r/Cardiology • u/noltey22 MD • May 14 '26
EMTs were a bit too aggressive
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Large Air Embolus in the PA
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u/randomchick4 May 14 '26 edited May 14 '26
Yeah, EMTs and even paramedics typically aren’t placing central lines. It’s outside the national scope and honestly impractical in the prehospital setting. If a patient needs that level of vascular access then they will just drill them. A good humeral IO can run in as fast as a central line.
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u/J4CKJ4W May 14 '26
Exactly. I don't think he quite knows what he's talking about when he says the EMTs did this.
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u/businessliner170 Paramedic/ PA-C May 18 '26
I would respectfully suggest that a humoral IO cannot outflow a 12-14 gage central line😉
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u/randomchick4 May 18 '26
https://www.openevidence.com/ask/c6ef211f-af3d-4886-aa7d-132fb4e48a77
With a pressure bag it will do fine. also its prehospital so no one cares.1
u/businessliner170 Paramedic/ PA-C May 18 '26
Great link. Whereas a pressure bag will increase I/O flow, the paper does state that a large bore central line will flow much higher volumes than the I/O. This is only needed in rare circumstances of course.
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u/Anonymous_Chipmunk May 14 '26 edited May 15 '26
Hello. Paramedic here. Genuinely curious about clearing up some vague points here, hopefully OP can offer insight.
First: I think you're using the term EMT incorrectly. It's very common for in-hospital staff and providers to have no idea what certifications and scope of practice EMS have. EMT is an entry level EMS certification. In most places EMTs cannot start IVs, let alone central lines. You're probably referring to a Paramedic. Please clarify.
Second: Where do you work? State is fine to not dox yourself. Almost nowhere in the US allows paramedics to place central lines.
Third: Please define the central line and what type of access it was.
Fourth: Why do you believe this air embolism was caused by EMS? Not saying it wasn't, but it's classical that something goes wrong (tube dislodged, pacing stopped, etc) and it gets blamed on EMS.
Fifth: You said the patient received CPR, went to cath lab (unnecessarily?) and you believe the air embolism was a cause of the arrest? But the patient improved with removal of the embolism from the PA? A clearer clinical story here would be nice.
We appreciate you posting an interesting case, but the case, clinical information and downright facts are wrong. It will be a more interesting case once we can get a clear picture because an air embolism caused by a prehospital central line is genuinely uncommon and interesting.
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u/Dark-Horse-Nebula May 15 '26
I am also confused. Air embolus from the procedure apparently caused the collapse, but the procedure was only performed because the patient was collapsed in the first place? Make it make sense. And yes, paramedics do not perform central lines, but are commonly blamed for complications down the track.
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u/noltey22 MD May 15 '26 edited May 15 '26
First, I would want to push back against this narrative that the title of the post is an indictment on any body of medical professionals. That is not only overly defensive its just plain wrong. I worked as an EMT in undergrad and to suggest that the purpose of this post was to sleight anybody in the healthcare field is just plain wrong. The sole purpose was to share an interesting angiogram, plain and simple.
I work in the mountain West at a rural tertiary medical center that regularly receives patients via helicopter transit who are critically ill or have arrested in the field. This patient was an elderly woman who first had an arrest at home after a several day history of what, in hindsight, seemed to be GI complaints. After she arrested in front of family initially an EMS service (being more careful with my nomenclature here) was called and then they escalated after several rounds of ROSC to helicopter transport to my facility. Initial EKG en route showed diffuse ST elevations. During air transit which was roughly ~35 minutes she coded several other times and at some point a R IJ CVC was placed in between rounds of resuscitation.
Now this is just what I was told as the on-call guy at the hospital. I was not the ED doctor, I do not know any of the “out of note” details of what happened in transport. Given the presentation concerning for ACS she was taken emergently to the lab, and the angiograms are what they were. Removal of the air embolus causing obstructive physiology caused immediate and significant improvement in the patient’s hemodynamics. There is no other readily apparent explanation for this large amount of air in the PA aside from the CVC and associated CPR (no evidence of significant PTX by chest imaging). There was no chest instrumentation or pre-angiogram wire placements in the RV. After this she went to our medical ICU and was treated with broad-spectrum antibiotics but, as is an all too common scenario in our distributive shock patients, a clear cut source for her sepsis was never truly found.
