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???

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Permalink Reply by John on April 22, 2009 at 10:52am

First of all, your patient is not a candidate for the cath lab; you've cured them! Patients who are pain-free after nitro go to the cath lab on a non-emergent basis. This allows for more information prior to surgery and a significantly better outcome.

Our local hospital, which has no cath lab, always does their own ECG, rather than use ours, however we are instructed to bypass them with STEMIs. The cath lab hospital calls in staff based upon our radio report of a STEMI. Although they do their own 12 lead, they compare the various ECGs. Our STEMI patients with active chest pain are usually in the cath lab less than 30 minutes after our arrival at the ER.

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Permalink Reply by christine Ploeg on April 22, 2009 at 3:25pm

Some nurses don't even glance at our 12 leads, and yet our service also has a protocol wherin we have the right to bypass the nearest ED and go straight to the Cath Lab on our own discretion.
Do you perform more than one? We do three: on scene, on route (obviously no t when the truck is moving) and on arrival.
And yet, if we have a CP that for some reason does not meet our bypass protocol and we end up at a local ED, they dont even look at them. Bad!

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Permalink Reply by MARK on April 22, 2009 at 5:30pm

Interesting debate: Here is London, England we convey our STEMI's direct to one of eight 24/7 "Heart Attack Centres" - HAC - and have been doing so since 2006. Both our EMT's and Paramedics read the ECG's and activate the HAC via our control
I don't see what is controversial?
The overall benefits are well proven and very well practiced in a large number of cities throughout the world. Sure EMS staff will get it wrong; I have agreements with the 8 centres that our staff will falsely activate the HAC 10-15% of the time, however, the patients that turn out not to have a STEMI are usually suffering other acute cardiac conditions and are assessed by a senior doctor on our arrival - so the patient wins each time.
Usually the HAC accept our ECG's

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Permalink Reply by pete jubie on April 23, 2009 at 9:03am

I did have that trouble and then some...

I worked for an agency that worked quite closely with a hospital. We were part of the same group. The doctors loved it when we brought them the 12 lead ekg, some of the nurses were not as happy. "If the doctoer wants one, he will order it". Well, the docs put an end to that, real fast. Now they look for the ekg's asap. This hospital also loves EMS to draw bloods, so the patient does not have to be stuck a second or third time.

I have had three occasions in which an e-job cardiac call was taken directly to the cath lab on our stretcher, only after the ed did a 12 lead. My blood draws were the first round markers.

On the same line, a hospital that was in the closing phase of getting their stroke center cert. was refusing to take prehospital bloods. The reason was that the ED nurses were not sure that the bloods were your patient's, even though the tubes were labled and you had 1 patient. That also was ended fast.

I have been told by some bitter nurses that prehospital bloods are not used because they are hemolised, cells are broken, and the tubes are not the ones- brand- they use. All those reasons have been cleared.

The hospitals I now deal with accept both prehospital bloods and 12 or 15 lead ekg's. But, it also has alot to do with the doctor, pa, or np that is on, as well as the nursing staff. We can only convey our assessment findings and "gut- feelings", and try to educate them. Be patient... It takes one STEMI or a "look what we found" and the ed will be wanting the 12 leads.. Usually, it is when the patient is getting worse, and "I told you so" is said.

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Permalink Reply by Pascal Hay on April 23, 2009 at 2:15pm

You spoke of pre-hospital cardiac markers. Are you refering to Bio-site and Bio-stat type testing?

Jeffrey R. Jackson said:

You make a good point but the doctor does not preform the 12 lead in the emergency department so he or she is taking the word of the worker preforming the 12 lead. To allow a certain level of trust is important. I work closely with my EMT's and watch them in their practice so I know I can trust their results or findings.

ArcticKat said:
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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Permalink Reply by MA Leong on April 25, 2009 at 3:35am

Hi,
In my work place, Not all the ambulances are equiped with EKG machine, as such, paramedic on duty have to make diagnosis of acute coronary syndrome such as IHD, STEMI and NSTEMI based mainly on clinical sign and symptom. i believe having ECG recorded during chest pain will be valuable information for doctor who treat the patient. The patient may have his angina pectoris subsided and ECG normalized when reaching ED. thus the prehospital 12 leads ECG will be useful record of the cardiac event..and may help doctor in deciding weather to conduct exercise stress test for this patient..

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Permalink Reply by MA Leong on April 25, 2009 at 3:40am

MA Leong said:

Hi,
In my work place, Not all the ambulances are equiped with EKG machine, as such, paramedic on duty have to make diagnosis of acute coronary syndrome such as IHD, STEMI and NSTEMI based mainly on clinical sign and symptom. i believe having ECG recorded during chest pain will be valuable information for doctor who treat the patient. The patient may have his angina pectoris subsided and ECG normalized when reaching ED. thus the prehospital 12 leads ECG will be useful record of the cardiac event..and may help doctor in deciding weather to conduct exercise stress test for this patient..

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Permalink Reply by Keith Paton on June 26, 2009 at 11:18pm

Two things about the blood draws are some may not be labeled properly and hospitals use different tubes to run tests on their machines. Departments in my area no longer draw bloods for this reason. Doing a 12 lead on scene should not delay transport as other treatments can be done while the machine and wires are placed.