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

[Arctickat]

We've been doing Prehospital 12 leads for 8 years, we transmitted them for the first 3 years but after that the docs were comfortable with paramedic interpretation. About 2 years ago we started doing point of care blood tests like these to identify elevated cardiac markers in the prehospital setting and also forwarding those results to the hospital prior to our arrival.

Currently we are conducting a pilot study comparing the advantages of tenecteplase in the field to immediate transport to a cardiologist.

[celticcare]

12 lead acquisition is currently a Intermediate Care skill and interpretation is ALS here. I agree with Doc on the elements of GTN and inferior infarcts. Do I really want to bum my patients pressure out and cause more issues because I didn't do a 12 lead and interpret it? Anyone can pick up the basics of ECG and look and see a big wave that shouldn't be there, but the basis of interpretation does have to include knowledge specific to cardiac anatomy.

Ben, please bear in mind that the process of BLS is not PHEC any more, it is acquisition of the National Diploma of Ambulance to practice at technician level. All new entry staff will be doing this process, which DOES include anatomy and physiology modules. And they are on a par to what I learnt during my Bachelors of Nursing.

Please refrain from comments such as you wouldn't trust BLS with meds or a BVM, as that is an insult to those who have actually achieved the qualification or the skill level.

And now back to topic....

More and more paramedic students *including degree and roadstaff upskilling* are required to spend time in Cath lab, CCU, ED and those areas to recognise STEMI's, interventions and bypass therapy options. The education is getting there and will increase, perhaps we are on a lucky level because we are a smaller population we can implement these strategies alot easier.

Scotty

RN /ACLS L6/ EMT / EMD

[Kiwiology]

12 lead acquisition is currently a Intermediate Care skill and interpretation is ALS here. I agree with Doc on the elements of GTN and inferior infarcts. Do I really want to bum my patients pressure out and cause more issues because I didn't do a 12 lead and interpret it? Anyone can pick up the basics of ECG and look and see a big wave that shouldn't be there, but the basis of interpretation does have to include knowledge specific to cardiac anatomy.

Agree .... infact, I've been agreeing with most things we've said here!

Ben, please bear in mind that the process of BLS is not PHEC any more, it is acquisition of the National Diploma of Ambulance to practice at technician level. All new entry staff will be doing this process, which DOES include anatomy and physiology modules. And they are on a par to what I learnt during my Bachelors of Nursing.

Read what I wrote mate, I know, it's always been Cert or Dip for BLS. The A&P in the National Diploma modules is generally impressive as it does provide an appropriate level of knowledge for the BLS level, heck I even think it exceeds it in some instances (like the ECG section) but I also think it falls short in some parts too e.g. no mention of cells and tissues which the old National Certificate did.

Now, are we really here to debate National Diploma A&P? No

You may also notice I'm agreeing with the majority of what is being said here.

Please refrain from comments such as you wouldn't trust BLS with meds or a BVM, as that is an insult to those who have actually achieved the qualification or the skill level.

Again, read what I wrote. I'm not trying to come off as a wanksta or be a bastard but you have to remember the context of what I said; no, for 120 hour course that doesn't teach F/A pharmo or A&P why should I. One of my bosses at summer camp was some form of "advanced" EMT who told me of an asthma call he went on and went on about oh I can give salbutamol and I can give adrenaline blah blah blah, yet when I quizzed him on basic's of (for example) why you don't bag the snot out of an asthma patient (dynamic hyperinflation) he threw his hands up in the air and goes "I dno". Now does that mean EVERY EMT is like this guy, nah, surely not and I might be guilty of a little generalisation here... but extrapolating what I've said and taking it out of context causes more problems than I am worth.

More and more paramedic students *including degree and roadstaff upskilling* are required to spend time in Cath lab, CCU, ED and those areas to recognise STEMI's, interventions and bypass therapy options. The education is getting there and will increase, perhaps we are on a lucky level because we are a smaller population we can implement these strategies alot easier.

I think you're right and I have pretty high expectations of this new Degree/PGC that's coming down and think it'll do wonders for ambo's here.

[kristo]

I'd like to second the opinion previously expressed that what works in one EMS system may not be the best for another one.

That being said, I noticed a few points that I happen to have an opinion on:

1. Administering nitrates prior to 12 lead EKG. This is not a good idea. Comparing this to when people take their own nitro at home without an EKG is not a just comparison because those patients have experienced something that made them call for EMS. The instructions (I hope) they received along with those pills was to take them when they experience their familiar chest pain, but have a professional health care provider evaluate them again if something out of the ordinary happened. This is now. That health care provider is you.

Another reason I read on this thread to administer nitrates prior to an EKG was pain relief. No one has ever died from pain. I'm all for pain relief, but I'm OK with delaying it for two minutes to make sure it won't send my patient into shock. If you can't even wait for an EKG, I'm guessing you don't have an IV up either, right?

2. Someone mentioned being careful with fluids in right MI, as it may become pulmonary oedema. Of course, you are administering fluids to a cardiac patient, so you should keep this in mind, but in general, this is extremely unlikely to happen in a right sided MI. It is, however, very important to give ample fluids to keep the blood pressure up.

3. Bypassing the ED based on pre-hospital STEMI finding. I'm sitting on the fence on this one. This would have to be based on your local system. A couple of thoughts come up, the proficiency of your paramedics in interpreting EKGs correctly, the capabilities of the cath lab to handle the patient if it turns out it's not a STEMI (can they keep the patient for observation for the ~ 6 hours needed to get double enzymes? Chest X-rays? What if it turns out to be pneumonia? Do they call for another transfer somewhere else? Etc. etc.). Another thought would be STEMI-equivalent, a left bundle branch block - that's a transmural infarct until proven otherwise, UNLESS there's an older EKG showing this to have been present previously. At the ED, they can often find old EKGs and hence decide whether or not the patient should go to the cath lab.

Another note here; with all due respect to well educated pre-hospital professionals everywhere, circumstances out there don't always allow for a "good" EKGs. There's movement, etc.

I'd think a system that did this would need highly trained paramedics and a cath lab that also had something similar to an ER...

4. Pre-hospital thrombolytics. Again, sitting on the fence. Usually, if you can get to a cath lab within 40-120 minutes (based on other factors), you want that and not thrombolytics. Hence, most EMS systems (not all, obviously!) shouldn't need thrombolytics. I'll assume those who think it would be beneficial work where a cath lab is not accessible in this time frame. In those cases I'd like to ask...have you ever been involved in administering thrombolytics? You need a very detailed history to see if there has been any bleeding (or if bleeding is likely)...preferably you need to be able to administer LOTS of fluids very quickly, this can get messy in more than one way. This is best done in a well-lit building with ample room and staff. In some cases, we want a short endo- and sigmoidoscopy prior to administering the treatment. Another note to consider is cost. If I had to guess, I'd guess that thrombolytics cost about $3,000 USD per case. Do we want to equip every truck with such an expensive drug, if we're not sure it's helping?

In cases where transport is longer than...well, 10-15 minutes, I am however all for starting the treatment en route. Give aspirin, clopidogrel, heparin, maybe even GpIIb/IIIa inhibitors. For prolonged transport times (on the scale of an hour or more), those would definitely help, regardless of the end-point treatment (PCI/thrombolytics).

Of course, this is just my opinion, but at least, I think it's reasonable.