12-Lead Interpretation in the Field

[UMSTUDENT]

Hey Everyone,

Done school and very bored. A bit of a thought provoking issue I've encountered in my early career:

The service I'm currently working for is comprised of multiple independent agencies that provide ALS service for multiple regions within our county. EMS oversight is provided by a county medical director, "EMS coordinator," and a committee of individuals from each county organization. This committee is usually comprised of a representative from each station (who may or may not be ALS), our EMS coordinator, medical director, and one of two EMS "representatives" from the county's largest hospital. I'm allowed to sit-in on these meetings, but have very few speaking privileges.

Recently, the hospital decided to develop and staff a emergency PCI center for treatment of AMI. It appears to be pretty rinky-dink and is nowhere near the size of some of the larger metropolitan cath-labs (it isn't a teaching hospital and I believe there are only a few interventionist). The hospital's representatives came to the meeting and requested that each EMS company purchase software and equipment to wirelessly transmit all 12-Lead ECGs performed in the field to the hospital. They stated that until we, as EMS providers, begin doing such the hospital will refuse to activate the cath-lab or prepare for cardiac intervention. They seemed to indicate that they have had a "few" instances where 12-Leads were misinterpreted to be MIs when they actually were not.

Of course, most of the committee responded in outrage for several reasons, but most importantly (in their eyes) they thought it was ridiculous that the hospital would institute a "unfunded mandate" that would negatively affect their patient's outcome. Furthermore, many providers thought their ultimatum was childish and irresponsible.

Myself, and a select few other ALS providers, raised objection to being required to "transmit" all 12-Leads. Most of us believe ourselves to be extremely proficient in our interpretations. I believe it to be a professional slap-in-the-face.

Many of us saw this coming. The hospital had begun becoming less and less responsive to consultations regarding ST elevation. When we arrived, anything short of 4-5 mm of elevation was regarded as uninteresting. Many of us observed patients being heavily medicated for pain and then languishing for up to an hour or more until proper cardiac enzymes were drawn, analyzed, and results posted for the physician. Then, suddenly, there would be a quite rush to transfer the patients to larger centers for PCI. We'd come back to find the patient mysteriously missing and new patients being moved to their room. Follow-ups would often reveal our suspicions.

What would you guys do? Specifically to our roaming physicians: is this behavior acceptable? What really takes so long? Why do we as EMS providers seem to place a larger importance on early recognition and treatment?

[Dustdevil]

First, welcome back! I been wondering where you went off to.

I feel your pain, but we are simply reaping what we sow here. It too often happens in this field that we jump to the defence of all medics simply because we ourselves know our stuff. The sad truth is that there is a frighteningly high percentage of medics in this country that are dangerously incompetent. And unfortunately, those are the ones that get remembered in the ER. That's just human nature. Look at this forum. How many medics have started a topic just to rave about a positive encounter with a great nurse or physician? Good luck finding one. It's just like the news media; if it bleeds, it leads. Good is not news. Bad is news. And bad is the lasting impression.

Consequently, the system must be dumbed down to the lowest common denominator. And that LCD may not be anywhere the level of competence that you rate yourself or your partners at. Instead of taking personal offence to something that was not directed at you personally, the constructive response would be to foster efforts to improve the organisation's overall image, because as long as there are losers in the field, we are all losers.

[spenac]

In defense of them they may have experienced some of the horrible paramedics out there that would confuse a-fib with normal sinus. Remember the saying one bad apple spoils the bunch. If they experienced an arrogant paramedic that was wrong multiple times they now relate his actions to all paramedics. Maybe suggest an EKG exam to prove who knows what. Have all including doctors take it. If you guys are good might prove interesting.

[irme]

One thing to be weary of is ever choosing pride over patient benefit. That being said one can sympathise your situation. However a move forward technologically would be to have the benefits of 12 lead transmission. Different texts state different rules for the MI. Hell a depression of 0.5mm should be considered as possible MI according to one of my text books (that half a square).

In my service 12 lead ecg’s are seen as often more important than IV access because if you can transmit an ECG that indicates an AMI you will get the staff at hospital into action and awaiting your arrival with a team versus a single triage nurse. At the end of the day your clinical interpretation of an ECG hasn’t got squat to do with the treatments the individual will see at the hospital, they are going to take their own and base their treatments on their ecg findings

[VentMedic]

12-Leads are very valuable starting in prehospital. Every hospital and EMS system have a learning curve in the beginning. Some have been transporting to the appropriate center for cardiac, trauma and peds for many years. 12-Leads have been utilized by some services for over 20 years. STEMI/Cath Alert is not new, nor is the utilization of resources appropriately. Not everyone is going to get a cath lab in 20 minutes. That does not mean they will not get treatment. Of course, there are hospitals, just like EMS, that are exceptions to the utilization of resources.

And, then we have the fine example in LA. Can you imagine a busy hospital being on their receiving end...."But the machine said".

http://www.jems.com/news_and_articles/arti...I_Patients.html

"But we have 2,500 paramedics [and 27 provider agencies] in L.A. County," Rokos said, "And obviously we can't train everyone to read ECGs." So Los Angeles County has paramedics rely on an automated computer ECG interpretation. "All they have to do is read ***Acute MI, and that's their ticket to go," he said.

[Just Plain Ruff]

When we arrived, anything short of 4-5 mm of elevation was regarded as uninteresting.

I would bet that the patient didnt consider that level of elevation to be uninteresting.

