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

[spenac]

http://www.bmj.com/cgi/content/full/327/7405/27

"This feasibility study of autonomous prehospital thrombolysis shows that paramedics can record and interpret 12 lead electrocardiograms and safely administer thrombolysis in the community. The potential average time saved was 48 minutes from the call for help to medication being administered. The physician assisted model was found to be unreliable because of technological failure and areas in which communication was hampered because mobile phones could not work, a problem observed elsewhere.5 We did not routinely collect data for these unanticipated events so their precise distribution cannot be reported. Autonomous paramedic prehospital thrombolysis seemed feasible and safe and was associated with improved call to needle times. Sensitivity may improve with experience and confidence."

[ERDoc]

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).

Kiwi, I respectfully disagree with you. Get the 12 lead so you have a clear picture of what is going on. The 2 minutes it takes to get the 12 lead is not going to change the outcome but giving nitro first may change you assessment. Case in point (I know, a case study does not equate with EBM) we had a guy brought in by EMS with a clear STEMI. They gave 1 nitro and 325 ASA. By the time he got to the ER (about 10 minutes after the initial EKG) his EKG was cold stone normal. Had we not had the first EKG this guy would have sat in the ER getting ruled out, costing him about 3-6 hours of time (his first troponin was barely elevated). Instead, because of the first EKG, he was taken to the cath lab and was stented.

Edited October 4, 2009 by ERDoc

[spenac]

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).

Kiwi, I respectfully disagree with you. Get the 12 lead so you have a clear picture of what is going on. The 2 minutes it takes to get the 12 lead is not going to change the outcome but giving nitro first may change you assessment. Case in point (I know, a case study does not equate with EBM) we had a guy brought in by EMS with a clear STEMI. They gave 1 nitro and 325 ASA. By the time he got to the ER (about 10 minutes after the initial EKG) his EKG was cold stone normal. Had we not had the first EKG this guy would have sat in the ER getting ruled out, costing him about 3-6 hours of time (his first troponin was barely elevated). Instead, because of the first EKG, he was taken to the cath lab and was stented.

Starting the lytics does not delay transport yet saves minutes of cardiac muscle because even the treatment at a stemi lab would be several minutes getting started. But I may be wrong as as you say I'm a long way from all real world services.

Also I was told if you can to get your 12/15/18 lead prior to oxygen it best. But not to deprive someone struggling to breath. Is that true or proven to your knowledge?

[theotherphil]

I've gotta say that I also disagree with your view kiwimedic. You really should get that 12 lead before administering the GTN. A full assessment should be made of your patient before implementing treatment options...you need all the info at hand to make an informed decision. Administering GTN beforehand could drop that BP irreversibly in the case of RVI....and you'd be wishing you had started that IV as well.

When I was working in the UK, my area used to have thrombolysis and PCI available to us depending on the patients location (and whether they were in the catchment area for PCI). All of it was done autonomously based on our interpretation of the 12 lead and the patient's presentation. We were able to transmit directly to the respective Coronary Care Units but it wasn't a requirement. We'd just call the unit and tell them we've either thrombolysed and need a bed or that we have a patient suitable for PCI and to get the cath labs ready. No passing through ED needed and we were also beating the ED's call to balloon/ needle times by a significant amount.

Here in Australia (NSW), cardiac care is behind the UK by a large amount. Only Intensive Care Paramedic vehicles have 12 leads but the ICP's only get sent to Cat 1A and 1B calls routinely. Chest Pains are usually categorised as a 1C so a BLS crew usually deals with those without the benefit of 12 leads and ICP backup is only sent if requested by the BLS crew. We can bypass ED for STEMI's but only after 12 lead transmit and you guessed it - only ICP's can do that

Edited October 5, 2009 by theotherphil

[HERBIE1]

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).

