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

[Tom B.]

I'm not disagreeing with you, per se, but where would you place that line such that research, success and failure can be transferred between services and learned from? We don't want EMS systems to reinvent the wheel, but I don't think "not invented here" is as likely to cause repeat research as it is to encourage an attitude of "Sure it works for them, but our system is different. That's why we'll keep doing what we're doing." That attitude is all too common an excuse and the last thing we need is to legitimize it.

I think the point is that you have to actually read the study and determine whether or not it can be fairly applied to your EMS system. An even more worrisome attitude than "sure it works for them, but our system is different" is the attitude that "it works for them, therefore it works for us" when the truth is that your system is probably different, and not in a good way. Let's take King County Medic One, Boston EMS, Austin / Travis County EMS, Hennepin County EMS, Wake County EMS, etc. as examples. If they produce research that shows paramedics can safely (insert whatever you like here) can that be extrapolated to EMS at large? Absolutely not! Why? Because EMS organizations that report their data and engage in EMS research tend to be in the very top tier of EMS systems in the country. They're good because they measure and create robust quality improvement mechanisms.

On the topic of 12-lead ECG interpretation, if you actually read many of the studies, the conclusion is often that "paramedics can identify ST-segment elevation on the 12-lead ECG". Well, whoop-dee-doo. A monkey could do that. The question is whether or not they can identify the ST-segment elevation of acute STEMI with a high sensitivity and specificity. Yes, you can find an occasional study that says this, but more often than not it is from a place like Boston or Ottawa (small number of highly trained paramedics). You have to invest in education and training as well as meaningful quality improvement techniques to replicate results like that. So it's really not a whole lot different from my comparison of the Navy SEALs or Delta to recruits from Ft. Jackson. It's often said that if you've seen one EMS system, you've seen one EMS system.

That's not to say that EMS research is unimportant, because it shows what is possible. Having said that, we shouldn't depend on results from other EMS systems for any other reason that to come up with a hypothesis for our own EMS system. That hypothesis should include a shared reality of how an EMS system achieved whatever it is they achieved. The devil is in the details, and too often we skip straight to the conclusion.

Tom

[WolfmanHarris]

Are you delaying transport to admimister lytics? STEMIs need cath labs. Granted in areas such as spenacs, the closest tumbleweed is several hours away and lytics are a great idea but in more developed areas you may actually be delaying definitive care. At the hospital system I work for they are looking at eliminating the ER and taking the STEMIs right to the cath lab (which will be activated by the ER doc after EMS transmits it).

Here we bypass the ED entirely and go to the cath lab directly. Our STEMI protocol is to ID the STEMI in the field (on Paramedic's interpretation NOT machine), verify they meet conditions for PCI and begin transport to cath lab, bypassing local hospitals. On route the crew calls the cath lab hotline and calls a "Code STEMI" which activates the cath lab team. We transmit the ECG so that it is waiting for the cardiologist when he or she arrives but the activation and bypass is on our field diagnosis. Apparently it's working quite well with our pt. contact to balloon time actually beating the times for the Emergency Department within the same hospital as the cath lab. (Not by much, but a nice feather in the cap)

Dr. Warren Cantor the Chief Interventional Cadiologist has continued to push the importance of Paramedic interpretation over transmission or machine interpretation as the most reliable method. In the first 100 STEMI patients enrolled in the bypass program EMS had a 13% false activation rate (including false positive ECG and cases where criteria for PCI were not met), which is comparable to the rates found in ED Physician interpretation. (His words, not mine.)

Currently ACP crews do need to transmit a 12 lead for MD interpretation when enrolling a patient in the STREAM prehospital fibrinolysis study, but as per Dr. Cantor this is an issue of medico-legal concerns and research ethics, not Paramedic competency and if the study shows fibrinolysis followed by later PCI to be a better route it is expected that wireless transmission will continue to augment Paramedic interpretation.

I've tried to attach some of the resources and stats we have on the service intranet, but their citrix virtual desktop does not let me link to it from outside.

Cheers,

- Matt

I think the point is that you have to actually read the study and determine whether or not it can be fairly applied to your EMS system. An even more worrisome attitude than "sure it works for them, but our system is different" is the attitude that "it works for them, therefore it works for us" when the truth is that your system is probably different, and not in a good way.

