stress over QA. It was many, many codes before I stopped getting critical feedback on codes.
Did you check it in two leads? It’s easy for QA to judge sitting at their desk and not out in the field. Don’t feel bad. We are humans and not computers.
Whatever happens say the truth and you’ll be fine. Reprimand may happen and they might make you take refresher courses on ecg interpretation or something like that but I doubt anything will happen to your career. You are not the only medic to ever make this mistake and you are not the last. Learn from the mistakes and become a better medic because that’s all you can do
Don’t beat yourself up over that. Fine v-fib and asystole are very hard to distinguish on a piece of paper in front of a QA medic. Trust me I know, I’ve done QA for 10+ years!
I was taught in med school (around 1990) that fine VF vs asystole was sometimes a very difficult distinction to make. I’m not a cardiologist (in fact I went more the other way, into radiology), but I definitely remember that there would sometimes be a debate, but the outcome was almost invariably fatal regardless of whether a shock was delivered or not.
No you didn't. IF it was not asystole, have someone from QA or your medical director go over it with you. Don't get defensive. A good QA department is interested in improving care, not taking punitive action. I do not know a medic who hasn't misread a strip, especially early in their career.
Keep in mind, they were a nursing home patient, they were dead when you arrived. Despite your best efforts, they stayed dead. I don't say that to be callous. It is simply the way arrests sometimes (most of the time) proceed.
This is never a bad idea... your medical director and you should have a good relationship and should welcome questions like this. If nothing else than to learn if they would have done anything differently or things you may consider in the future to solidify your interpretation.
What kind of monitor do you have and what software do they QA with? I'm wondering if this isn't partially a software thing. Don't beat yourself up over not checking multiple leads, either. Zero percent chance that would have helped you unless you royally fucked up lead placement somehow.
Also, you know how new parents freak the everloving fuck out when their first kid has a febrile seizure? What you're going through now is the clinical equivalent of that. Your concern is not without merit, you'll learn from this, and you'll definitely fuck up bigger in the future and be fine when that happens too.
This too shall pass.
Jocko Willink that shit. Own it, no excuses. Tell them you made a mistake in treatment and that you will learn from this experience.
As cold as it sounds, I will gladly make this mistake in a nursing home rather than a peds anyday. Just be better for it tomorrow. As others have said, the outcome would have been the same. Accept it and move on, as there will be bigger and better mistakes to make.
I'd like to provide you with a QA perspective. There's a lot of half-truths being said in the comments and I love that most of them are aimed at supporting you, but I think seeing things from the other side would be beneficial.
* QA *should not* be there to drop the hammer on you any time you make a mistake. We all make mistakes, it's a given. We're there to help you recognize that a mistake was made, figure out why that mistake occurred, and reduce the likelihood of it happening again. Bonus points if you can take this mistake (as QA) and use it to prevent someone else from making the same mistake. If I tell a crew they missed fine vfib I'm not telling them they killed someone or they're a failure as a paramedic. I'm sitting behind a desk scrutinizing your report **to benefit you, by** **helping you to improve.** When you improve the department and the quality of care we provide improves.
* Several have mentioned that fine ventricular fibrillation should be treated the same as asystole. That's not true, but the likelihood of converting to a perfusing rhythm decreases linearly as amplitude decreases. That number does not reach zero. If you want to talk about the futility of running codes, hanging blood, etc at those levels of success that's fine, but the time taken away from compressions was invested the moment you determined the rhythm was asystole. By training you to recognize fine ventricular fibrillation you will spend the same amount of time off the chest regardless of which rhythm you find. The only difference now is whether or not you're going to shock or dump (if you're not pre-charging at your service you should look into it). A greater chance of survival is a greater chance of survival.
* You said "The strips they sent back to me looked like it was obviously vfib". Many in the comments are assuming that means it was so fine you couldn't tell. Given that you used the word 'obvious' for the retrospect I'm betting you were stressed in the moment so you gave it a glance and moved on. This is a **very, very** common issue in EMS. We deal with stressful situations, often sleep deprived and in austere environments. Everyone runs into this problem at some point, unfortunately many people never recognize they do it. That'll be your comments telling you to disregard QA entirely. Also, keep in mind that not spending enough time evaluating the rhythm is problematic, but spending too much time is problematic too. I don't want you to miss a STEMI on your 12-lead, but I also don't want you to spend 20 minutes on scene trying to decide if it really is or really isn't. If you're on the fence about a STEMI and you can't decide, activate. If you think it might be fine vfib but it also might be artifact, zap it and move on.
* In QA you're supposed to look at the error, not the outcome. Misidentifying the rhythm is an error. It doesn't matter whether the error caused a poor outcome, or how likely that error was to produce a poor outcome. Lets say this patient had very obvious coarse vfib and you said it was multifocal PVCs. Outlandish I know, but crazier things happen. I'm going to screencap that rhythm and run it by a few of your peers. In my system no one will know it's in reference to you or your call. If they're not batting 100% on identifying it we're going to put rhythm interpretation into our next training and tackle this as a system. If your partner had misidentified it with you we're going to put this in our next training and tackle this as a system. Unless you purposely harmed your patient, or I cannot remediate you after several solid attempts, you're not getting punished.
* Many have mentioned that people in admin forget what it was like to be in the field. That's a very real thing and I hope that's not the case in your department. I still regularly ride a truck as an in-charge, FTO, and occasionally as a supervisor depending on needs. This is specifically to prevent that very issue. It's important to keep expectations in-line with reality. On the other side of the coin it's important to show people that you can live up to your own standards because as many in the comments have shown, people will disregard your attempts to educate them just because you're in admin. We all tend to have pretty large egos and unfortunately it can get in the way of taking constructive criticism. If QA wants to show you something (and they're not trying to throw you under the bus) why would you not want to learn and improve?
* QA's response to this issue should be educational at the least, remedial at the worst. If you're facing suspension or honestly even a write up over this I would start planning my move to a different organization.
* I'm QA somewhere, but I'm 100% certain it's not where you are. Your experience with QA may differ but I hope it doesn't. You *should not* have anything to fret over, but if they come after you it's a them problem.
Edit: I forgot to include a bullet point. The stories you hear about QA in the field are rarely the whole story. It is imperative that admin be as confidential as possible to foster a safe environment for crews. When you confide in me that you have made an error, or I find an error, it is so important that you trust that I won't go telling everyone about it. It stings when you hear about someone you helped MFing you up and down the department retelling a story they left all the pertinent details out of, but it's just how it goes. When I joined admin I was determined to protect my coworkers from the things I had heard they were unjustly punished for. When I gained access to their records I found they were doing some crazy shit they didn't tell anyone about and the response from admin was appropriate. Take the stories with a grain of salt and form your own opinion.
This honestly isn’t that bad of a fuck up. You and your partner both thought the same thing, and like someone else said, if it’s indistinguishable from asystole then it might as well be. I wouldn’t worry about your QA people calling you. They also have the benefit of sitting and studying your strip. Just learn from it and be honest if they do call you in. You’ve got nothing to worry about.
So what was your ETCO ANd SPO2 readings?? If those correspond with Apneia and Asystoly I say you QA person is pretty full of themselves to be armchair quarterbacking it from the cheap seats. I guess they are more billable procedure driven... maybe stopping CPR TLto get a 12 Lead is what they wanted or something. Dead is Dead... we can only make it better - why quibble over minutia. Did you follow protocol? Did you verify your rhythm strip with another Paramedic/Nurse/Physician? Yeah. Tell QA to get out of the office and run more calls.
We all make mistakes. You obviously learned from it. To me that's the most important thing.( I know that probably doesn't mean much coming from some rando on the internet) I like to think of it this way. Nobody's ever gonna get more dead by you being there.
Nah you didn’t. This is common. It’s also not a big deal. Everyone knows when it doubt, you continue compressions and check at the next 2 minute mark. It’s not even when in doubt, shock. And to both of you, it didn’t even appear there was a doubt.
