Remove 12 Lead from ambulances ???????

[ambodriver]

Yes my friends this is why EMS sucks ass. We have barely medically educated buffoons trying to rationalize medical care without the slightest clue of how, when and why. Let's just drive fast and go to the hospital b/c hey, we don't know WTF the tools on our rig even do!

This is why we get paid shit, and this is why it sucks to be an educated EMS professional!

[spenac]

I can not believe someone says it takes to long to get a 12 lead. How idiotic!!!! By the time my partner has completed getting a manual BP I have all the leads in place, ask the patient to remain still, hit the button, darn, I'm done. By the time my partner walks to the drivers seat I know what needs done, and if I had a hospital with a cath lab I could direct the driver to divert to that location. I do not delay any treatment or transport time doing a complete exam.

Maybe in some systems basics just go sit in the drivers seat and do not assist in getting vitals? Thats the only way doing a complete exam would cause a delay that I can see, but that would be just stupid so surely it does not happen.

[fiznat]

Thought I might help put the last nail in this coffin by posting the 2005 AHA guidelines on the subject. This is from Circulation. 2005;112:IV-89 – IV-110, where the AHA gives a Class I recommendation for the prehospital 12 lead.

Out-of-hospital 12-lead ECGs and advance notification to the receiving facility speed the diagnosis, shorten the time to fibrinolysis, and may be associated with decreased mortality rates.51–64 The reduction in door-to–reperfusion therapy interval in most studies ranges from 10 to 60 minutes. EMS providers can efficiently acquire and transmit diagnostic-quality ECGs to the ED53,58,65,66 with a minimal increase (0.2 to 5.6 minutes) in the on-scene time interval.52,56,65–68

Qualified and specially trained paramedics and prehospital nurses can accurately identify typical ST-segment elevation (>1 mm in 2 or more contiguous leads) in the 12-lead ECG with specificity ranging from 91% to 100% and sensitivity ranging from 71% to 97% when compared with emergency medicine physicians or cardiologists.69,70 Using radio or cell phone, they can also provide advance notification to the receiving hospital of the arrival of a patient with ACS.56,61–64

We recommend implementation of out-of-hospital 12-lead ECG diagnostic programs in urban and suburban EMS systems (Class I). Routine use of 12-lead out-of-hospital ECG and advance notification is recommended for patients with signs and symptoms of ACS (Class IIa). A 12-lead out-of-hospital ECG with advance notification to the ED may be beneficial for STEMI patients by reducing time to reperfusion therapy. We recommend that out-of-hospital paramedics acquire and transmit either diagnostic-quality ECGs or their interpretation of them to the receiving hospital with advance notification of the arrival of a patient with ACS (Class IIa). If EMS providers identify STEMI on the ECG, it is reasonable for them to begin to complete a fibrinolytic checklist (Figure 2).

[ambodriver]

I can not believe someone says it takes to long to get a 12 lead. How idiotic!!!! By the time my partner has completed getting a manual BP I have all the leads in place, ask the patient to remain still, hit the button, darn, I'm done. By the time my partner walks to the drivers seat I know what needs done, and if I had a hospital with a cath lab I could direct the driver to divert to that location. I do not delay any treatment or transport time doing a complete exam.

Maybe in some systems basics just go sit in the drivers seat and do not assist in getting vitals? Thats the only way doing a complete exam would cause a delay that I can see, but that would be just stupid so surely it does not happen.

Seriously. I am so frustrated with this argument, "It takes to long", or "We are 5 mins from hosptial". It's ridic. and obviously said by those under educated. I hope to god that soon they make more education requirements to become a medic!

[ERDoc]

Ambo, great post. I couldn't agree more. I believe that one of the studies I posted showed that the slight on-scene delay to get a 12 lead was more than compensated for in the ER since the cath lab could already be activated (some systems are going so far as to bypass the ER and go directly to the cath lab, saving even more time). Someday EMS will step into the 21st century.

[CBEMT]

My 911 department just did a STEMI today while I was at my FT job- pain to cath lab in under 60 minutes with on-scene 12-lead, result in a 3-minute ER time.

Most importantly, the 12-lead post first NTG is nearly normal, and would have easily fooled an inexperienced/under-educated provider- a huge advertisement for pre-everything ECGs!