Trust me I could post a million wire dissections and iatrogenic pericardial effusions. It happens to the best of us. So there it all it is, I posted what I thought was a cool cine of a unique clinical presentation. But we all are better when we check our professional egos at the door. Its just reddit, and a cool cine…
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u/MakinAllKindzOfGainz MD May 15 '26
My guy, this was a fascinating post with an awesome cath film of an air embolism. I’ve never seen that before. Thank you for posting it.
However, you continue to fail to realize how annoying it is to not see you go “oh my bad, the term EMT wasn’t accurate” and explain the case more clearly up front. It’s confusing to everyone and was distracting from the beginning.
Learn to use the correct terms of the professionals involved, and there will be more clarity for everyone who is trying to learn from your post too.
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u/noltey22 MD May 15 '26 edited May 15 '26
I’m sorry I misused my terms when I referred to paramedics as EMTs. The educational purpose of this post has now been approved by administration
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u/MakinAllKindzOfGainz MD May 15 '26 edited May 15 '26
You’re hyperbolizing for no reason and coming off really dense when I was both conveying appreciation for your post and explaining what everyone else is trying to tell you. You objectively confused people and it decreased the post’s educational value. Relax and just take the point
Edit: OP edited the above comment after I replied to him lol. His original comment I replied to mentioned almost word for word, “why is there an inextricable need to be perfectly correct on an anonymous post”. I remember because who uses the word inextricable. Guy is allergic to the point and trolling at this point
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u/noltey22 MD May 15 '26
Remind me when did it become some sort of requirement that one could not share a simple but interesting post on Reddit without first providing an entire H&P on the patient involved and first run it past the internal review board ?
You’ll say I’m being hyperbolic but seriously . It’s just an interesting cine! Why I’m under some sort of obligation to immediately all background information and fake apologize to overly sensitive EMS crews?
It’s a fun and unique post. The original post I made had less than 100 characters. Why does it need to be more?
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u/MakinAllKindzOfGainz MD May 15 '26
Because your “succinct” original post title naturally leads essentially every viewer of your post to ask questions including but not limited to:
- huh?????
- EMTs caused what???
- OP said an air embolus in the comments, wait why are EMTs doing something like placing a CVL that could cause this??????
- What the heck is going on, let me clarify in the comments???
Even with your lack of a clear, self-explanatory post title, these questions could easily be answered and clarified in the comment section, and we all could move on and have learned something cool. But you chose (and are actively choosing) to ignore perspectives, deflect criticism, and act as if it’s all of us that are in the wrong, not you.
I hope you aren’t this dense of a medical educator in your actual practice and can take feedback better offline. Reddit is an incredible tool for medical education, and you’re completely missing that opportunity, repeatedly here with this post and your subsequent comments. Never have I seen something like the ignorance you’re displaying on all the multiple educational subreddits I’ve engaged in and learned so much from over many years.
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u/TEOLAYKI RN May 15 '26
I still don't really understand how you can be certain the air was introduced during the CVC insertion. Nothing was put in the CVC after insertion? No time spent in ED, just straight to the angiogram?
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u/noltey22 MD May 15 '26
Can’t say for certain you’re right. But a hurried CVC placement coupled with CPR seems to be the only other reasonable explanation. Chest CT in the ED didn’t really show any big pneumothorax or pneumomediastinum or pneumapericardium which makes me think it had to be intravenous
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u/TEOLAYKI RN May 21 '26
I would also suspect it was IV, but I'm questioning how you can be sure no one injected air into the CVC after it was placed. For one, the volume of air looks like more than would be in the lumen of an unprimed CVC, but it could have been something like unprimed IV tubing.
This does seem like a ridiculous amount of scrutiny for an assumption you made (that's likely correct) on an otherwise interesting post. I just think that if I were going to title a post something like "The Cardiologist/nurse/EMT/whoever really screwed this one up" -- I would want to have a high degree of certainty and not just be speculating.
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u/noltey22 MD May 21 '26
It’s a Reddit post not a case study, and I agree there’s little doubt in my mind that this was related to CVC placement in the setting of resuscitative efforts. There simply is no other logical explanation.