Agreed. I actually think we may be on the same page on this one.

Because EMS organizations that report their data and engage in EMS research tend to be in the very top tier of EMS systems in the country. They're good because they measure and create robust quality improvement mechanisms.

No disagreement. Now we need to make this the rule, not the exception. Luckily we have large research programs that not just covers our service, but is part of the Rescu program at University of Toronto. This has brought even smaller services into research.

Yes, you can find an occasional study that says this, but more often than not it is from a place like Boston or Ottawa (small number of highly trained paramedics).

Ottawa is like the rest of Ontario doesn't have a small number of Paramedics, it is an ALL Paramedic service, with a moderate number of Advanced Care Paramedics. Not sure of the exact percentage for Ottawa, but currently 36% of my service is ACP and growing as more PCP's are selected for ACP. Not truly important, just wanted to clarify.

I didn't quote the rest, but I do think we're essentially in agreement but approaching the issue from a different direction.

[Kiwiology]

I can identify ST elevation on a 12 lead ECG with my lazy eye tied behind my back but that doesn't mean I want to be dishing out heparin and streptase.

One study I read on the Los Angeles County FD said thier 12 lead program relies on the machine interpretation of the ECG; wow that's just bad.

Locally 12 leads are quite "new" in that we have only had them for about the last two years. At the moment they have limited use beyond "future-proofing" so that when we get prehospital thrombolysis everybody already knows how to interpret a 12 lead ECG. That said we do use them for early notification of a possible STEMI and in some limited areas, for choice of destination.

[WolfmanHarris]

One study I read on the Los Angeles County FD said thier 12 lead program relies on the machine interpretation of the ECG; wow that's just bad.

That's the frustrating thing about one of the regional base hospitals here. They recently changed their directives for a nearby service to remove Paramedic interpetation, despite zero issues of false positives. It was done purely to harmonize their protocols with Toronto. Which is a back asswards service in terms of cardiac care (only ACP's do 12 leads and must use machine interpretation. And this is a medic with three years formal education.)

[Tom B.]

Ottawa is like the rest of Ontario doesn't have a small number of Paramedics, it is an ALL Paramedic service, with a moderate number of Advanced Care Paramedics. Not sure of the exact percentage for Ottawa, but currently 36% of my service is ACP and growing as more PCP's are selected for ACP. Not truly important, just wanted to clarify.

I should also clarify, I realize that terminology is different in Canada, and that you are all "paramedics" whereas we in the U.S. draw distinctions between EMT-B, EMT-I, and EMT-P (or whatever we're calling them these days). When I said "small number of highly trained paramedics," I was referring to your ACPs.

Tom

[Kiwiology]

That's the frustrating thing about one of the regional base hospitals here. They recently changed their directives for a nearby service to remove Paramedic interpetation, despite zero issues of false positives. It was done purely to harmonize their protocols with Toronto. Which is a back asswards service in terms of cardiac care (only ACP's do 12 leads and must use machine interpretation. And this is a medic with three years formal education.)

Interesting. On a side topic, how does medical oversight work in Canuckistanada? We have a medical director but not a "base" point of contact; we do not have to talk to a doctor for orders.

[WolfmanHarris]

Interesting. On a side topic, how does medical oversight work in Canuckistanada? We have a medical director but not a "base" point of contact; we do not have to talk to a doctor for orders.

My bad. Base Hospital is a misnomer and an old term. We now have Central East Prehospital Care Program, or Sunnybrook-Osler Centre For Prehospital Care, or some other long name. Guys on the road still just call them all "Base Hospital" which is their name from years ago.

The "base hospital" consists of a group of 3-4 medical directors who provide the license for the various services. They together determine the medical directives for each service. Under the medical directors are a list of approved Physicians who can provide online medical direction if required. As it stands now we only contact a BHP for a pronouncement, or for combative sedation (long story), or circumstances where we would like to go outside directive (hitting max allowed dosage and wishing to continue) or would like advice. I've only needed to call when on with my ACP preceptor and we wanted Fentanyl for a pt. who didn't meet the letter of the analgesic directive. Online medical direction is very rarely utilized. Also within "base hospital" are the educational and quality improvement staff, most of whom are Paramedics. They handle yearly recertification, retraining, continuing education, chart audits, etc. All of this exists separate from the service.