[Arctickat]

does the Istat magically detect a reliable troponin level far sooner than any other test ?

it has to be a system wide view which is where the 'evils' of socialised healthcare are extremely beneficial .

if the paramedics are able to interpret and communicate findings send a copy of the 12 lead to the recieving facility then forget door to needle for ither lytics or PPCI and start thinking 'call to needle' or 'pain to needle'

Why use an expensive machine like the Istat? I'm using an invitro diagnostic device that provides qualitative results for cTnI, Myoglobin and CK-MB. They are 100% accurate and provide positive results if the trops are over 1.5mcg/ml. It takes about 4 drops of whole blood and gives a result in about 5 minutes. Each cassette costs about 13 bucks, this compared to 16 for the troponin cassette in the ISTAT and the $10,000 for the machine just to get a quantitative reading.

[Christopher.Collins]

Ok so heres something Ive been pondering in recent times. While learning the equipment in my new fire department... I noticed our BLS ambulance has an old Phillips monitor that we use for our pulse OX and as an SAED. We can not perform cardiac monitoring as EMT-Bs in a diagnostic sense, but the monitor is capable of cardiac monitoring no less.

What Im pondering is, would it be benneficial for BLS to conduct monitoring? I dont mean determin what kind of rythm the patient has, just simply hook 'em up and thats it. For instance you get dispatched to a chest pain call... no medic available and your 15 min out from the nearest hospital. Would it help the hospital to have a print out of an EKG taken on scene (for comparison)? Would it help the medic when and if they become available? Granted both the hospital and medic will take their own more than likley, could that first EKG, the soonest one prove important? Other than this I would say continue BLS care by your local protocols.

Not trying to toot my own horn, sorry if I come off as a bit arrogant but its not difficult to hook up a monitor. I can remember many a time my BLS rig would have the medics gear on board (from a previous or for the next shift) and if I ever called for an ALS intercept Id be expected to have the monitor hooked up before we even met. And more often than not even working ALS, my medic partner would have me hooking up the monitor.

I realize there can be factors where a reading may be wrong and adjustments may have to be made. But it could be something anyone can learn. Medical Assistants, CNAs and EMT-Bs in clinical settings can all be taught this skill.

[WolfmanHarris]

You're right that it's not hard to set up the monitor or even that hard to interpret Lead II with some practice. The problem is, a little knowledge can be a dangerous thing. More and more I'm realizing the gap in education between Canada and the United States in EMS.

I'm currently training to be a Primary Care Paramedic, a BLS provider in Canada. It's a two year program in Ontario. A quick examination of an EMT-B scope and PCP scope shows a lot of similarities. The main differences in skills are the symptom relief package, 3 Lead monitoring and interpretation, 12 lead and more and more in Ontario IV starts. These components as a physical skill do not take a lot of training.

So ya, any basic could toss a 3 lead on with next to no training and print a strip for the ED. Heck with an hour more they could be transmitting 12-leads for STEMI. These could be beneficial. (not hugely in Lead II, but it's a slippery slope down to 12 lead)

Here's the problem. While 3 lead and other skills could be given to a basic with minimal effort and training and under strict protocol they could be beneficial, you're adding a third floor to a house with a shitty foundation.

Four the couple hours we spent actually learning to hook up the monitor, trouble shoot and the like, we spent two semesters on Anatomy and Physiology, many lecture hours on cardiac physiology and the ECG, hours on home study and are still constantly tested on it routinely with any quiz regardless of the content being covered. This is to ensure that if we're going to do something, we're going to do it right and understand it.

So let's take all the basics and have them print a strip to give the hospital. Great, but it's being done with absolutely no understanding of why and what it means. Now let's take a Basic who's done a bit of extra reading on their own (which is great, do this) and have them look at the strip with that bit of reading. So now they can pick out a few different rhythms and they get some funny ideas in their heads . I've seen this with students in my program who have a less than full grasp of the concepts. I've seen a fellow student look at Lead II (before we'd done 12 lead) see normal sinus and say "well its probably not ischemic CP, so I'm not going to give nitro at this time." or "I'm seeing ST-elevation so I'm assuming MI at this time." The same things happen with O2 being ruled out based on SPO2 readings. Luckily these have either been taught out of them or they've flunked out at this point, but without understanding you begin treating the monitor not the patient.

- Matt

[jbanagas]

Seriously. I am so frustrated with this argument, "It takes to long", or "We are 5 mins from hosptial". It's ridic. and obviously said by those under educated. I hope to god that soon they make more education requirements to become a medic!

More education WHY?, people will still give their service away for free.