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The Prehospital 12 Lead EKG and the Emergency Room
This is my issue and wonder if other systems face the same issue. Emergency Rooms not accepting the Prehospital 12 Lead, performing there own and delaying time to treatment of the AMI. The same holds true for blood work done by EMS in the field it is often times discarded by ER staff.
the talk around is time is muscle, so i often come into any ED in my system with a 12 lead some showing ST Elevation and some with no changes i inform the nurse that i have a chest pain 8/10 relieved by two nitro. I have only once taken a patient straight to the Cath lab and that was when i was a Paramedic Student.
comments???
the talk around is time is muscle, so i often come into any ED in my system with a 12 lead some showing ST Elevation and some with no changes i inform the nurse that i have a chest pain 8/10 relieved by two nitro. I have only once taken a patient straight to the Cath lab and that was when i was a Paramedic Student.
comments???
Replies to This Discussion
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Permalink Reply by Justin on -
Yeah I see this too, I'm curious if there's even a point in us doing a 12-lead in the field. It burns time and they won't even look at it. If they aren't going to look at it, why don't we just not do one and save 2 minutes of scene time. If the patient comes in with a chief complaint of chest pain they will do a 12-lead asap anyways, so in theory by not doing one in the field you could get the patient treatment 2 to 4 minutes faster(depending on how long it takes to get the stickers on and the patient to hold still). I'd prefer they just start accepting our 12-leads as credible, but if they aren't going to do that why not make it so we don't have to waste our time. Plus it's a possibility that the patient could have had ST elevation in the field and not have it at the hospital. They should at least take it to compare to their new one because their symptoms could have resolved during transport from the nitro. I usually offer to give it to them and they don't want it so I usually just leave it on the counter in the room.
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Permalink Reply by EMTP211 on -
so true, ive even had my EKGs thrown out, so whats the benefit of prehospital EKG's do they change they way we treat no, but i border NYC and in NYC you can no divert to STEMI Centers so im assuming this STEMI Centers which are capable of performing some kind of angiplasty, bypass, or stent. Will accept the prehospital EKG
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Permalink Reply by Tom Bouthillet on -
Taking a patient directly to the cardiac cath lab is controversial. I agree time is therapy for STEMI patients and time spent in the ED should be kept to a minimum. Having said that, if you investigate you might find out that the quality control team at the hospital is tracking the "door-to-ECG" time as a quality measure. If so, then they're going to capture an ECG within 10 minutes, regardless of what the PH12ECG shows.
The real value of the PH12ECG is that it allows parallel processing. In other words, the cardiac cath lab can be activated while EMS is still in the field. If that hasn't happened by your arrival in the ED, then you've already missed out on the lion's share of the time savings. Maybe it would help in the beginning if you transmitted the ECG and worked out some kind of "STEMI Alert".
The D2B Alliance and AHA Mission: Lifeline has been helping bridge the gap between EMS, the ED, and cardiology. Where is your Medical Control Physician and EMS Chief or Administrator? They should find out if there's a quarterly STEMI meeting at the hospital and find out why EMS isn't invited. EMS has to have a seat at the table, because data sharing is extremely important if you're building a STEMI system.
As a final thought, I would suggest that there's a difference between ST segment elevation and the ST segment elevation of acute STEMI. Do all of your paramedics know the difference? I don't know what system you work with, but a lot of times it turns out that paramedics are capturing PH12ECGs with poor data quality, relying on the computerized interpretation, falling for the STE-mimics of AMI, etc. The hospital needs to trust EMS but EMS needs to make sure that it's trustworthy.
Good luck!
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Permalink Reply by EMTP211 on
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WELL IN THE STATE OF NEW YORK ALL PARAMEDICS ARE REQURED TO BE ABLE TO RECORD, INTERPRET, AND TRANSMIT 12 LEAD EKGS. BUT I BELIEVE AS YOU SAID THERE IA BREAK BETWEEN THE HOSPITAL AND EMS. CURRENTLY WE HAVE NO RUNNING SYSTEM THAT TRANSMITS OUR 12 LEAD EKG'S. OUR CARDIAC MONITORS SYNCS WITH OUT EPCR TABLET WHICH UPLOADS THE EKG'S TO THE SERVER AND TRANSMITS THEM TO THE HOSPITAL, BUT 99.9% OF THE TIME THE COMPUTER DOESN'T OR WONT SYNCHRONIZE WITH THE COMPUTER. SO THATS ANOTHER ISSUE THAT NEEDS TO BE WORKED OUT. BUT THERE SOME BUREAUCRACY INVOLVED IN IT. THATS BECAUSE OUR NEW ZOLL MONITORS ARE SHITTY.. I HATE THEM ... THE M SERIES SUCKS ASS... BUT WE HAVE THEM. THE LIFEPAK 12 IS BEST I THINK IT CONNECTS TO OUR COMPUTERS EACH AND EVERY TIME WITH NO PROBLEM OR DELAY. BUT IM JUST A INDIAN.
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Permalink Reply by Tom Bouthillet on
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When you say that all paramedics in the State of NY are required to be able to interpret a 12 lead ECG, is there a specific state sponsored curriculum? Who trains the paramedics? Who decides how much they need to know? How do they ensure competence? From what I've seen, there's tremendous variability from location to location, which is a major flaw in paramedic education.