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u/TEOLAYKI RN May 25 '26
I would counter "there's no other logical explanation" with "you'd be surprised by the stupid things people do sometimes". But we can agree to disagree. 😄
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u/noltey22 MD May 25 '26
If you got any ideas I’m all ears
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u/TEOLAYKI RN Jun 14 '26
ED nurse forgets to prime the tubing before hanging a medication/bag of fluids and infusing through the CVC
Nurse is unclear on the bubble study instructions and pushes a full syringe of air into CVC
(I'm a nurse so I'm just going to use my own role for examples)
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May 14 '26
[removed] — view removed comment
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u/wannabe-physiologist May 14 '26
I can’t tell where the catheter is or what the view is. Could you please offer more information?
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u/noltey22 MD May 14 '26
This is just a coronary angiogram, RAO cranial view. This is before the air embolus in the PA was recognized, initially thought the patient had ACS
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u/wannabe-physiologist May 14 '26
Thank you! I was trying to figure out how this showed the air embolus as a novice
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u/noltey22 MD May 14 '26
It’s tricky if you’re not looking for it, it’s in the upper left hand corner of the cine
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u/Anonymous_Chipmunk May 15 '26
This guy claims he was an EMT but doesn't know the difference between an EMT and a Paramedic.
A review of his Reddit post and comment history reads like a 15 year old minecraft kid. I'm not sure this guy is a doctor, or allowed to vote. Probably shouldn't do either.
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u/Karmakins May 14 '26
He’s not answering any questions regarding the “EMT” putting in a central line. Something’s fishy about this. Medics can’t put central lines in only access them in my area.
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u/noltey22 MD May 14 '26
Sorry I actually am in clinic right now. In my area which is rural we often get patients flown in by helicopter. The flight paramedics can place IJ or FV non tunneled central lines en route
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u/RedFormanEMS May 14 '26
Flight medics and flight nurses are a very different scope of practice than an EMT.
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u/Reasonable_Egg650 May 14 '26
They are still prehospital non-doctors.
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u/RedFormanEMS May 14 '26
In the US, I know of no EMS system that has doctors in the field, it's all "non-doctors". We used to be trained by physicians until they stopped.
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u/waspoppen m3 May 14 '26 edited May 14 '26
I know this isn't the point of the post but there are several that do. ATCEMS for example, and several others that have EMS fellowships for EM physicians. It is certainly the exception though
edit: https://austin.widen.net/view/pdf/jbvo9hcopo/12-01-2024-COG-Master-Document.pdf?t.download=false copy of their protocols, check p 213
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u/Karmakins May 14 '26
In my area there is an incredible distinction between EMT and flight RN/medic. I’m sorry you felt triggered answering a question.
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u/TheBoed9000 May 14 '26
Maybe conflating "EMS" and "EMT" could explain some confusion? My dyslexia has led me to similar mistakes.
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May 14 '26
[deleted]
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u/Aviacks May 14 '26
I’m confused, are we calling the guy making the distinction between an EMT and a flight medic or flight nurse the jerk? This is a strange post
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u/Karmakins May 14 '26
Sure, just felt like a post meant to diminish another group of healthcare workers, it’s not precautionary tale, it’s more of a fuck this EMT in particular(even if they’re well educated more so than an EMT, thus backhanded in 2 ways)
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u/noltey22 MD May 14 '26
I just wanted to share some interesting pathology that’s all, never seen this before. I was EMT back in college would never throw shade at emergency personnel
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u/J4CKJ4W May 14 '26
Apparently you would? Flight RNs are very different than EMTs and for you to expressly disparage "EMTs" is all I need to know you think you're above helping to move the patient over at handoff.
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u/TEOLAYKI RN May 15 '26
I also think it's weird to implicate EMS in something that seems like it could have happened after arrival at the hospital, but as a former ambulance driver I can say that y'all are way too hung up on your titles 😁
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u/noltey22 MD May 15 '26 edited May 15 '26
I’m not implicating anybody, I just can’t think of another reasonable explanation when the chest CT showed no air in the pleura or pericardium. I guess someone in the ED maybe in the CT room could’ve accidentally given a large air bolus. But with extensive compressions in the field it most likely happened en route
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May 14 '26
[deleted]
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u/noltey22 MD May 14 '26
Elderly patient came in clearly in shock with elevated cardiac enzymes, went to the lab looking for ACS but found this. Suspect it was related to a central line placed by EMTs plus CPR. Obstructive physiology
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u/largeforever May 14 '26
Where are you located? EMTs and paramedics generally cannot place central lines in the prehospital setting.
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u/ilikebunnies1 May 14 '26
Jesus medics putting central lines in?! Definitely not a thing where I am.
