The Prehospital 12 Lead EKG and the Emergency Room

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Permalink Reply by Jeff Frederick on April 20, 2009 at 4:16pm

In the Twin Cities area we have numerous cath labs available to us. In general we are able to activate the cath labs with the pre-hospital ECG interpretation as the deciding factor. In several cases (Including my own employer)we have community hospitals which function as "staging areas" for prehospital STEMI patients. The "Level ! Heart" criteria (the name for our program) is activated based on the pre-hospital ECG if we are closer to our own hospital vs. the large metro hospital staffed by the cardiology group we use (or another cath lab center). The paramedics have a specific protocol to follow including the administration of 600 mg. of Plavix on direct MD order. Upon delivery, the attendant stay with the patient in the ED while several other things get accomplished such as Heparinization, then re-loads the patient and continues to the cath lab center. If we are closer to this center, we start directly for it and get the plavix order from them, but the lab staff is activated.

Lvel 2s or NSTEMIs require the ED say so after drawing of cardia markers, etc.

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Permalink Reply by Lin Rainey on April 20, 2009 at 4:20pm

Try this. Did you know that ER physicians can charge for interpreting prehospital EKG's. We had the same problem until I told the nurse manager about charging. Now all of our EKG's are read.
Lin

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Permalink Reply by John Fekety on April 20, 2009 at 4:32pm

The issue with regard to the blood draws is lot more simple to explain. Because of the need to be able to document exactly who drew the blood and from what patient many hospitals do not want the liability that could occur when pre-hospital samples are used. Like many other things it runs in cycles. When I first started volunteering in EMS in the 90's, if the medic did not have blood tubes when he arrived with the patient the nurses would have a hissy fit. Now, they would toss the tubes without a second glance.

I have run into the same issue with the pre-hospital 12 leads. One way that I have gotten attention for the patient is to develop a good raport with the ED docs ( as well as the nurses) and when I have a 12 lead that I think is suspicious, I take it right to the doc. That not only helps the patient initially, but is has also helped me learn more about 12 lead interpretation thereby helping future patients.


When I was at EMSToday in 2008 I asked Dr. Corey Slovis how to handle a situation where the ED simply blew off pre-hospital 12 leads. His suggestion was to contact the head of the cardiology department and let him/her know about the problem. He believed that the cardiology staff would be sufficiently upset that their patients might be having treatment delayed that they would shake up the ED. Fortunately I never had to go that far since most hospitals in the area have become very good at working with the medics bringing in potential AMI patients.

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Permalink Reply by Gerard Seling on April 20, 2009 at 4:39pm

I am a Paramedic that works in the ER. It is not that we discard the field EKG, in fact we take the report from the field medic. We do another EKG within 10 minutes or less to CONFIRM what might have been found in the field amongst other factors e.g. PmHx, Family Hx etc. As for going straight to the cath lab...the cardiologist must concur and that is simply not possible from the field except for an EXTRAORDINARY scenario. As for the blood draws some labs accept field draws where others do not. I have had blood draws rejected by the lab stating that they were "hemolyzed". Who knows....the bottom line is continue to do what you do best....and let the powers that be do their thing. It really is less stressful.

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Permalink Reply by dov maisel on April 20, 2009 at 4:43pm

well hi guys
minde my spelling english is not my mother tounge,
i am a paramedic in Jerusalem Israel and i find that as you mentioned our 12 leads are dismissed or even thrown out. however, the first thing is i think it is very important for us to preform the 12 lead in the field in order to give us a picture of what is going on, is this an AMI or not and what the dynamics are of the 12 lead during evacuation , do we see deterioration on the one hand or we might end up holding printed proof of reperfusion after asprin and heparin. over the years we have developed a very proffetional relationship with one of the major hospitals in the city and when we diagnose an stelevation MI we often transport the patient directly in to the cath lab bypassing the er totally and having the guy cathed and reperfused in the cath lab befor we finish folding up our gear.
be carefull out there.