Kiwi, I respectfully disagree with you. Get the 12 lead so you have a clear picture of what is going on. The 2 minutes it takes to get the 12 lead is not going to change the outcome but giving nitro first may change you assessment. Case in point (I know, a case study does not equate with EBM) we had a guy brought in by EMS with a clear STEMI. They gave 1 nitro and 325 ASA. By the time he got to the ER (about 10 minutes after the initial EKG) his EKG was cold stone normal. Had we not had the first EKG this guy would have sat in the ER getting ruled out, costing him about 3-6 hours of time (his first troponin was barely elevated). Instead, because of the first EKG, he was taken to the cath lab and was stented.

How often do you think that happens(EKG returning to normal after o2, NTG and ASA), doc? I assume the patient must have called EMS immediately after the first twinge in his chest. Am I to assume his symptoms would have returned fairly quickly after the Nitrates wore off, especially if he was that occluded?

[Tom B.]

It's dangerous to extrapolate data from one EMS system to another. Just beceause the Navy SEALs or Delta can sneak behind enemy lines and blow up a bridge doesn't mean that a handful of recruits from Ft. Jackson can do the same thing. This type of thing needs to be highly contextualized, because the variables are almost always different.

Tom

[WolfmanHarris]

It's dangerous to extrapolate data from one EMS system to another. Just beceause the Navy SEALs or Delta can sneak behind enemy lines and blow up a bridge doesn't mean that a handful of recruits from Ft. Jackson can do the same thing. This type of thing needs to be highly contextualized, because the variables are almost always different.

Tom

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.

[Kiwiology]

I agree with what we are all saying and in an "ideal world" yes everybody would have a 12 lead printed and interpreted before we did anything.

12 lead ECG acquisition might drop down to a basic level skill soon but they won't be able to interpret them. GTN will remain a basic level medication and it's been one for nearly a decade.

Personally I think the balance of benefit vs risk is in favour here of it being a BLS medication; ALS is the exception rather than the rule here.

[WolfmanHarris]

I agree with what we are all saying and in an "ideal world" yes everybody would have a 12 lead printed and interpreted before we did anything.

12 lead ECG acquisition might drop down to a basic level skill soon but they won't be able to interpret them. GTN will remain a basic level medication and it's been one for nearly a decade.

Personally I think the balance of benefit vs risk is in favour here of it being a BLS medication; ALS is the exception rather than the rule here.

It's a mistake to drop more and more things down to a BLS level a it continues to reinforce a system of piecemeal skill based education. We shouldn't define ourselves by skills, but any change in skillset should first be compared against education to ensure that the requisite knowledge is part of the education for that provider. I don't believe an EMT-Basic has anywhere near the time spent on cardiac physiology and patho, or pharmacology to allow them to take ECG's, or give NTG as anything other than a rote skill under restrictive medical directives.

I still spend a lot of time with Campus Emergency Response Teams, all of which are First Responder trained (40hrs) and some of which are EMR trained (80-100 hrs). One of the most common discussions that comes from these students is "we'd like to carry ______ ." My first question is always, "Explain to me how it works, why you'd use it and how it would benefit the population you serve?" The requisite knowledge is just not there in a hundred some odd hours of training. (Of course Kiwi, if by BLS you meant PCP or similar, well that's different.)

[Kiwiology]

It's a mistake to drop more and more things down to a BLS level a it continues to reinforce a system of piecemeal skill based education. We shouldn't define ourselves by skills, but any change in skillset should first be compared against education to ensure that the requisite knowledge is part of the education for that provider. I don't believe an EMT-Basic has anywhere near the time spent on cardiac physiology and patho, or pharmacology to allow them to take ECG's, or give NTG as anything other than a rote skill under restrictive medical directives...

(Of course Kiwi, if by BLS you meant PCP or similar, well that's different.)

I wouldn't trust an EMT-Basic with an oxygen tank or BVM let alone any form of medication ... it was the topic of some fierce debate elsewhere that EMT-Basic's were not taught dyanmic hyperinflation/risk of PEA when bagging an asthma patient or the risk of high flow O2 and COPD'ers.

Yes, our BLS Ambulance Technician is very simmilar to your PCP.

Edited October 6, 2009 by kiwimedic