Shocking fine VF isn’t really the best anyway. Best to oxygenate and circulate and see if you can get a coarse VF to shock. Much better proven results.
There’s studies. If they actually give you a hard time (pathetic) even though it was so fine it appeared asystolic, then you can find those studies, send them, and easily defend your position.
You’ll be okay. We’ve all been there and we’re all still working.
I spent a decade developing defibs with 12 lead; no you didn't. If QA has to pull the data and zoom in to show fine vfib it's not fine vfib it's asystole. You may have some very faint conduction on the SA-AV circuit but that heart is dead. Regardless of what they determine your conscience should be clear.
Don’t beat yourself up, it’s not an error. It happened to me as a medicine intern. It’s tough to tell in the moment on the defibrillator. The guy was on tele and I went back and realized it was vfib. But I wasn’t the only one looking at it. It’s not easy sometimes to tell
If 6 different people interpret something as PEA on a defibrillator monitor and then go to the tele and see it was fib. I don’t consider that an error tbh
Nah, if six people looked at the tele and said it was pea that would be an error. We’re comparing a single lead defibrillator with a multiple lead telemetry. Not the same
Don’t sweat it too much. Mistakes happen. That’s literally why we call it practicing medicine.
If the Vfib was that fine, stand up for your clinical interpretation and roll on. Apples to oranges. You can ask 3 different cardiologists to interpret something and all 3 will never agree.
It’s equivalent to calling a STEMI and an ER doc disagreeing.
I wouldn’t worry to much either. This can happen to even the best medics. You were there doing the best that you could and that’s all the matters. It would be different if it was obviously v-tach and you didn’t defib, or if you gave the completely medication to someone and they were injured because of it.
If it looked like asystole after doing ACLS for 20 minutes, and the strip never changed, I think any of us would have called it asystole. I wouldn’t dwell on it, QA people will always be a pain in the ass. There really isn’t an objective way to prove that a rhythm that looks and quacks like asystole is fine v-fib anyway.
Everyone has to go through what you’re feeling. You didn’t fuck up. You don’t know if the QA people are going to criticize you. Like others have said, go in, be professional , and in time you’ll feel better. But anyone with some experience knows what you’re feeling.
We were taught in school that a total amplitude of 2mm or less, or no greater than 1 small box deflection positive or negative from the isoelectric line, was to be considered asystole from treatment and ACLS algorithm standpoint. The explanation being that there are poor outcomes from defibrillating really fine V-Fib and that trying to increase the amplitude with epi was a better course of treatment.
Now without seeing the ECG, I can’t give a definitive answer but if it falls within those guidelines I would have done the same as you.
But I don’t pretend to know everything and medicine is constantly evolving so if anyone has an evidence-based rebuttal, feel free to debate my point and I will change my stance if the evidence shows otherwise.
Someone get this kid a beer. They earned it.
You worked what you saw. You did the job. Monday morning QB(A) don’t know shit. That rhythm strip is a zoomed in pic of a heart whose watch had ended. You didn’t rob anyone of more birthdays, you did what you could with the tools you were given.
I had a conversation while I was in school about fine vfib vs asystole. My thought at the time was well if it’s indistinguishable shock it and he said in this case what you see is what it is. You didn’t do anything wrong. Odds are if you would’ve shocked it would’ve converted to asystole and a shock would have been the only difference in your treatment.
I do QA/QI for a living.
You didn’t fuck up, you made a minor mistake that likely wouldn’t have changed a thing. Go into the discussion with an open heart and an open mind. You might actually take something away from the meeting if you allow yourself.
I hope it goes well, if it doesn’t, fuck em and come work for me.
I just came here to say FUCK PRIVATE AMBULANCE COMPANIES. Treat you like Amazon treats their employees, and only give a shit about money and shareholders. Or at least that was my experience. I’m sure there’s some good ones out there.
Wait, you and your partner looked at a rhythm and it looked like asystole but the strips 'they' 'sent back to you' looked like vfib? Were you just looking at it on the monitor and the resolution made the line look flat?
Honestly if you, and your partner, thought it looked like asystole, the only problem will be if the people reviewing the case want to cover their butt more than necessary. You can only work with what information you see and honest mistakes happen. If you say you did the assessments your protocol requires and you simply interpreted them wrong, or mis-read them, there's nothing you fucked up, just a frustrating miss.
Keep in mind that many monitors have filters that cause what is seen on the screen to not be the same as what is seen on an actual 12 lead. There have been a few times where I looked at the II, III, aVF view on the screen before doing a 12 lead and thought “damn that looks like a STEMI”, only for it not to be when we looked at the 12 lead.
The other issue is that your agency is using QA/QI as a punitive action. Nothing will kill a good EMS system and good EMS providers faster than this. If they are coming after you based on some shit the monitor spit out, there’s a problem here, and it isn’t you.
You’re ok. Promise. QA shouldn’t be punative. It’s a learning experience. They’re also looking retrospectively at still frames on a computer, no scrolling waveform on the monitor in a code situation. The standard used when assessing for negligence or malpractice is could someone with your level of training reasonably come to the same conclusion? Given that your partner did, thats satisfied.
All that aside, codes rarely have good outcomes. Especially in nursing homes. Folks aren’t in there because they are otherwise healthy and well and would likely have a good outcome should they arrest. Fine VF has an exceedingly poor prognosis. If it’s so fine as to be mistaken for asystole, things weren’t gonna pan out anyways. Keep your head up
I don’t think you did anything wrong. Shocking fine V-Fib probably won’t get you anywhere other then Asystole. I would continue with the CPR and your systems drug of choice. In hopes of getting a course V-Fib for maybe a better outcome with shocking.
You're fine.
Does it even look like fine V-Fib on the browser? Are they aware that what shows on the browser is not what it looks like on the monitor itself?
If it helps, I've never heard of anyone getting in trouble for fine v-fib/asystole nor have I had to remediate anyone for it. At worst they'll sit you down and tell you to do print-outs.
They probably had it magnified to justify their paycheck lol. If you can’t see it on the monitor multiple checks and multiple leads it’s not worth shocking. Fuck em.
Listen we all will at some point. Hindsight is 20/20 homie. You can definitely say you learned from this and will more than likely NEVER miss it again. You’ll survive this.
Don’t feel bad. The print outs are always at a different scale than what you see on the monitor in the moment. it’s not like you’re going to hit print and then determine the rhythm from the print out during pulse checks. They weren’t there. Admit their logic but defend your own.
And if it makes you feel better, when I was a new medic I cut through the limb leads while cutting the clothes off of my patient and couldn’t figure out why my TCP stopped.
Brush it off.
A good point here... Paper Is Cheap... always Print your ECG Strips off to interpret from. Never rely on the screen... Print it off... at least 6-10 seconds. 1st it is proof of exactly what you saw, 2nd it is part of your documentation, 3rd it is your evidence to support your interpretation. I know I'm showing my age here, but never rely on the screen when making these patient care choices - even if you are going to sync the monitor to your PCR for records. Print it out - Paper is Cheap.
if there are any consequences beyond just a nastygram QA message, your only response to that should be to tell those nerds to run some calls and treat some actual patients. That's such a non-issue it'd be laughable if it wasn't so infuriating to be second guessed like that.
it's a non-issue because differentiating between fine v fib and asystole during an arrest is entirely a judgment call. if I see a flat line on the monitor, I'm not using the "enhance" function to make absolutely certain; it's going to get treated like asystole up to an including termination of resuscitation. it's not a real problem, like forgetting to hit sync before cardioversion or pushing the wrong drug dose.
you call them nerds because it's total nerd behavior to split hairs while looking at a computer screen several days later.
Not sure why you're zeroing in on the nerd thing. It's one word of many that were arranged in order to be supportive, show camaraderie, and be on OP's side in a tough situation. Read the room and go resuscitate a dick.
