Saving time, saving muscle: The 12-Lead EKG program

[Miss Sasha]

Caught a blurb about this on the bulletin board at one of our hospitals, couldn't find the exact article but I did find this one, thought I'd share.

Does anyone have any experience with this, or is it implemented in their service? How does it work for you?

Saving time, saving muscle: The 12-Lead EKG program

Full Text: http://www.stjohn.org/innerpage.aspx?PageID=5242

When a patient has a heart attack, minutes can make a huge difference in the patients chances of survival...and a full recovery.

Detroit resident Darryl Price knows the benefits of the 12-lead EKG technology first-hand. In summer 2008, while cutting his lawn, Darryl had a heart attack. He was one of the first to benefit from the Detroit Fire Department's use of 12-lead EKGs in the field. Today, Darryl is a healthier individual who strongly advocates proper diet and exercise to family and friends

Edited October 4, 2009 by Miss Sasha

[NRPinNEPA]

12 leads became the big new thing in my area three or four years ago. Even though the treatment doesn't change (O2, IV, monitor, nitro, aspirin), the 12-lead still gives a much better view of the heart than the traditional 3-lead and can save the roto-rooter man, er... interventional cardiologist some time.

In reference to sending EKGs to physicians before arrival, Geisinger (our local heart hospital) has a program where paramedics can take a picture of the EKG with their phone and send a picture message to the physician. I've never used this or seen it used, so I don't know exactly what happens after it's sent, but it's a nifty idea.

Edited October 4, 2009 by EMTinNEPA

[WolfmanHarris]

Umm... I'm confused. I'm read this twice and haven't quite got anything but puff piece out of this story?

Right now, my service is beating the Regional Cardiac Centre's own ED door to balloon time from anywhere in the region based on Paramedic 12 lead interpretation and STEMI bypass. We're also involved in a thrombolysis study, the ROC consortium studies, Community EMS, etc.

As far as treatment changing based on 12 lead, do you not consider witholding NTG based on modified 12 lead/ 15 lead indicating an inferior MI and potential RVI? A 12 lead is not just a "much better view" it's diagnostic where a 3 lead is not. Are you not able to bypass ED and go straight to cath lab based on prehospital diagnosis? Are you able to transmit your 12 lead wirelessly to the cath lab for cardiologist confirmation while en route?

Maybe the real story here is how behind the curve some areas are in prehospital cardiac care.

Edit: Sorry Sasha, somewhere in there I missed your initial question and got kinda snippy. 12 ecg are part of the PCP (BLS) and ACP (ALS) scope in Ontario, including medic interpretation. This has been HUGE in early identification and rapid transport to regional PCI centres. The chief Interventional Cardiologist has been singing the praises of our service and medics in international conferences due to the huge success the STEMI bypass program and thrombolysis study has been having. There has been an incredibly low false positive and missed STEMI rates throughout the region. 12 lead ECG should be on every Paramedic truck around the world (if it isn't all ready).

Edit 2: Fixed a few typos and outright mistakes. Shouldn't try to watch tv, plan tomorrows lesson plan, stop and do other things and otherwise distract myself.

Edited October 4, 2009 by docharris

[JakeEMTP]

Gotta agree with Docharris on this one. The 12-lead ECG is a diagnostic tool. If you do a right-sided 12-lead and see infarct, you would withhold the nitro and Morphine right? You are given the tools, use them correctly.

The service I am employed by is not cutting edge by any stretch of the imagination. On the other hand, we aren't exactly Podunk USA either. Recently a new procedure was implemented where, based on Paramedic field interpretation of the 12-lead, we can take the patient directly to the cath-lab after a brief consult in the trauma bay with the Attending ED doc simply to confirm our, dare I say it, diagnosis.

I have been told do the "newness" of this protocol change, the Medical Director wants to be sure we are taking true STEMI patients to the cath-lab. His feeling is it took so long to get the Cardiologists on board with this that he'd like to keep it that way. The general consensus is this too shall pass.

Edited October 4, 2009 by JakeEMTP

[Miss Sasha]

Ok. Just to clarify, I meant transmission of ekg via cell phone. Not EKGs themselves.

[spenac]

Some services now after interpretation of the 12 lead even start the treatment in the field saving many many minutes. Think about it. Even if you go straight to the cath lab you have 10 minutes to the hospital. Get there the cath lab will run additional 12/15/18 leads, draw labs, etc, then start pushing the drugs. Thats 25-30 minutes of dead heart cells. So by interpreting the 12/15/18 lead and treating your patient beyond just MONA you may have given the patient a change of returning to basically a normal lifestyle, and may have even kept them alive. Sadly though many services refuse to accept that responsibility and will not carry the drugs and instead just choose the diesel bolus therapy that has proven deadly in more than one way.

[fiznat]

I don't really see the big deal about ECG transmission. Research has shown that paramedic 12 lead ECG assessment in the field is both sensitive and specific for recognition of STEMI. Is this really anything other than hospital physicians trying to keep a grip on their "turf?" If we can do this in the field I see no reason to add another step, especially when everyone seems to agree that time is of the essence.

[p3medic]

Some services now after interpretation of the 12 lead even start the treatment in the field saving many many minutes. Think about it. Even if you go straight to the cath lab you have 10 minutes to the hospital. Get there the cath lab will run additional 12/15/18 leads, draw labs, etc, then start pushing the drugs. Thats 25-30 minutes of dead heart cells. So by interpreting the 12/15/18 lead and treating your patient beyond just MONA you may have given the patient a change of returning to basically a normal lifestyle, and may have even kept them alive. Sadly though many services refuse to accept that responsibility and will not carry the drugs and instead just choose the diesel bolus therapy that has proven deadly in more than one way.

Which drugs are we talking about?

[spenac]

Which drugs are we talking about?

Oops I better start proof reading better. I was speaking of thrombolytic therapy.

[Kiwiology]

Oh wow ... we haven't transmitted an ECG since what, the late seventies?

Our Ambulance Technicians (BLS) are able to give GTN without acquiring a 12 lead ECG first (they can acquire a 3 lead) while our Intensive Care Paramedics (ALS) can obtain and interpret a 12 lead.

In reality I think it's inappropriate to withold GTN until a 12 lead can be acquired as the nitro can provide some pain relief.

We were talking about this topic on my last night shift and came to a consensus that we did not want to cause so much reduction in filling pressure that the patient became shocked but also that some GTN prior to a 12 lead was acceptable as 1) the patient (if they have thier own GTN and are having an inferior STEMI) will not perform a 12 lead prior to taking GTN, 2) it provides some pain relief and 3) a small fluid bolus may reverse any adverse reduction in cardiac output (caution here is required to not cause a pulmonary edema).

One service here is already using 12 leads in prehospital thrombolysis and we are trialing the same (with good results).