Tom
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Permalink Reply by EMTP211 on
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its based on the NREMT Curriculum, you are required to be able to recognize cardiac rhythm, read and interpret an EKG, including bundle branch block, axis deviations, ventricular hypertrophy, electrolyte changes, interpreting infarct, location of infarct and so on....
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Permalink Reply by MA Leong on -
Dear Sir.
The prehospital 12 leads is important as it is needed in diagnosing AMI. we need 2 out of 3 WHO criteria to make the diagnosis.. without the initial 12 leads it will waste more time for the emergency staff by beating around the bushes trying to form a diagnosis,.hence more muscle will be gone... as i am attached to ED, i found the referred 12 leads very, very important in managing AMI, we often repeat a 12 leads to look for changes of the event.. and we often start Streptokinase as soon as possible.
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Permalink Reply by Mike Bjarköy on -
I questioned this practice with senior cardiologists here in the UK back in the mid 90's.
There are a couple of reasons for performing a secondary 12 lead EKG once we get to the ED.
The main one is to review changes since the prehospital care was performed. ST changes up or disappeared completely, which has been known on a few occasions especially with syndromes such as Prinz Metal Angina. So there is a clinical side to this.
However there is a trust issue as well. There have been a a few incidents over here and I am sure it's replicated in the US, where the ST elevation seen on prehospital 12 leads do not exist on the EKGs done on arrival in the ED and have been put down to the machine rather than clinical changes. Once there is doubt in senior medics from years gone by it is difficult to change attitude.
There was one other issue we have. The ED staff just chucked our EKGs in the bin. We got around this (slowly) by automatically taking a second EKG and attaching it to our clinical report form and it went to the cardiologist. Once satisfied that what we were doing was accurate, attitudes changed in the ED.
Secondary EKGs are still performed here in the UK but for the right reasons and have to be done as a multi-treatment approach not delaying TNK or transfer to cath labs.
Mike
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Permalink Reply by Duncan Hitchcock on -
This is another of those educational and standard of care issues that still plagues prehospital care throughout our country. Different agencies undoubtedly will respond with different stories as to how this type of issue continues in their jurisdiction, is slowly changing or has been resolved. Fortunately, our area is in the later. But it took time, involvement and tenacity.
We are finally reaching the point in the development of our profession where evidence based scientifically proven treatment modalities are impacting how and why we do what we do. The 12-Lead EKG is one such example. THe American Heart Association, ACEP, Society for Chest Pain Centers, state health care oversight agencies and others have taken positions based on best practices that the STEMI patient receives positive improvements in care when EMS agencies do 12-Lead EKGs, the Paramedics can interpret them, provide advanced notification of a STEMI patient to an appropriate facility, and transport the STEMI patient to a certified Chest Pain Center.
Unfortunately, changing the mind sets and past practices of allied health care practicianers can be like herding cats.
One of the measurable standards that is being closely evaluated and seems to be trending to reality is the old measure of "ED door the balloon" time. A lot of research and position papers are pushing the standard to become "EMS contact to balloon" when ALS EMS agencies can run and interpret the 12-Lead.
Back to herding cats.....changing these attitudes can be a waste of energy and causes much frustration. One approach that has proven succesful is having this issue supported and championed by hospital administrators, ED physicians, Cardiologists, ED Nurse managers, EMS Medical Directors, EMS management and Paramedics. By creating a unified team of all stake holders that can develop an action plan, measurable performance objectives and time lines pulls all memebers of the health care team onto the same page.
There will always be a foot draggers, nay sayers and a nurse fuzzy warts that will resist change. But the implementation of a multiagency, multidiscipline approach to providing best practices for the STEMI patient will win out. And the occassion may arise where the stumbling block will be have to be held accountable for impeeding progress.
Someone has to start the bus. Look around your agency. Who has the temperment, skills and tenacity to drive?
This is too important of a system to let it sit and stew.
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Permalink Reply by Robert Sullivan on -
In my system we are lucky to have hospitals that base decisions on our EKG's. Not only are we expected to have them done on chest pain patients, but also for vague complaints, syncope, and difficulty breathing. We interpret them ourselves, radio our interpretation to the hospital, and do not transmit them. A study showed that our paramedics are as accurate as ED residents at detecting STEMI's.
Studies from my system also show that nitro, morphine, and oxygen can temporarily resolve EKG changes. A pre-treatment EKG is valuable.
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Permalink Reply by EMTP211 on
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so maybe a study evaluatiing all those concepts EKG interpation, ED door to needle vs ems door to needle, effectiveness our prehospital treatment of chest pain, and weather activation of the hospital STEMI center, would proove to the hospital cause in EMS we know already, but to the hospital that Paramedics are more than just ambulance drivers.
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Permalink Reply by ArcticKat on -
Our nearest Cath Lab is 2 hours away. Our local hospital takes our 12 Lead at face value and we back it up with prehospital cardiac marker tests. Usually they will also get their own 12 lead if time permits, but more often than not they go with ours.
Just a question. How many providers here conduct patient treatments based on someone else's assessment? If you're a medic, do you give a spray of nitro to the patient complaining of chest pain based on the blood pressure the BLS or First Responder took 5 minutes ago, or do you check yourself.
Who would be responsible should that patient crash because his pressure was in his boots?
Should the Doctor be less accountable than we are?
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