There is presently a fascinating discussion I am having with some colleagues on Twitter. We are tossing about the merit of having EMT’s perform 12-lead EKG/ECG’s on patients in the prehospital environment. Nevada is a very rural state, second only to Alaska, where it can literally take hours to access ALS-level care. God help you if the flight crews are unavailable or cannot fly due to weather. I work per diem for a rural service that is 3 1/2 hours away from our closest trauma/cardiac/stroke center, and there’s another three hours of driving to a burn center. By our last estimates and figures, 80% of Nevada is covered by BLS, with some services providing intermittent access to ILS. Now we have a push to get ALS into some of the larger rural towns, but that is presently only in a single-town pilot study (the one I work for). Reasons I am aware of for no ALS include budget (you have to pay Paramedics a healthy wage to get them to travel that far to work), many towns insisting on mandating Paramedics live in their community (hours away from full-service grocery stores and airports with even a commuter flight service – although some are willing to have Paramedics per diem instead of full-time just to keep the service level), and inability to provide sufficient call volume to maintain skills (CME and simulation are great, but real life use is still important).
So what if the EMT’s could perform the capture of a 12-lead EKG?
I know this is a loaded question, but it’s already a skill performed by cardiac rehab techs, medical assistants (MA), and monitor techs. No one in those trades is qualified to interpret and treat an MI either. They all have the skillset, however, to apply EKG leads and capture a good quality 12-lead EKG. It is a physician who interprets the EKG, then they or their designee (PA, EMT-P, RN, NP, etc.) who delivers the prescribed treatment(s). In my perspective, an EMT can do it as well as the MA or other tech. Teaching someone to place the leads and demonstrate it takes about one hour, and you can require annual competence and easily integrate QA with run review. Monitors can automatically transmit the EKG to a care facility or doctor’s office nowadays. I see potential here, especially in rural areas. If I had to respond in a chase car to rendezvous with a BLS unit, I’d like to have a baseline 12-lead in my hand. I might see ST segments trending upward, or I might be aware of a certain dysrhythmia prior to arrival. I can begin to formulate a better plan for care. It might help me determine if I should transport to a local ER/clinic/doc-in-the-box or if I should try to get the patient to a higher level of care in the big city. Serial EKG’s are expected standards of care, even in the prehospital environment, when time permits.
Do I think this is something to be used in the big city or if transport times are less than 20 minutes? Nope! This will become a time waster. Beyond that, I do not see any detriment to employing this assessment tool. It isn’t going to be right for every agency, but I think it warrants strong consideration. The learning curve is low. It’s non-invasive. It doesn’t permit the EMT from exceeding the Basic or Intermediate scope of practice of oxygen, aspirin, and SL NTG. They’re giving these meds without an EKG as it is. In my eyes, it’s a great implementation of medical technology.
Chime in on the conversation with @unwiredmedic, @hp_ems, @ems12lead, Cardioligist @wmdillon, and the rest of us, or post your thoughts in the comments section here. All opinions, dissenting and supportive, are valued.
EDIT: I wanted to make sure you had a chance to read this article from Dr. Dillon: http://www.kevinmd.com/blog/2013/01/allowing-emts-perform-ecg-controversial.html
ADDENDUM (01/21/2013 @ 18:00): Be sure to check out EMS Office Hours for this post on EMS 12 Lead ECG and reducing Door To Balloon Time (D2BT): http://emsofficehours.com/2013/01/21/ems-12-leads-tips-on-d2bt/