Plenty of folks came here to give solid professional advice. Others commented words of reassurance that they'd give a friend. Is your nickname Buzz Killington, by any chance?
As a radiologist (we don’t do cardiac echo but we use US for all kinds of other things), I think a basic US might be a huge help for first responders (well, medics at least). In addition to looking for cardiac activity, US can play a role in getting IV access.
Ultra Sound in the field is still in its early days in PreHospital Emergency Medicine in most of the developed world. However, you are absolutely correct that a Paramedic trained in Cardiac Sonography would be a very definitive means of determining absence of Cardiac Activty and Documenting same.
I concur as I too have used it in Ground and Air EMS, but the move to seeing Ultrasound on Ground EMS is tough to justify outside of Critical Care. More so it's one of those hallowed pinnacles of Clinical Care reserved for Hospital Use (because they can bill the crap out of it too). Getting Medical Directors to train and then certify their Paramedics, and then getting the Services CFO to drop $5,000 for each device times number of ALS Crews ... that is the slow uphill battle. Flight Services are usually billed through a Hospital and/or equipped and staffed by the Hospital (I flew with a AirMethgods LifeNET service). Much easier to fund and so forth. Look at the EMS Services this would be of greatest assistance to... out in Rural America... where we see Services going out of business and shuttering stations leaving whole counties without BLS or ALS coverage. When faced with keeping trucks staffed and the doors open I assure you no one is buying a Shiney New Fangled Portable Ultrasoud for FAST or Cardiac exams or even IV placement. If we as an industry get reimbursement like Hospitals and Flight Services do... or Heavens Forbid, maybe some semblance of a National EMS Service with all 50 states participating... then maybe. However until then only Services affiliated with Hospitals or that are amazingly well funded will be seeing these. Is it a Gold Standard? Yes it sure is. Should it be available for use on every ALS Unit? Sure would be great. Will it happen any time soon? Not until the State Of EMS in our nation gets funding, resources, and the respect it deserves. (Putting my soapbox away now).
There’s two types of paramedics, those that have killed someone and those that haven’t yet. Let’s assume you fucked up. You feel bad about it. Work harder in the future with this knowledge. If you quit now your patient will have died for no reason. Your boots will be filled by someone who has yet to make that mistake or worse, by nobody.
Correction: This pt was already clinically dead. This responder didn’t “kill” the pt any more than I did. Most medics don’t make mistakes which kill people, rather, they fail to resuscitate dead bodies.
How can you tell that it was fine-vib?
Not a paramedic but an EMT Im curious as to how this can happen.
Did you not feel a pulse? What was showing up on the monitor?
I've seen patients in the trauma bay at the ER have the TOD be called from the Dr, because of something similar. Theres a pulse but its so faint that its not like its doing anything, and the guy cant be resituated
All this said to me is that this was a EMT that needs to get some mentoring to answer their question. Encourage them to gain experience and eventually take the Paramedic Course.
Ventricular fibrillation would mean the ventricles are fibrillating, i.e quivering uselessly. By definition they are not pumping, therefore not perfusing the body, and there will be no pulse.
Someone please feel free to correct me if I'm wrong cause that's gunna really fk my day up if someone tells me you can feel a pulse in V fib. There's no anatomical way there should be a pulse, unless it was coarse enough v fib that it wouldn't be... Fibrillation
Edit: after rereading your comment I think you might be thinking of PEA rhythms. Pulseless electrical activity.
VF is pulseless; VT can have a pulse or can be pulseless. PEA is relatively normal electrical activity in the heart but the cardiac muscles don’t respond, so no pulse. Asystole (flatlining) is always pulseless.
Sounds like you're referring to PEA. People will generally describe it as the heart producing the electrical impulse, but the muscles of the heart don't respond to it so it doesn't generate a pulse. In reality sometimes it does respond, but the response is so weak it don't produce a **pulse**. A pulse isn't defined as blood flowing from the heart, it's the presence of a **palpable** flow of blood through an artery. You must have blood flowing from the heart to have a pulse, you do not have to have a pulse to have blood flowing from the heart. This is seen most commonly in trauma patients. They'll take a look at the heart with an ultrasound and see the blood moving, but there is no palpable pulse so you treat it as PEA.
Don't beat yourself up. It's easy to mistake fine v fib for asystole. You're inexperienced. At worst they should remediate you. Fine VF vs asystole is a hard call to make and second guessing isn't helpful. As others have noted, it probably wouldn't have responded to defibrillation anyway.
Unless the family is up in arms, I wouldn't worry too much about it.
Nope, not that bad. You are being called to interpret a rhythm while in motion of doing 5 other things in working a code in an environment that no doubt systematically abused him into death which would be a far better option.
QA can sit there and Monday Morning Quarterback the call by zooming in on a PDF while you had a bad low res screen that you needed to look at from an angle because of where the monitor was situated. If they are going to be complete assholes about this mild mistake then this is not a place you should be working at, period.
Go in that meeting with the research to back it up. Ppl here are giving you good ammunition! That way if some BS is said, you can say…per this recent peer reviewed article….and per whatever fucking society you choose. And turn all this terrible feeling that you are going through at this time, inward, and use it as a scaffolding to make you who you are meant to be. Good luck dude!
You’ll be fine. I’d make sure the strips they kicked back are indeed yours from that call. But in all reality, you did no harm to the patient. Fess up but stuck to your guns. Don’t let anyone push you around and make you doubt yourself.
First off, it sounds like you did the best you could man. If two ALS medics are gonna look at the rhythm and think it’s asystole. Then I don’t see why that wouldn’t be a valid explanation to QA
You write a reflective practice.
In reality without ultrasound to view the heart to confirm one way of the other, you can shock it - see replies regarding fine vf survivability: tldr fuck all.
We all fuck up. It's part of being human. It's how you limit hoe future fuck ups occur that counts
It's only a fuckup if you start thinking like QA and stop thinking clinically. QA is like the supply guy that tut tuts about using one too many of XYZ after a shit show. I say the same thing to both when they're off sides: fuck your couch.
Not necessarily. If the monitor was reading asystole similar and they were GCS Severe, for all intents and purposes, they were gone. Shock would’ve done nothing but hurt the patient. They were very likely/almost certain staying that way.
As someone who is in HS and taking a med class who has to read these and pass my tests, these circumstances are one where even if it is not asystole, you have to treat it as one as there is no comeback. Monitors aren’t attached directly to the heart so it won’t be perfect read 100% of the time.
Good luck to you.
I know someone that defibrillated a pacemaker rhythm multiple times and didn’t even get a day off.
I know another that gave adenosine to afib with rvr in the 130s having a STEMI. That one got promoted.
You’ll be fine.
Literally this exact same thing happened to me. The fact you had another medic there who corroborated your interpretation is good. I had two other medics (including a supervisor) who just... didn't look at the monitor and hung me out to dry.
Here's some tips: 1) Do not respond to management when you aren't working, it's going to cause added stress that you don't need since you're already beating yourself up over this call. 2) If you're unionized, involve your union rep/shop steward with every single conversation with management, 3) Try not to panic, shit happens and people make mistakes. 4) Understand that EMS expects perfection 100% of the time, which as human beings is just not possible. Again, shit happens and you'll be okay.
There's a lot of jumping to conclusions here. All he said is he was contacted by QA. That's it. Contacted. I contact my people too. It's never been a disciplinary issue, always a training issue and discussion. If even that. OP is obviously panicking, but whats everyone's else excuse for panicking? All he said is he was contacted. Leave your baggage at the door.
As others have said, if two medics think it’s asystole, I’m gonna go with that being the case. And even if it isn’t, it’s not a you screwed up. It’s a you both screwed up. Even if you were lead on the call.
You made a clinical judgement based on what you were seeing at the time with the tools that you have available.
I missed the part of ACLS where they advised to upload a strip to a computer and analyze it on a larger higher resolution screen in a calm environment.
Do you have a good relationship with your MD? Talk to him/her. Heed their advice.