Now to make things more complicated, all the various prehospital care programs are part of the Ontario Base Hospital Group which is a council of all the medical directors who meet and agree on provincial directives. There is some variation from service to service, (dosages, conditons, etc.) but the actual protocols are essentially the same.

Research does throw another iron into the fire. As part of the ongoing STREAM study ACP's do need to contact the on-call cardiologist for direction on the thrombolytics study. The cardiologist first has to confirm pt. meets study enrollment criteria and then has to review the 12 lead and randomize the pt. before calling the crew back to instruct them which side to enroll them in. The base hospital approved the protocol, but does not run the study.

[Tom B.]

Here we bypass the ED entirely and go to the cath lab directly. Our STEMI protocol is to ID the STEMI in the field (on Paramedic's interpretation NOT machine), verify they meet conditions for PCI and begin transport to cath lab, bypassing local hospitals. On route the crew calls the cath lab hotline and calls a "Code STEMI" which activates the cath lab team. We transmit the ECG so that it is waiting for the cardiologist when he or she arrives but the activation and bypass is on our field diagnosis. Apparently it's working quite well with our pt. contact to balloon time actually beating the times for the Emergency Department within the same hospital as the cath lab. (Not by much, but a nice feather in the cap)

Dr. Warren Cantor the Chief Interventional Cadiologist has continued to push the importance of Paramedic interpretation over transmission or machine interpretation as the most reliable method. In the first 100 STEMI patients enrolled in the bypass program EMS had a 13% false activation rate (including false positive ECG and cases where criteria for PCI were not met), which is comparable to the rates found in ED Physician interpretation. (His words, not mine.)

Currently ACP crews do need to transmit a 12 lead for MD interpretation when enrolling a patient in the STREAM prehospital fibrinolysis study, but as per Dr. Cantor this is an issue of medico-legal concerns and research ethics, not Paramedic competency and if the study shows fibrinolysis followed by later PCI to be a better route it is expected that wireless transmission will continue to augment Paramedic interpretation.

I think Dr. Warren Cantor is talking out of both sides of his mouth.

"So what we're looking at is whether patients may benefit by getting the clot-busting medication in the ambulance," explains Cantor. "And in order to do that, you can't rely on a paramedic interpreting the ECG. A physician really has to confirm the heart attack."

The full story is HERE.

I see no reason whatsoever for there to be a medico-legal or ethical concern if the paramedics are competent to interpret the ECG.

Tom

[WolfmanHarris]

We actually received a letter from him to the service following that article and the response he received from medics. It was a three page explanation, the full text of which I don't have available where I am at the moment. Essentially his quote was with regards to the thombolysis study when the reporter asked him why we were interpreting for STEMI bypass but not the STREAM study. His explanation centered on the medico-legal issues with it being an ongoing clinical trial. I will try to remember to copy the relevant sections when I get back to work on Tuesday. At this time I'm not cynical enough to discount everything else we've been receiving based on a TorStar article. We were all still taken aback when we read that article around here, especially when compared to the latest feedback we were getting from the CCU/cath lab on the program.

Official average pt. contact to balloon time from anywhere in the region I work = 82 minutes.

[Tom B.]

We actually received a letter from him to the service following that article and the response he received from medics. It was a three page explanation, the full text of which I don't have available where I am at the moment. Essentially his quote was with regards to the thombolysis study when the reporter asked him why we were interpreting for STEMI bypass but not the STREAM study. His explanation centered on the medico-legal issues with it being an ongoing clinical trial. I will try to remember to copy the relevant sections when I get back to work on Tuesday. At this time I'm not cynical enough to discount everything else we've been receiving based on a TorStar article. We were all still taken aback when we read that article around here, especially when compared to the latest feedback we were getting from the CCU/cath lab on the program.

Official average pt. contact to balloon time from anywhere in the region I work = 82 minutes.

It's interesting there was a backlash from the paramedics about that quote. Even more interesting that he cared enough to provide a detailed explanation! That says something. Thanks for the insight.

Tom