My suspicion is that there are a few if not more than a few medics in your overall county system that cannot read 12 leads but rely on the interpretation. The hospital sees money down the drain when they call a cardiac alert only to have it not be warranted. I always say, better safe than sorry but the hospital sometimes will eat the cost of a mis-called cardiac alert because the patient disputes the bill for all the extra personnel that are activated yet not used but the patient still gets billed.

[MSDeltaFlt]

There are several cliche's going on here.

1. One bad apple spoils the bunch.

2. A person is smart. People are stupid

3. Too many chefs spoil the broth

The list just goes on.

A small portion of medics (or just one) who, for one reason or another, misinterpreted a 12 Lead, got the ball rolling at 2 am, getting the cath lab out uncecessarily too many times... this tends to get doctors pissed. When they get pissed, heads roll; and we are cannon fodder. And I will bet you money that just one physician was made upset and voiced a complaint. That's usually all it takes.

The best thing to do is go ahead and transmit all the 12 leads, and get with ALL of the bigwigs to set up inservices to the cardiologists' liking, making it mandatory so the medics can get paid, and start up a QA/QI with a 100% review to see how well you guys are progressing.

Once you prove all of this to those doctors, they'll let you guys get back to calling them in the field. As they are giving you their blessings with a pat on the back and a handshake telling you, "Good job", you can smile, shake their hand all the while thinking to yourselves, "****** ******, we've been doing this good the whole time. Your rectocerebral inversion syndrome just prevented you from seeing it".

That last paragraph was just a rant, but you get my drift... with or without the insinuated profanity.

Good luck.

[logos]

You said you don't have many interventionalists? Seems to me like thats the likely reason. If you have say three of them, they likely take call every third night. If something like that were the case, it is quite understandable not wanting to be called in for bogus cases.

A similar problem occured at one the local hospitals with stroke alerts. Nurses were calling them in from the floors without notifying the resident. After several neurologist trips into the hospital for amaurosis fugax and diabetic 3rd nerve palsy, the neurologists required that only physicians initiate the stroke alert protocol.

Getting called out of bed for a real case sucks enough, let alone getting called out of bed for a bogus consult. I would imagine that it wouldnt take more than one or two screw ups to ruin things for everyone.

[UMSTUDENT]

First, welcome back! I been wondering where you went off to.

I feel your pain, but we are simply reaping what we sow here. It too often happens in this field that we jump to the defence of all medics simply because we ourselves know our stuff. The sad truth is that there is a frighteningly high percentage of medics in this country that are dangerously incompetent. And unfortunately, those are the ones that get remembered in the ER. That's just human nature. Look at this forum. How many medics have started a topic just to rave about a positive encounter with a great nurse or physician? Good luck finding one. It's just like the news media; if it bleeds, it leads. Good is not news. Bad is news. And bad is the lasting impression.

Consequently, the system must be dumbed down to the lowest common denominator. And that LCD may not be anywhere the level of competence that you rate yourself or your partners at. Instead of taking personal offence to something that was not directed at you personally, the constructive response would be to foster efforts to improve the organisation's overall image, because as long as there are losers in the field, we are all losers.

Dust, thanks for the welcome.

I definitely understand your concern regarding the overall quality of our paramedics. You're right, personally, I consider myself one of the top 10% in the county. Granted, I only have a year of experience as an ALS provider, and I'm definitely not as "skills" competent as some of the more salty guys, but I know that on a consistent basis I recognize things more often than my counterparts. I've had colleagues tell stories that make my head spin...

Still, I was educated in metropolitan Baltimore. I completed hundreds of hours of clinical time with incompetent providers that I had to baby sit all the time. Granted, I had many good preceptors, but also many poor ones. Even the worst providers in my county (more rural area) are light years beyond the idiots riding around down there. Still, the hospitals in-and-around Baltimore extend medics a type of reverence that I've never seen elsewhere. In some regards, their incompetence is perpetuated by hospital personnels' making excuses for them (ex: "Oh, well we don't know what its like out 'there.'" ) A lot of this, in my opinion, is MIEMSS' need to pump PR trauma BS up every nurse's a$$ whose within reach of their home office. If you hear it enough, eventually you'll really believe that these guys are excellent. Still...

Medicine is interesting. The attitudes and egos that are found in a hospital are amazing. I try on a daily basis to extend some level of respect to everyone I meet. The bias that I experience as an educated paramedic is astounding.

The other day I brought a nurse a patient with a weird AMS presentation. With a 25 minute transport and an extensive interview, I was able to determine that the patient had a history of hypertensive crisis, Stage IV Non-Hodgkins Lymphoma (in remission), and a recent diagnosis of diabetes. The patient was experiencing weird neurologic symptoms that seemed to indicate several different etiologies (the most simple being heat exhaustion). She seemed stunned that I was able to lead a conversation with her about these conditions, my treatments, and my thoughts on his problem. This should be the rule, not the exception.

[MrSpykes]

I think it might be very useful to look at individual statistics here for 12-lead interpretation. See if it is just a handful of medics calling the bogus MIs or if its everybody calling one occasionally. Obviously everyone isn't going to be batting 100%. In the system I worked in about a year ago they had a QA team for just cath lab alerts and they checked everyones percentages on STEMI recognition.

Maybe your system needs to enact a similar setup. They should setup some sort of committee to make a protocol for reviewing these cases and decide on a standard line. Over three months review each EMS PCI activation. Review the initial 12 lead that was done in the field and all serial 12 leads after that, prehospital and in hospital, review the PCR and the hospital charts. Figure out all the medics percentages on recognition and those below the standard line go to remediation with the medical director, or cath lab, or a cardiologist.

I agree with always erring on the side of the patient. I would rather the PCI team get woken up for nothing as opposed to sleeping through something.