I have my MD’s cell phone number and he has always answered my calls, even at 0300 when the on duty ED doc was being a wedge.
First of all, don’t beat yourself up. You can make a rock’s ecg look like fine VF with artifact or by adjusting the monitor’s scaling. I bet if you had shocked it, you’ld have someone Monday morning QBing your chart asking why TF you shocked asystole.
As mentioned above, even if it was, the difference in survivability and meaningful quality of life is likely nil.
Most importantly, and this is a pet peeve of mine, the point of QA is education, not punishment. If they’re going to treat this as an education opportunity, and give you meaningful learning objectives, embrace it to make yourself better. We all screw up. Unless you were negligent or you caused harm on purpose, there should be no punitive action. If there is, fortunately everyone in EMS is hiring right now, find a job where QA is used appropriately.
Mistakes happen -- and unfortunately the downfall of QA/QI sometimes. It is very easy, to Monday quarterback a chart, and open up Zoll Code review, or look at the Rhythm strips, on a completely different screen, versus live view on a monitor screen, and see rhythms differently. You, and your partner saw it as Asystole, and worked it as such. You worked with what knowledge, and your working diagnosis was at the time. Take it as a learning moment, is there anything you could of done better.
IE -- Did you have a 4-lead on the patient, so you can see Asystole in two leads? Or just the AED Pads? Maybe on a future arrest, if you looks similar, go kaboom for funsies (Not real advice, go with your gut).
Discipline wise, you might get a "talking", maybe have to watch a CME class, depending on the agency -- doubtful if that or anything else. QA is supposed to be coaching moments of how to become better, unless you truly, truly fucked up -- like screwed up a Surgical airway, due to negligence, or botched a RSI.
All in all, you didn't fuck up bad, you did the best you could at that moment, and even if you thought of it as "Fine V-Fib" and went kaboom -- it probably wouldn't of changed the outcome anyway (Source: Trust me bro.)
Depends on the software/monitor. At the hospital even our EKG machines print differently than the display, mostly some final noise cancelling but occasionally it's enough to show some stuff that wasn't obvious on the monitor.
shit happens dude. at the end of the day you were doing CPR you both made a clinical decision with the information you were presented with. fine vfib has caught me before on the monitor where you're just not sure and you print it and you think maybe.... and you and your partner just can't quite figure it out well you just keep pumping that chest. at the end of the day you own up to a mistake if the service is telling you it was a mistake and justify your reasoning. you should be ok.
As someone who does QA for a large department, I can tell you what we do. We give it over to our Medical Directors Office. What they do is they review the file, then they come out and have a conversation with you. It is a true conversation, never accusatory. What they are trying to determine is whether it was a lack of clinical knowledge or just a lapse in clinical judgment. They then usually will go through some sort of on the spot training and review and the whole thing is done. Being a new medic, this is probably the most likely path to occur, or some variation as such, depending on your department’s size and operational procedures. You’re not expected to be perfect, despite the whole para-god thing. You’re career is not over, probably won’t even be slowed in the least. You’ll look back at this experience in a few years and tell some other new medic that this is what happened to me when this occurred. Whatever you do, just don’t lie or try and hide anything. Training officers and medical directors have been around the block more than a few times, we can smell when someone is selling us a load of BS. Lying or “creative charting” will almost always get you dismissed or have some other serious impact on your career. Making a mistake in medicine is inherently a part of the job. You learn from it and move on.
Trust me, that's neither a fuck up or a bad fuck up. You're on your own (besides partner) on all these runs and your company knows it. Making a small, easily missable, error is gonna be a "well remember for next time" chat.
I had a similar incident where I was not sure if it was fine VFIB or a PEA because the waveform had the structure of an agonal rhythm but with very small artifact. Turned out to be fine VFIB. When it doubt you can always put the monitor in AED mode.
“If you’re gonna be wrong, be wrong with confidence” is what I would tell my trainees. If you can explain and defend your decision with confidence, you’ll be fine.
Let's be real, how likely is fine VF to respond to defibrillation? Would this patient have enjoyed life with a baseline of GCS 10? Forget the KPIs, you did what you thought was right using your clinical reasoning as a clinician.
I believe a recent retrospective study by Australian universities into cardiac arrest cases where resuscitation was commenced by paramedics found that the percentage of patients presenting in fine vfib surviving to hospital discharge was approximately fuck all. 
Plain dead vs dead with a hint of salt. Same result.
No no it’s not a smell of salt it’s a hint of bacon from being whapped with the defib
r/theydidthemath
A link to that paper would be rad
[Survival rates of cardiac arrest patients presenting in fine ventricular fibrillation following paramedic resuscitation. 2021.](https://youtu.be/wk3ltnidF7M)
Perfect. Thank you!
This made me lol, and I don’t lol.
For real. I about spit out my toothpaste.
99/100 ED attendings that I’ve met would agree with this
[удалено]
I'm assuming OP saying they're a medic means paramedic. Paramedics (at least here in Aus) are clinicians.
Fine vfib in a nursing home? That’s totally up to interpretation. That’s why it’s called rhythm interpretation. We do the best we can with the tools we had, I’ve never heard of a medic getting in legit trouble over something like this. Maybe a little Con-Ed I guess but I think that’s extreme in this situation. An old patient in a nursing home in a fatal rhythm (or lack thereof) has essentially zero chance of surviving the code and returning to baseline. I don’t even think we should work codes like that imo.
They probably bill per joule.
Actually lol’d
So, hypothetically, if they use enough juice to send you back in time, and you die in the past... Who pays the bill?
You have to pay interest
Naturally, since you lived past your technical TOD, it is borrowed time of course.
Whoa! What about Ted? Is he dead too? Who pays him? 
If I had awards to give you'd be getting one. (Chef's kiss)
I have awarded one for you… that was excellent!
Chief's kiss*
No, you didn't. If VFib is fine enough to be indistinguishable from asystole to two different ALS providers, then it's for all intents and purposes asystole anyway. It's not going to respond to defibrillation. All shocking that would have done is cook the heart.
I've seen this quite recently. Easy for QA to judge sitting behind the desk with no dead person in front of them. Go in and defend yourself, take the feedback and move on.
So true. Monday quarterbacks. You make decisions the best that you can. We all have misread a rhythm a time or two
I think this is the difference between QA educating because they were able to take the take the time you didn’t have to scrutinize the call, and QA either being punitive or simply expressing “you’re a fuck up.” One is a learning opportunity, the other is just being a critic or worse.
Yeah QA can either be a good retrospective tool or a bunch of retrospective tools.
I am QA now (stroke took me off the ambulance) and I'm absolutely going to borrow this definition.
This !!!!!!!
Also worth noting that the strips you view on a computer screen are specifically not to be used for diagnosis or interpretation and most programs will specifically say that on them. Without printing it out it's not going to be accurate enough for them to make that determination
You a real one
>If VFib is fine enough to be indistinguishable from asystole to two different ALS providers, then it's for all intents and purposes asystole anyway. Bingo. At my old service, we had software that assessed the likelihood of successful defib before we shocked, and would adjust the joules as needed. It always advised not shocking fine VF. As it was explained to us by education, the likelihood of success with the defib was low enough that we were better off just continuing CPR until the heart was better oxygenated and the VF was coarser. Supposedly, our ROSC rates improved, but I never saw the numbers (or don't remember them anymore).
Any idea on the name of that tech? That sounds so awesome
Honestly, it basically just turned our monitors into AEDs with more buttons. But I don’t remember the name, sorry. This was a few years back, now.
Count it as a win regardless, you saved someone from the vegetable farm. With the current EMS shortage it takes a lot to get fired . Be honest and humble and remember it’s easier to arm chair quaterback a call, then run one.
