Remove 12 Lead from ambulances ???????

[crotchitymedic1986]

OP was abit antagonistic, but I think this is a valid question. Let me put my spin on it.

Reasons for removal:

1. If you have a symptomatic 50 year old male, with a normal 12-lead, you still treat the symptoms. So a negative 12 lead does not stop or start the care that was provided prior to the introduction of 12 leads.

2. It was thought that field 12 leads would quicken the treatment in the ER. Most credible ERs have their own door to needle time parameters, that occur regardless of what a prehospital 12 lead shows, and regardless of whether or not the patient comes in by ambulance. Even in the presence of a positive EMS 12 Lead, the ER will still do their own 12 lead prior to beginning treatment. You could make the arguement that a positive EMS 12 lead may make the ER staff move a bit faster, but how many minutes are actually saved ? At the ERs I usually transport to, they must complete a 12 lead within 5-10 minutes of the patients arrival. My heads-up, may mean that the 12 lead machine is in the patient's room and not in the hall. I realize your anectdotal experience may be different.

3. The technology is expensive, and with what i perceive to be little return, I ask if those thousands of dollars would be better spent on capnography, CPAP, salaries, or benefits ?

4. I dont want to speak for everyone, but i dont know that i can claim a 12lead has saved the life of any of my patients, whereas, i know that CPAP has.

My arguements for keeping the technology:

1. It does help you identify the asymptomatic (i just feel weak or sick, or i have right arm pain) patient or the unusual symptomatic patient (26 year old with chest pain -- or female in her 30s), that you might have missed. But this is a small percentage of cardiac patients.

2. If you live in a rural area, based on a positive 12 lead, you may decide to transport the patient to the more distant hospital that performs CABG, versus the local hospital that can only do thrombos. Then again, if you live in a rural area, you may not have the EMS resources to have your ALS ambulance out of county for 2-3 hours.

What are your thoughts ?

[reaper]

Most systems are becoming more progressive, when it comes to STEMI's. In our system, If we have a STEMI in the field, we bypass the ED and go straight to the cath lab. So yes, they do save time and possibly lives.

Yes, a 12 lead can change my treatment of a chest pain pt. Depending on where the infarct is coming from, determines my treatment.

Wanting to give up 12 leads would be taking a step back. I for one will not give mine up. I interviewed with a service, that was great. Nice people, great pay. I turned it down for the simple fact that they did not have 12 lead capability!

[crotchitymedic1986]

Reaper, your system is obviously more advanced than mine --- how does the location of the MI change your "field" treatment ?

[reaper]

MI with right side involvement, gets different treatment. I may hold ntg till I can get a bolus in, or I may hold off on it all together.

It depends on what I find in my assessment!

[fiznat]

I think you are correct in that prehospital 12 leads are largely ineffective for STEMI when they lack a system to back them up. The strength of 12 leads (and 12 lead interpretation) in the field is that the cath lab may be activated and the ball set rolling before the patient even reaches the hospital doors. This requires a certain level of coordination (and probably most importantly) trust between the medics and the docs though. If you don't have that, you've got nothing.

I find 12 leads useful for other things besides STEMI though. I find them very helpful in determining the origin of an otherwise unknown tachycardia, and they can also play a role in identifying syndromes like cor pulmonale, brugada, old cardiac disease, RVI, etc. 12 lead ECGs contribute greatly to the clinical picture, and are indispensable in my opinion.

BTW I hate the "well, what does it change in your treatment" argument that we see so often in EMS. Just because an assessment point doesn't lay directly at heart of a treatment decision does not mean that it isn't important. That is "technician" kind of thinking, not "clinical" thinking.