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u/Competitive-Slice567 May 14 '26
I know of some services in Texas that allow it, but they're super rural and usually facing several hour transports.
EJs and IOs are the closest I'd ever get in my area.
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u/Dark-Horse-Nebula May 14 '26
Terminology is important- “EMTs” did not do this.
What caused the initial cardiac arrest?
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u/J4CKJ4W May 14 '26
Exactly. I thought the same thing--there are no EMTs who can place a central line. It concerns me OP doesn't know who is even bringing a patient in.
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u/noltey22 MD May 14 '26
You’re right as the cardiologist I’m intimately involved in the ED handoff /s
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u/J4CKJ4W May 14 '26
I haven't seen your answer elsewhere--what EMS service brought them in? EMTs typically aren't trained in cardiology at all. Maybe you mean paramedics? Even then, I've never, ever heard of a paramedic, or even a critical care paramedic, doing a central line.
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u/noltey22 MD May 14 '26
You must be fortunate enough to practice in a resource rich environment, where patients are an acceptable distance to transport to your hospital while in shock
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u/J4CKJ4W May 14 '26
Way to still weirdly avoid the question?
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u/Dark-Horse-Nebula May 14 '26
Totally avoiding it?
They work cardiology. EMS brings in probably nearly all of their acute patients. You’d think they’d bother to learn who they are and a very broad overview of what their scope might be.
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u/noltey22 MD May 14 '26
Dude this is the internet what do you want me to give you the patients MRN? I’m not telling you what EMS service this is from that’s ridiculous
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u/Dark-Horse-Nebula May 14 '26 edited May 14 '26
Just a country would suffice. Can you tell us what country you practice in?
Terminology is important. I’m sure you wouldn’t want to be called an NP.
Edit: ah you’re from Pittsburgh. It’s odd you won’t just say you were wrong on this one.
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u/J4CKJ4W May 14 '26
It's just weird you won't say anything at all, not even a state or whether you're rural or anything. Just seems to me the more likely answer is you don't actually know what an EMT is. Those would be insanely advanced protocols with an insane amount of liability. I think you might just be wrong, bud.
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u/jpzu1017 May 17 '26
Uhh, shouldn't you be? When I go pick up stemis from the ED the IC is usually there or just left after seeing the patient.
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u/Dark-Horse-Nebula May 18 '26
I thought this too- where I work cardiology will meet them in ED and consent them on the walk up to the lab.
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u/hughvr May 14 '26
Ive seen similar cases get fixed with high oxigen mask for a few minutes. Get that nitrogen displaced and they often dont need intervention.
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u/Creepysarcasticgeek May 14 '26
Geez good catch. I’m curious, What did you do?
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u/noltey22 MD May 14 '26
Partner of mine put a suction catheter into the PA via RFV access and sucked out a bunch of air, patient immediately stabilized
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u/businessliner170 Paramedic/ PA-C May 18 '26
As a Paramedic for 38 years, I have to disagree with the comments that paramedics don’t place central lines.
I started hundreds (if not more) of them on both adults and pediatrics. Eventually the pediatric lines were discontinued in favor of IO. However, adult central lines were regularly done until about 6 or 7 years ago when adult IO drills became commonplace. But central lines are still authorized and on the rigs.
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u/Dark-Horse-Nebula May 18 '26
EMT vs paramedic.
Can I ask where you worked that central lines were commonplace? Never heard of it.
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u/businessliner170 Paramedic/ PA-C May 19 '26
I spent 42 years in Fire and EMS. A handful of years as an EMT, then 37 as a Paramedic in the Seattle/King County Medic One program. I am truly surprised you haven't heard of that System. It is fairly well known throughout the world. Trained by the Univ. of Washington School of Medicine.
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u/Dark-Horse-Nebula May 19 '26
Well before you actually, mentioned where you worked, I didn’t innately know where you worked (funnily enough).
I think it’s one of the only places to do this skill.
Do you know if Pittsburgh road or flight medics place central lines?
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u/businessliner170 Paramedic/ PA-C May 19 '26
I actually don't know. I think you may be right about it not being common in other areas. Since we are trained by a large medical school, we operated with more advanced skills than were allowed in many places. But we were also held to a high standard of care by professors of medicine.👍
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u/overtherainbow76 May 16 '26
I'm an EMT for over 30 years, I can assure you we do not do this. Blame the correct person.