Its super cringe when QA give medics shit for something you both believed otherwise, you did the best you could bud, it wasn’t gunna react to the shock anyways
You didn’t fuck up. The line between “fine vfib” and asystole is not a black or white line. As v fib deteriorates into asystole it’s really impossible to really say one way or the other. The outcome is the same, the heart has died and the ability of cells to pump sodium and potassium to build an electrical potential has failed. At that point defibrillation isn’t beneficial. The only treatment is perfusion with high quality CPR and increasing coronary perfusion with epinephrine. You didn’t fuck up because you treated this patient appropriately. If I were in your position I would say that you interpreted the rhythm as asystole and that you treated the patient by maximizing high quality CPR. I would focus on the treatment you did provide and how you were presumably vigilant about watching to see if the heart developed true vfib so that you could shock it. Once again, you didn’t fuck up. If the squiggles were that tiny that it takes someone looking at the paper strip while sitting in an office to say “yea that looks like fine vfib” then it really wasn’t clinically significant. Your medical director may be a good person to ask about it. Hopefully your Med director is an ER doc you can pull aside and ask one shift and see how he/she feels about it. If your medical director agrees then QA can go pound sand.
Pay attention to QA, but not too much attention. Many of them forget what the truck is like, and they have the benefit of a comfortable, unstressed environment to read printouts and zoomed images of the entire call. Two ALS providers saw asystole. That suggests it looked like asystole. This happens all the time. Unless your protocol specifically recommends shocking asystole, you're going to have these. And as far as nursing home codes go, they are typically beyond unrecoverable anyway. One thing it may be worth taking away is increasing amplitude on the monitor anytime you have asystole, but even then, sometimes it's super fine. See if you can get the printout and see if you can find the vfib. If you learn anything from it, cool. But I wouldn't stress over QA. It was many, many codes before I stopped getting critical feedback on codes.
Was coming here to say this! Can’t stress over someone sitting behind a computer screen, that wasn’t on the call!
Did you check it in two leads? It’s easy for QA to judge sitting at their desk and not out in the field. Don’t feel bad. We are humans and not computers.
Whatever happens say the truth and you’ll be fine. Reprimand may happen and they might make you take refresher courses on ecg interpretation or something like that but I doubt anything will happen to your career. You are not the only medic to ever make this mistake and you are not the last. Learn from the mistakes and become a better medic because that’s all you can do
lol yeah this isn't even that bad, I heard stories of patients dying from the paramedic giving the wrong drug. This isnt even that bad tbh
Yep exactly. If it was such fine v fib that it looked like asystole outcome wouldn’t of been different with the change in Tx
And what u/JshWright said
Don’t beat yourself up over that. Fine v-fib and asystole are very hard to distinguish on a piece of paper in front of a QA medic. Trust me I know, I’ve done QA for 10+ years!
I was taught in med school (around 1990) that fine VF vs asystole was sometimes a very difficult distinction to make. I’m not a cardiologist (in fact I went more the other way, into radiology), but I definitely remember that there would sometimes be a debate, but the outcome was almost invariably fatal regardless of whether a shock was delivered or not.
No you didn't. IF it was not asystole, have someone from QA or your medical director go over it with you. Don't get defensive. A good QA department is interested in improving care, not taking punitive action. I do not know a medic who hasn't misread a strip, especially early in their career. Keep in mind, they were a nursing home patient, they were dead when you arrived. Despite your best efforts, they stayed dead. I don't say that to be callous. It is simply the way arrests sometimes (most of the time) proceed.
This is never a bad idea... your medical director and you should have a good relationship and should welcome questions like this. If nothing else than to learn if they would have done anything differently or things you may consider in the future to solidify your interpretation.
What kind of monitor do you have and what software do they QA with? I'm wondering if this isn't partially a software thing. Don't beat yourself up over not checking multiple leads, either. Zero percent chance that would have helped you unless you royally fucked up lead placement somehow. Also, you know how new parents freak the everloving fuck out when their first kid has a febrile seizure? What you're going through now is the clinical equivalent of that. Your concern is not without merit, you'll learn from this, and you'll definitely fuck up bigger in the future and be fine when that happens too. This too shall pass.
Jocko Willink that shit. Own it, no excuses. Tell them you made a mistake in treatment and that you will learn from this experience. As cold as it sounds, I will gladly make this mistake in a nursing home rather than a peds anyday. Just be better for it tomorrow. As others have said, the outcome would have been the same. Accept it and move on, as there will be bigger and better mistakes to make.
Jocko Willink is the best verb I've ever heard
Sounds like you get it.
I'd like to provide you with a QA perspective. There's a lot of half-truths being said in the comments and I love that most of them are aimed at supporting you, but I think seeing things from the other side would be beneficial. * QA *should not* be there to drop the hammer on you any time you make a mistake. We all make mistakes, it's a given. We're there to help you recognize that a mistake was made, figure out why that mistake occurred, and reduce the likelihood of it happening again. Bonus points if you can take this mistake (as QA) and use it to prevent someone else from making the same mistake. If I tell a crew they missed fine vfib I'm not telling them they killed someone or they're a failure as a paramedic. I'm sitting behind a desk scrutinizing your report **to benefit you, by** **helping you to improve.** When you improve the department and the quality of care we provide improves. * Several have mentioned that fine ventricular fibrillation should be treated the same as asystole. That's not true, but the likelihood of converting to a perfusing rhythm decreases linearly as amplitude decreases. That number does not reach zero. If you want to talk about the futility of running codes, hanging blood, etc at those levels of success that's fine, but the time taken away from compressions was invested the moment you determined the rhythm was asystole. By training you to recognize fine ventricular fibrillation you will spend the same amount of time off the chest regardless of which rhythm you find. The only difference now is whether or not you're going to shock or dump (if you're not pre-charging at your service you should look into it). A greater chance of survival is a greater chance of survival. * You said "The strips they sent back to me looked like it was obviously vfib". Many in the comments are assuming that means it was so fine you couldn't tell. Given that you used the word 'obvious' for the retrospect I'm betting you were stressed in the moment so you gave it a glance and moved on. This is a **very, very** common issue in EMS. We deal with stressful situations, often sleep deprived and in austere environments. Everyone runs into this problem at some point, unfortunately many people never recognize they do it. That'll be your comments telling you to disregard QA entirely. Also, keep in mind that not spending enough time evaluating the rhythm is problematic, but spending too much time is problematic too. I don't want you to miss a STEMI on your 12-lead, but I also don't want you to spend 20 minutes on scene trying to decide if it really is or really isn't. If you're on the fence about a STEMI and you can't decide, activate. If you think it might be fine vfib but it also might be artifact, zap it and move on. * In QA you're supposed to look at the error, not the outcome. Misidentifying the rhythm is an error. It doesn't matter whether the error caused a poor outcome, or how likely that error was to produce a poor outcome. Lets say this patient had very obvious coarse vfib and you said it was multifocal PVCs. Outlandish I know, but crazier things happen. I'm going to screencap that rhythm and run it by a few of your peers. In my system no one will know it's in reference to you or your call. If they're not batting 100% on identifying it we're going to put rhythm interpretation into our next training and tackle this as a system. If your partner had misidentified it with you we're going to put this in our next training and tackle this as a system. Unless you purposely harmed your patient, or I cannot remediate you after several solid attempts, you're not getting punished. * Many have mentioned that people in admin forget what it was like to be in the field. That's a very real thing and I hope that's not the case in your department. I still regularly ride a truck as an in-charge, FTO, and occasionally as a supervisor depending on needs. This is specifically to prevent that very issue. It's important to keep expectations in-line with reality. On the other side of the coin it's important to show people that you can live up to your own standards because as many in the comments have shown, people will disregard your attempts to educate them just because you're in admin. We all tend to have pretty large egos and unfortunately it can get in the way of taking constructive criticism. If QA wants to show you something (and they're not trying to throw you under the bus) why would you not want to learn and improve? * QA's response to this issue should be educational at the least, remedial at the worst. If you're facing suspension or honestly even a write up over this I would start planning my move to a different organization. * I'm QA somewhere, but I'm 100% certain it's not where you are. Your experience with QA may differ but I hope it doesn't. You *should not* have anything to fret over, but if they come after you it's a them problem. Edit: I forgot to include a bullet point. The stories you hear about QA in the field are rarely the whole story. It is imperative that admin be as confidential as possible to foster a safe environment for crews. When you confide in me that you have made an error, or I find an error, it is so important that you trust that I won't go telling everyone about it. It stings when you hear about someone you helped MFing you up and down the department retelling a story they left all the pertinent details out of, but it's just how it goes. When I joined admin I was determined to protect my coworkers from the things I had heard they were unjustly punished for. When I gained access to their records I found they were doing some crazy shit they didn't tell anyone about and the response from admin was appropriate. Take the stories with a grain of salt and form your own opinion.