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Permalink Reply by Jeff on April 20, 2009 at 4:45pm

All the ED's in our area accept the 12-leads that are faxed from the field. We have been meet by a cardiologist in the ED, in our garage and have taken some straight to the cath lab. This did not come quickly but over time. It took getting all depts on board, especially MDs and it took us, EMS, to make sure we were confident in our interpretation of what came out of the monitor.
As far as blood, we stopped drawing blood in the field 2 years ago. We could never make lab happy with our draws, they always stated it was hemolized by the time it got to them and/or it wasn't labeled correctly. So we stopped doing it and we are out of the equation/fault line for lab errors.

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Permalink Reply by ArcticKat on April 20, 2009 at 4:55pm

Gerard Seling said:

As for the blood draws some labs accept field draws where others do not. I have had blood draws rejected by the lab stating that they were "hemolyzed".

That's why I like having the cardiac markers completed prior to arrival at the ED. Besides, hemolyzed blood is irrelevant, at least for me it is since the markers are measured in the plasma, not the red cells. Since we started using the IVDDs to test for cardiac markers in the field we've even caught more than a few NSTEMIs.

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Permalink Reply by DAVID NICHOLS on April 20, 2009 at 5:05pm

hi there in upstate ny we are working together with area hospitals to make 12lead transmission a standard,creates less time from ed to treatment ,upon transmission of 12 lead we contact hospital make sure was rec by phy. full report and pt cond,upon arrival @ed staff waiting .. cuts down time well ....

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Permalink Reply by Brett on April 20, 2009 at 5:14pm

I work in the Phoenix Metro area for a small department that was dealing with this issue for a VERY long time. There was only one thing that changed the way we operate and overall patient outcome. That change was a group of doctors and cardiologists from the local ER and Heart Hospital who saw that we had been doing prehospital 12 leads for the last 12 years and that we were competent at interpretation and treatment of STEMI's. This group of doctors (along with our medical director of course) set a goal that the patient will be catheterized within 90 minutes (starting from the time that 911 was called). So far the outcome has been great. When we have a true STEMI, we prep the patient for transport while faxing a copy of the 12 lead to the ER. We call them while enroute to confirn they received it, then we call the heart hospital (attached to the ER) and advise them we have a STEMI coming also. The heart hospital gets their team ready. We arrive at the ER, they run a quick set of vitals, an additional 12 lead and draw labs. Then the patient goes directly to the cath lab and gets taken care of. Most of our times are under 1 hour from 911 call to cath, but either way it is still a huge time saver, and an overall benefit to the patient. The doctors in charge of this program REALLY BELIEVE in the success of this program, and I think that is why it works.

My advise to you is to start or improve your communications with your receiving facility where your patients will be transported and get involved with the upper management and doctors who would be in charge. You need to start at the top.

Good luck.

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Permalink Reply by Squishymedic on April 20, 2009 at 5:41pm

Jeez Louise 211,
You sound like you work in Rhode Island.I have only taken the left (at Miriam Hospital) and gone to the cath lab TWICE in 10 years,despite 12 lead,and bloods,and a proper work-up and treatment.It seems the ED always want their work-up to maybe bill or something.EMS in Rhode Island was just exposed in the local newpaper for services not doing 12 leads,but 95% of the services are both fire-based and at the cardiac(EMT-C) level.I am lucky to work in one of the only 2 ACTUAL medic level services.But for all the fan-fair,we are not treated any different at the stoke centers,or cath lab POI's.It sucks.They throw away our bloods and discount our assessments.With exception of the smaller community ED's we go to,who appreciate our work and subsequently LOVE US for that,and also if we call for medical control,the community ED docs give us carte blanche,and actually believe us when we say something,I can attest to a decline in hospital-EMS relations,not the opposite.It's a joke.

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Permalink Reply by EMTP211 on April 20, 2009 at 6:27pm

i have a perfect example for this... i will only accept the blood pressure if i know the EMT taking it and i trust and know they can take one if not i just take one myself and monitor it with the NIBP for changes.

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Permalink Reply by Mike on April 20, 2009 at 7:31pm

we were taught that doing a pre hospital 12 lead is also important because you get a good look at the heart prior to administering medications and interventions. we have the ability to transmit the 12 lead to the hospital and it greatly decreases door to balloon time.

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