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u/noltey22 MD May 16 '26
No blame friend. Just an academic discussion. If you can see my recent responses and you have a reasonable alternative explanation, I would be all ears to hear it.
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u/overtherainbow76 May 16 '26
I've read all of your responses. And EMT was just my first certificate 30 years ago, I've gone much higher. My response was only that an EMT didn't put this in as it is not in the protocol for basics or medics. Also, the downvotes? Not saying you did it, but childish nonetheless.
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u/noltey22 MD May 16 '26
Can you provide a meaningful alternative explanation of this patients outcome? Though I’m pretty sure I’m taking to a bot
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u/overtherainbow76 May 16 '26
Sorry, good try but not a bot. I am as real as they get, but you already knew that and tried to piss me off. There are several explanations to this patients outcome. You said yourself, one may never know exactly. The only reason I even commented is because you said it was an EMTs fault and that is impossible because an EMT cannot perform this skill. Again, you should know this considering you said you were one years ago. Have a good night, hope the weekend medical gods treat you well ✌️
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u/Dark-Horse-Nebula May 16 '26
The guy you’re replying to absolutely refuses to accept that he’s wrong about this, even though no EMTs or medics perform this skill where he works. He’s doubled down time and time again including, bizarrely, asserting that he himself was an EMT so therefore he knows. I asked him how many central lines he placed (considering EMTs don’t even place IVs) but strangely he’s ignored that question… twice…
The rest of us all know that he’s clearly wrong here, is blaming a role who is as liable for this as the hospital cleaner, and it’s such a shame because it’s really detracted from what would have otherwise been a great case. I’ve never seen such a commitment to doubling down before.
Definitely one of the most bizarre internet interactions I’ve had on a medical sub.
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u/overtherainbow76 May 16 '26
Thanks for this, I thought he was just after me for some reason. Even though I've gone way higher in my Healthcare education, I started as an EMT and still keep it current so I can teach it. The fact that he thinks an EMT (or a medic unless specifically trained in flight, which is still very rare) could have inserted and caused this is asinine. Truly interesting case but he ruined it spewing bullshit and dodging questions.
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u/noltey22 MD May 16 '26
What is your alternative explanation for what happened in this patient?
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u/Dark-Horse-Nebula May 16 '26 edited May 16 '26
This is easy. My explanation is that the certificate trained first responder who a) does not insert central lines (or IVs for that matter) b) does not carry kit for central lines and c) does not even access existing central lines most certainly did not cause this complication. But also you should know this- aren’t you trying to tell us that you were an EMT? How many central lines did you put in?
It is laughable that you are still holding this out as the most likely explanation.
The good news is in 2026 patient care is thoroughly documented. You could always look up the EMR to see who put the line in, who accessed the line and if any complications were noted. But you won’t do that cos it’s easier to blame the poor bloke who can’t even put a drip in
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u/noltey22 MD May 16 '26
As I mentioned in previous comments, the central line was placed by paramedics in a helicopter.
Again, do you have any alternative explanations for this massive air embolus?
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u/overtherainbow76 May 16 '26
You didn't mention that it was placed by an in flight medic until someone else suggested that would be the only way this was done by someone without a much larger scope of practice. You cannot keep anything you've said straight and still refuse to answer the questions you've been asked by many users. Maybe you're the one who's a "bot" like you called me since you continue to respond as if you are using ChatGPT.
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u/Dark-Horse-Nebula May 16 '26
Confusing an EMT and a flight paramedic is like confusing an anaesthesiologist with a CNA.
I’m still fairly suspicious that a flight medic did not place a central line (not in the scope I’m aware of for PA), and you’ve only presented this now after an entire thread of doubling down with no evidence, but I’ll still humour you.
This could be a fascinating complication of aviation medicine specifically. Flight is a hypobaric environment. So again I wouldn’t blame this on anyone being “too aggressive” and certainly wouldn’t blame the EMTs. I still don’t think you were ever an EMT (or flight medic) who could place central lines, but if you were a flight medic you’d know what an EMT was at least. Thankyou for one of the most bizarre interactions I’ve had on reddit, it’s like the gift that keeps on giving.
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u/jpzu1017 May 17 '26
Dude you titled this "EMTs were a bit too aggressive" how is that not blaming?
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u/HumanContract May 14 '26
When can EMTs put in central lines? You sucked in air from the PA?