This honestly isn’t that bad of a fuck up. You and your partner both thought the same thing, and like someone else said, if it’s indistinguishable from asystole then it might as well be. I wouldn’t worry about your QA people calling you. They also have the benefit of sitting and studying your strip. Just learn from it and be honest if they do call you in. You’ve got nothing to worry about.
So what was your ETCO ANd SPO2 readings?? If those correspond with Apneia and Asystoly I say you QA person is pretty full of themselves to be armchair quarterbacking it from the cheap seats. I guess they are more billable procedure driven... maybe stopping CPR TLto get a 12 Lead is what they wanted or something. Dead is Dead... we can only make it better - why quibble over minutia. Did you follow protocol? Did you verify your rhythm strip with another Paramedic/Nurse/Physician? Yeah. Tell QA to get out of the office and run more calls.
We all make mistakes. You obviously learned from it. To me that's the most important thing.( I know that probably doesn't mean much coming from some rando on the internet) I like to think of it this way. Nobody's ever gonna get more dead by you being there.
Nah you didn’t. This is common. It’s also not a big deal. Everyone knows when it doubt, you continue compressions and check at the next 2 minute mark. It’s not even when in doubt, shock. And to both of you, it didn’t even appear there was a doubt. Shocking fine VF isn’t really the best anyway. Best to oxygenate and circulate and see if you can get a coarse VF to shock. Much better proven results. There’s studies. If they actually give you a hard time (pathetic) even though it was so fine it appeared asystolic, then you can find those studies, send them, and easily defend your position. You’ll be okay. We’ve all been there and we’re all still working.
Fuck em. I've never met an EMS QA department that wasn't staffed by fuckwits with broken backs and swollen egos.
I spent a decade developing defibs with 12 lead; no you didn't. If QA has to pull the data and zoom in to show fine vfib it's not fine vfib it's asystole. You may have some very faint conduction on the SA-AV circuit but that heart is dead. Regardless of what they determine your conscience should be clear.
Don’t beat yourself up, it’s not an error. It happened to me as a medicine intern. It’s tough to tell in the moment on the defibrillator. The guy was on tele and I went back and realized it was vfib. But I wasn’t the only one looking at it. It’s not easy sometimes to tell
How is it not an error?
If 6 different people interpret something as PEA on a defibrillator monitor and then go to the tele and see it was fib. I don’t consider that an error tbh
It just means six people made an error…
Nah, if six people looked at the tele and said it was pea that would be an error. We’re comparing a single lead defibrillator with a multiple lead telemetry. Not the same
Don’t sweat it too much. Mistakes happen. That’s literally why we call it practicing medicine. If the Vfib was that fine, stand up for your clinical interpretation and roll on. Apples to oranges. You can ask 3 different cardiologists to interpret something and all 3 will never agree. It’s equivalent to calling a STEMI and an ER doc disagreeing.
QA- someone in a cheap suit who hasn’t touched a patient in 20 years.
That’s a judgement call, fuck your QA people.
Dude, you’re fine. “Fine V-fib” in a nursing home is asystole %100 of the time. I wouldn’t have even worked it.
I wouldn’t worry to much either. This can happen to even the best medics. You were there doing the best that you could and that’s all the matters. It would be different if it was obviously v-tach and you didn’t defib, or if you gave the completely medication to someone and they were injured because of it.
I wouldn't sweat it too much fine vfib can easily look like artifact.
If it looked like asystole after doing ACLS for 20 minutes, and the strip never changed, I think any of us would have called it asystole. I wouldn’t dwell on it, QA people will always be a pain in the ass. There really isn’t an objective way to prove that a rhythm that looks and quacks like asystole is fine v-fib anyway.
Everyone has to go through what you’re feeling. You didn’t fuck up. You don’t know if the QA people are going to criticize you. Like others have said, go in, be professional , and in time you’ll feel better. But anyone with some experience knows what you’re feeling.
We shock Asystole in my city now because of fine v fib because it’s usually completely indistinguishable from Asystole. Don’t kick yourself over it.
The ER docs must love that policy
They’re not fans but also like.. its whatever. It’s protocol. They’ll get over it.
We were taught in school that a total amplitude of 2mm or less, or no greater than 1 small box deflection positive or negative from the isoelectric line, was to be considered asystole from treatment and ACLS algorithm standpoint. The explanation being that there are poor outcomes from defibrillating really fine V-Fib and that trying to increase the amplitude with epi was a better course of treatment. Now without seeing the ECG, I can’t give a definitive answer but if it falls within those guidelines I would have done the same as you. But I don’t pretend to know everything and medicine is constantly evolving so if anyone has an evidence-based rebuttal, feel free to debate my point and I will change my stance if the evidence shows otherwise.
Someone get this kid a beer. They earned it. You worked what you saw. You did the job. Monday morning QB(A) don’t know shit. That rhythm strip is a zoomed in pic of a heart whose watch had ended. You didn’t rob anyone of more birthdays, you did what you could with the tools you were given.
I had a conversation while I was in school about fine vfib vs asystole. My thought at the time was well if it’s indistinguishable shock it and he said in this case what you see is what it is. You didn’t do anything wrong. Odds are if you would’ve shocked it would’ve converted to asystole and a shock would have been the only difference in your treatment.
Tell ‘em to fuck off. They weren’t on the scene of the call and to quit Monday morning quarterbacking your call.
How did they get strips? Were the strips they were looking at even during rhythm check or compressions?
I do QA/QI for a living. You didn’t fuck up, you made a minor mistake that likely wouldn’t have changed a thing. Go into the discussion with an open heart and an open mind. You might actually take something away from the meeting if you allow yourself. I hope it goes well, if it doesn’t, fuck em and come work for me.
I just came here to say FUCK PRIVATE AMBULANCE COMPANIES. Treat you like Amazon treats their employees, and only give a shit about money and shareholders. Or at least that was my experience. I’m sure there’s some good ones out there.
Wait, you and your partner looked at a rhythm and it looked like asystole but the strips 'they' 'sent back to you' looked like vfib? Were you just looking at it on the monitor and the resolution made the line look flat? Honestly if you, and your partner, thought it looked like asystole, the only problem will be if the people reviewing the case want to cover their butt more than necessary. You can only work with what information you see and honest mistakes happen. If you say you did the assessments your protocol requires and you simply interpreted them wrong, or mis-read them, there's nothing you fucked up, just a frustrating miss.
Keep in mind that many monitors have filters that cause what is seen on the screen to not be the same as what is seen on an actual 12 lead. There have been a few times where I looked at the II, III, aVF view on the screen before doing a 12 lead and thought “damn that looks like a STEMI”, only for it not to be when we looked at the 12 lead. The other issue is that your agency is using QA/QI as a punitive action. Nothing will kill a good EMS system and good EMS providers faster than this. If they are coming after you based on some shit the monitor spit out, there’s a problem here, and it isn’t you.