[ERDoc]

There is lots of literature to support prehospital 12-leads. It can help you change your destination. If you have a STEMI, you should be taking them to a hospital with a cath lab and not the closest. If you go to the closest and there is no cath lab, they will only be getting lytics which is not ideal. If you have an inferior or right sided MI you will want to avoid nitro and instead give lots of fluids. Below are a few articles that support prehospital 12-leads. EMS is the part of the chain that has the greatest potential to impact morbidity and mortality in pts with STEMIs.

http://www.ncbi.nlm.nih.gov/pubmed/1835931...Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/pubmed/1622610...ogdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/1705631...ogdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/1817839...ogdbfrom=pubmed

[mshow00]

If you look at the Springfield MO area, where Bob Page is from, the paramedics in that system give lytics in the field based on presentation and the 12 lead. If you think about it time being key to the level of damage done to a heart then their pts have the absolute best chance at a fast recovery from a small infarct. All because of the trust the doctors have in the medics ability to read and correctly interrupt the 12 lead.

[ERDoc]

It's just like the saying goes, "Time is tissue and tissue is the issue." We've pretty much done everything we can to optimize time in the hospital. The place where we can cut more time is in the field.

[UMSTUDENT]

I think you are correct in that prehospital 12 leads are largely ineffective for STEMI when they lack a system to back them up. The strength of 12 leads (and 12 lead interpretation) in the field is that the cath lab may be activated and the ball set rolling before the patient even reaches the hospital doors. This requires a certain level of coordination (and probably most importantly) trust between the medics and the docs though. If you don't have that, you've got nothing.

I find 12 leads useful for other things besides STEMI though. I find them very helpful in determining the origin of an otherwise unknown tachycardia, and they can also play a role in identifying syndromes like cor pulmonale, brugada, old cardiac disease, RVI, etc. 12 lead ECGs contribute greatly to the clinical picture, and are indispensable in my opinion.

BTW I hate the "well, what does it change in your treatment" argument that we see so often in EMS. Just because an assessment point doesn't lay directly at heart of a treatment decision does not mean that it isn't important. That is "technician" kind of thinking, not "clinical" thinking.

I have to agree with much of what has been said here. 12-Leads, when placed in the hands of paramedics who do not have institutional or system support for recognition, are pretty much useless.

Our system specifically transmits suspected STEMIs to the local center so that the cath lab can be activated.

Where I think the 12 lead fails prehospital providers is in the rarity at which a provider will see a true STEMI. I have seen very few true, "look at me", STEMIs in my practice. I find new onset BBBs, T-wave abnormalities (hyperacute, inverted), and noncontiguous/nonspecific ST abnormalities more often than true ST elevation. I think patients simply access the system during one of two phases in the disease process: Early or Late. First onset of chest pain or other abnormality and people seem pretty quick these days to dial 9-1-1 OR they have a latent MI that manifest as chest tightness, abdominal pain, or nonspecific pains later in the continuity of the illness. I have a lot of patients where I see suspicious 12-Lead presentations, but that don't meet criterion as STEMIs. This is where I really wish I had enzymes...

The problem is, IMHO, is that we in EMS are taught to alarm the bells every time we see the slightest hint of ischemia. We take this very seriously, administering nitro and aspirin and aggressively transporting to ERs for evaluation. The problem is that we don't necessarily get to see the whole picture. We never get to see the enzymes that allow physicians to determine general onset. We often don't get complete medical historys that tell us if that BBB is preexisting...

In the continuity of care, in-hospital providers are able to develop experiences that let them gauge the severity, specificity, and sensitivity that certain signs (aka ECG changes) represent. They also have many more tools at their disposal to properly diagnose the issue.

I think this problem could be better solved through better education both in and out of the hospital. ED physicians and nurses need to understand that we're doing what we believe to be right with the limited resources we have. They need to take our sincerity, well seriously, and look at our ECGs with an inquisitive eye. They also need to realize that for all intensive purposes, most prehospital 12 leads are of diagnostic quality. I understand that JCAHO has the 10 minute requirement, but that doesn't mean you can't take a look at our good work.

Paramedics need to be better educated on the sensitivity and specificity of these test. We need to learn how to properly identify real issues. What is essentially nondiagnostic and what requires immediate notification and intervention.

[fiznat]

UMSTUDENT,

Do you have the opportunity to follow up on patients where you work? If I've got a patient that I'd really like follow up with, I just write down the basic info and one of the nurses or docs will look him/her up in the system later on. This has helped me quite a bit. It is nice to hear "how things turned out" and to apply that experience to the next patient. It is up to the individual medic to find out for him/herself, though.