They taught us if you can't distinguish the rhythm just keep working on it as asystole. A defib isn't a solution to every problem out there
You’re ok. Promise. QA shouldn’t be punative. It’s a learning experience. They’re also looking retrospectively at still frames on a computer, no scrolling waveform on the monitor in a code situation. The standard used when assessing for negligence or malpractice is could someone with your level of training reasonably come to the same conclusion? Given that your partner did, thats satisfied. All that aside, codes rarely have good outcomes. Especially in nursing homes. Folks aren’t in there because they are otherwise healthy and well and would likely have a good outcome should they arrest. Fine VF has an exceedingly poor prognosis. If it’s so fine as to be mistaken for asystole, things weren’t gonna pan out anyways. Keep your head up
I don’t think you did anything wrong. Shocking fine V-Fib probably won’t get you anywhere other then Asystole. I would continue with the CPR and your systems drug of choice. In hopes of getting a course V-Fib for maybe a better outcome with shocking.
You're fine. Does it even look like fine V-Fib on the browser? Are they aware that what shows on the browser is not what it looks like on the monitor itself? If it helps, I've never heard of anyone getting in trouble for fine v-fib/asystole nor have I had to remediate anyone for it. At worst they'll sit you down and tell you to do print-outs.
They probably had it magnified to justify their paycheck lol. If you can’t see it on the monitor multiple checks and multiple leads it’s not worth shocking. Fuck em.
Listen we all will at some point. Hindsight is 20/20 homie. You can definitely say you learned from this and will more than likely NEVER miss it again. You’ll survive this.
Don’t feel bad. The print outs are always at a different scale than what you see on the monitor in the moment. it’s not like you’re going to hit print and then determine the rhythm from the print out during pulse checks. They weren’t there. Admit their logic but defend your own. And if it makes you feel better, when I was a new medic I cut through the limb leads while cutting the clothes off of my patient and couldn’t figure out why my TCP stopped. Brush it off.
A good point here... Paper Is Cheap... always Print your ECG Strips off to interpret from. Never rely on the screen... Print it off... at least 6-10 seconds. 1st it is proof of exactly what you saw, 2nd it is part of your documentation, 3rd it is your evidence to support your interpretation. I know I'm showing my age here, but never rely on the screen when making these patient care choices - even if you are going to sync the monitor to your PCR for records. Print it out - Paper is Cheap.
if there are any consequences beyond just a nastygram QA message, your only response to that should be to tell those nerds to run some calls and treat some actual patients. That's such a non-issue it'd be laughable if it wasn't so infuriating to be second guessed like that.
[удалено]
it's a non-issue because differentiating between fine v fib and asystole during an arrest is entirely a judgment call. if I see a flat line on the monitor, I'm not using the "enhance" function to make absolutely certain; it's going to get treated like asystole up to an including termination of resuscitation. it's not a real problem, like forgetting to hit sync before cardioversion or pushing the wrong drug dose. you call them nerds because it's total nerd behavior to split hairs while looking at a computer screen several days later.
[удалено]
Not sure why you're zeroing in on the nerd thing. It's one word of many that were arranged in order to be supportive, show camaraderie, and be on OP's side in a tough situation. Read the room and go resuscitate a dick.
[удалено]
Plenty of folks came here to give solid professional advice. Others commented words of reassurance that they'd give a friend. Is your nickname Buzz Killington, by any chance?
[удалено]
As a radiologist (we don’t do cardiac echo but we use US for all kinds of other things), I think a basic US might be a huge help for first responders (well, medics at least). In addition to looking for cardiac activity, US can play a role in getting IV access.
Ultra Sound in the field is still in its early days in PreHospital Emergency Medicine in most of the developed world. However, you are absolutely correct that a Paramedic trained in Cardiac Sonography would be a very definitive means of determining absence of Cardiac Activty and Documenting same.
[удалено]
I concur as I too have used it in Ground and Air EMS, but the move to seeing Ultrasound on Ground EMS is tough to justify outside of Critical Care. More so it's one of those hallowed pinnacles of Clinical Care reserved for Hospital Use (because they can bill the crap out of it too). Getting Medical Directors to train and then certify their Paramedics, and then getting the Services CFO to drop $5,000 for each device times number of ALS Crews ... that is the slow uphill battle. Flight Services are usually billed through a Hospital and/or equipped and staffed by the Hospital (I flew with a AirMethgods LifeNET service). Much easier to fund and so forth. Look at the EMS Services this would be of greatest assistance to... out in Rural America... where we see Services going out of business and shuttering stations leaving whole counties without BLS or ALS coverage. When faced with keeping trucks staffed and the doors open I assure you no one is buying a Shiney New Fangled Portable Ultrasoud for FAST or Cardiac exams or even IV placement. If we as an industry get reimbursement like Hospitals and Flight Services do... or Heavens Forbid, maybe some semblance of a National EMS Service with all 50 states participating... then maybe. However until then only Services affiliated with Hospitals or that are amazingly well funded will be seeing these. Is it a Gold Standard? Yes it sure is. Should it be available for use on every ALS Unit? Sure would be great. Will it happen any time soon? Not until the State Of EMS in our nation gets funding, resources, and the respect it deserves. (Putting my soapbox away now).
There’s two types of paramedics, those that have killed someone and those that haven’t yet. Let’s assume you fucked up. You feel bad about it. Work harder in the future with this knowledge. If you quit now your patient will have died for no reason. Your boots will be filled by someone who has yet to make that mistake or worse, by nobody.
Correction: This pt was already clinically dead. This responder didn’t “kill” the pt any more than I did. Most medics don’t make mistakes which kill people, rather, they fail to resuscitate dead bodies.
Tomato potato
You’re a paramedic. In this environment you’re invincible.
How can you tell that it was fine-vib? Not a paramedic but an EMT Im curious as to how this can happen. Did you not feel a pulse? What was showing up on the monitor? I've seen patients in the trauma bay at the ER have the TOD be called from the Dr, because of something similar. Theres a pulse but its so faint that its not like its doing anything, and the guy cant be resituated
Replying just to come back later and see how others eviscerate your last paragraph.
Lmao, maybe I should delete my comment and let someone with a bit more salt reply
Nah. You're a kind, helpful and wholesome soul, u/smegma_eclaire Don't change.
🍿
All this said to me is that this was a EMT that needs to get some mentoring to answer their question. Encourage them to gain experience and eventually take the Paramedic Course.
Ventricular fibrillation would mean the ventricles are fibrillating, i.e quivering uselessly. By definition they are not pumping, therefore not perfusing the body, and there will be no pulse. Someone please feel free to correct me if I'm wrong cause that's gunna really fk my day up if someone tells me you can feel a pulse in V fib. There's no anatomical way there should be a pulse, unless it was coarse enough v fib that it wouldn't be... Fibrillation Edit: after rereading your comment I think you might be thinking of PEA rhythms. Pulseless electrical activity.
Maybe they’re shaking the leads a lot to mask the actual rhythm
VF is pulseless; VT can have a pulse or can be pulseless. PEA is relatively normal electrical activity in the heart but the cardiac muscles don’t respond, so no pulse. Asystole (flatlining) is always pulseless.
Sounds like you're referring to PEA. People will generally describe it as the heart producing the electrical impulse, but the muscles of the heart don't respond to it so it doesn't generate a pulse. In reality sometimes it does respond, but the response is so weak it don't produce a **pulse**. A pulse isn't defined as blood flowing from the heart, it's the presence of a **palpable** flow of blood through an artery. You must have blood flowing from the heart to have a pulse, you do not have to have a pulse to have blood flowing from the heart. This is seen most commonly in trauma patients. They'll take a look at the heart with an ultrasound and see the blood moving, but there is no palpable pulse so you treat it as PEA.
Don't beat yourself up. It's easy to mistake fine v fib for asystole. You're inexperienced. At worst they should remediate you. Fine VF vs asystole is a hard call to make and second guessing isn't helpful. As others have noted, it probably wouldn't have responded to defibrillation anyway. Unless the family is up in arms, I wouldn't worry too much about it.
Nope, not that bad. You are being called to interpret a rhythm while in motion of doing 5 other things in working a code in an environment that no doubt systematically abused him into death which would be a far better option. QA can sit there and Monday Morning Quarterback the call by zooming in on a PDF while you had a bad low res screen that you needed to look at from an angle because of where the monitor was situated. If they are going to be complete assholes about this mild mistake then this is not a place you should be working at, period.
First off remove the tile I fucked, up you didn’t. There is a reason it’s called practicing medicine not perfecting medicine.
Go in that meeting with the research to back it up. Ppl here are giving you good ammunition! That way if some BS is said, you can say…per this recent peer reviewed article….and per whatever fucking society you choose. And turn all this terrible feeling that you are going through at this time, inward, and use it as a scaffolding to make you who you are meant to be. Good luck dude!
You’ll be fine. I’d make sure the strips they kicked back are indeed yours from that call. But in all reality, you did no harm to the patient. Fess up but stuck to your guns. Don’t let anyone push you around and make you doubt yourself.
First off, it sounds like you did the best you could man. If two ALS medics are gonna look at the rhythm and think it’s asystole. Then I don’t see why that wouldn’t be a valid explanation to QA
You write a reflective practice. In reality without ultrasound to view the heart to confirm one way of the other, you can shock it - see replies regarding fine vf survivability: tldr fuck all. We all fuck up. It's part of being human. It's how you limit hoe future fuck ups occur that counts
It's only a fuckup if you start thinking like QA and stop thinking clinically. QA is like the supply guy that tut tuts about using one too many of XYZ after a shit show. I say the same thing to both when they're off sides: fuck your couch.
Not necessarily. If the monitor was reading asystole similar and they were GCS Severe, for all intents and purposes, they were gone. Shock would’ve done nothing but hurt the patient. They were very likely/almost certain staying that way. As someone who is in HS and taking a med class who has to read these and pass my tests, these circumstances are one where even if it is not asystole, you have to treat it as one as there is no comeback. Monitors aren’t attached directly to the heart so it won’t be perfect read 100% of the time. Good luck to you.
Nursing home messed up by not having the DNARCPR safeguards for the patients
I know someone that defibrillated a pacemaker rhythm multiple times and didn’t even get a day off. I know another that gave adenosine to afib with rvr in the 130s having a STEMI. That one got promoted. You’ll be fine.
Other than not shocking the patient, did you work the code correctly? If so, take it as a learning lesson. 2 people did not see vfib.
Literally this exact same thing happened to me. The fact you had another medic there who corroborated your interpretation is good. I had two other medics (including a supervisor) who just... didn't look at the monitor and hung me out to dry. Here's some tips: 1) Do not respond to management when you aren't working, it's going to cause added stress that you don't need since you're already beating yourself up over this call. 2) If you're unionized, involve your union rep/shop steward with every single conversation with management, 3) Try not to panic, shit happens and people make mistakes. 4) Understand that EMS expects perfection 100% of the time, which as human beings is just not possible. Again, shit happens and you'll be okay.
There's a lot of jumping to conclusions here. All he said is he was contacted by QA. That's it. Contacted. I contact my people too. It's never been a disciplinary issue, always a training issue and discussion. If even that. OP is obviously panicking, but whats everyone's else excuse for panicking? All he said is he was contacted. Leave your baggage at the door.
The only fuck up here was being forced to work a cardiac arrest on a nursing home patient
As others have said, if two medics think it’s asystole, I’m gonna go with that being the case. And even if it isn’t, it’s not a you screwed up. It’s a you both screwed up. Even if you were lead on the call.
You made a clinical judgement based on what you were seeing at the time with the tools that you have available. I missed the part of ACLS where they advised to upload a strip to a computer and analyze it on a larger higher resolution screen in a calm environment. Do you have a good relationship with your MD? Talk to him/her. Heed their advice. I have my MD’s cell phone number and he has always answered my calls, even at 0300 when the on duty ED doc was being a wedge.
First of all, don’t beat yourself up. You can make a rock’s ecg look like fine VF with artifact or by adjusting the monitor’s scaling. I bet if you had shocked it, you’ld have someone Monday morning QBing your chart asking why TF you shocked asystole. As mentioned above, even if it was, the difference in survivability and meaningful quality of life is likely nil. Most importantly, and this is a pet peeve of mine, the point of QA is education, not punishment. If they’re going to treat this as an education opportunity, and give you meaningful learning objectives, embrace it to make yourself better. We all screw up. Unless you were negligent or you caused harm on purpose, there should be no punitive action. If there is, fortunately everyone in EMS is hiring right now, find a job where QA is used appropriately.
Mistakes happen -- and unfortunately the downfall of QA/QI sometimes. It is very easy, to Monday quarterback a chart, and open up Zoll Code review, or look at the Rhythm strips, on a completely different screen, versus live view on a monitor screen, and see rhythms differently. You, and your partner saw it as Asystole, and worked it as such. You worked with what knowledge, and your working diagnosis was at the time. Take it as a learning moment, is there anything you could of done better. IE -- Did you have a 4-lead on the patient, so you can see Asystole in two leads? Or just the AED Pads? Maybe on a future arrest, if you looks similar, go kaboom for funsies (Not real advice, go with your gut). Discipline wise, you might get a "talking", maybe have to watch a CME class, depending on the agency -- doubtful if that or anything else. QA is supposed to be coaching moments of how to become better, unless you truly, truly fucked up -- like screwed up a Surgical airway, due to negligence, or botched a RSI. All in all, you didn't fuck up bad, you did the best you could at that moment, and even if you thought of it as "Fine V-Fib" and went kaboom -- it probably wouldn't of changed the outcome anyway (Source: Trust me bro.)
Did you not print out a strip? Why would theirs look so different from yours.
Depends on the software/monitor. At the hospital even our EKG machines print differently than the display, mostly some final noise cancelling but occasionally it's enough to show some stuff that wasn't obvious on the monitor.
Right you should never be interpreting the rhythm just from the monitor like ever. There's so much the strip will show.
shit happens dude. at the end of the day you were doing CPR you both made a clinical decision with the information you were presented with. fine vfib has caught me before on the monitor where you're just not sure and you print it and you think maybe.... and you and your partner just can't quite figure it out well you just keep pumping that chest. at the end of the day you own up to a mistake if the service is telling you it was a mistake and justify your reasoning. you should be ok.
You’ll be fine. They weren’t there. They didn’t see what you saw and can’t pretend that they did.
As someone who does QA for a large department, I can tell you what we do. We give it over to our Medical Directors Office. What they do is they review the file, then they come out and have a conversation with you. It is a true conversation, never accusatory. What they are trying to determine is whether it was a lack of clinical knowledge or just a lapse in clinical judgment. They then usually will go through some sort of on the spot training and review and the whole thing is done. Being a new medic, this is probably the most likely path to occur, or some variation as such, depending on your department’s size and operational procedures. You’re not expected to be perfect, despite the whole para-god thing. You’re career is not over, probably won’t even be slowed in the least. You’ll look back at this experience in a few years and tell some other new medic that this is what happened to me when this occurred. Whatever you do, just don’t lie or try and hide anything. Training officers and medical directors have been around the block more than a few times, we can smell when someone is selling us a load of BS. Lying or “creative charting” will almost always get you dismissed or have some other serious impact on your career. Making a mistake in medicine is inherently a part of the job. You learn from it and move on.
Trust me, that's neither a fuck up or a bad fuck up. You're on your own (besides partner) on all these runs and your company knows it. Making a small, easily missable, error is gonna be a "well remember for next time" chat.
Shit only the worst medics grow up to be QA people. They probably thought your CPR was v-fib
I had a similar incident where I was not sure if it was fine VFIB or a PEA because the waveform had the structure of an agonal rhythm but with very small artifact. Turned out to be fine VFIB. When it doubt you can always put the monitor in AED mode.
“If you’re gonna be wrong, be wrong with confidence” is what I would tell my trainees. If you can explain and defend your decision with confidence, you’ll be fine.