The Unwired Medic

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Should EMT’s be performing 12-Lead EKGs?

| 15 Comments

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).

heart monitor

Picture Credit: Stock Exchange (http://sxc.hu/photo/44129 by user: pixelbox)

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.

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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

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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/

15 Comments

  1. Chris,
    Thanks for stoking this discussion. Many issues not well suited for 140 character twitter. First, ECGs are easy to do. The ECG tech in the hospital was often the patient transporter last week. Most of the time there is brief on the job training and they are good to go. Some training does have to occur. Second, the reason there are not paramedics on every rig is money. Most/all EMS systems are strapped for cash and trying to do the best we can. I am not sure that we need a paramedic for every call but you EMS guys would know better than me. There are many non-emergency calls that are responded do and many atypical chest pains that have to be sorted out to find a true ACS/STEMI. I live in a urban environment and there is a 50% chance of getting a BLS crew despite great dispatchers due to many calls.
    The main point is that by allowing EMTs to do ECG it increases access to medical care. Prehospital activation of the cath lab lowers mortality by up to 50%. Heart disease the number one killer. We can do better. Most up to date guidelines for STEMI care by the ACC recommend EMS to perform ECG on arrival. It does not specify EMT or paramedic.

    • Dr. Dillon, thank you for participating here and on Twitter as well. Perhaps this can be a catalyst to adding it into the EMT-Basic (soon, we will drop the “Basic” off the title EMT) scope. I can’t see any harm other than if the EMT were to delay other care or transport to the patient’s detriment, but then a 12-lead EKG takes but a minute or two.

  2. The EMT’s I work with are all trained on how to place leads for a 12 lead. They’re also taught how to do a right sided ECG, which is simple to do. Although they can’t technically interpret it, a good chunk of them know “good squiggles” versus “bad squiggles,” enough to ask for an ALS unit to expedite, if they’re available.

    Our region isn’t as rural as Nevada or Alaska. But, our nearest hospital with cardiac cath capabilities is 1-1.75 hours away in good weather, depending on where you are in our district. We typically do have paramedics available, but for several hours out of each day, we run at the AEMT/EMT-I level or lower. I’ve found that having an EMT capable of applying a 12-lead has been very helpful. They can throw the strip to the paramedic as soon as he intercepts with the truck, and speed along treatment. Also, if the case is complicated, the paramedic can be busy starting an IV while the EMT applies the 12-lead, so we can get more things done quicker. I can’t think of a single time where we thought the EMT’s did a bad job of placing the leads…heck, we have a diagram in the truck that clearly outlines where they’re supposed to go in case they get confused. It’s only worked out in positive ways for us.

    • P2P: It sounds like you have a great system to maximize efficiency on scene and enroute. It’s also nice to hear of examples where people aren’t afraid of giving a little more technology to a lower certification level provider. Applying electrodes to capture an EKG is simple and non-invasive, and it sounds like the patient and Paramedic benefit here. Thanks for sharing!

  3. I see no reason to prevent EMTs from obtaining a 12-Lead. My concern would be having EMTs make treatment / triage decision based on the computer interpretation of the 12-Lead.

    I have seen many incorrect computer diagnosis on 12-Lead ECGs, I have considered turning-off the interpretation box at my department thereby making the Paramedic read / interpret the strips. I can run two ECGs thirty seconds apart and get complete different computer interpretations (without any actual clinical change in the patient).

    I would be very worried about a computer interpretation saying normal / no problem and the EMT not bring in ALS when the patient may actually have some significant, undetected problem. I’m sure this concern could be minimized with transmission of ECG to a physician (or medic).

    • Bruce, I agree with your assessment of the interpretation software. When I was working ICU’s and telemetry, I’d do some work with the visiting cardiologists and the stress test lab and the showed me the stats. The interpretation software was wrong 80% of the time, and totally correct less than 10%. It wasn’t never to be trusted. New algorithms and interpretation software have been made since LP12’s and MRX’s came onto the market and it has gotten better, but not enough to trust a computer to make the diagnosis.

      As I think we all agree, the EMT’s should not be making independent interpretations and basing treatments off that. The EKG should be sent to the ER and the on-site doc will make the interpretation and issue online medical control. This makes it a technician issue, not a practitioner issue. Besides, the limited scope of practice for an EMT means they still can only provide O2, ASA, NTG (it isn’t universal, but also not uncommon to see systems provide these on a BLS unit). Maybe an IV in some areas with expanded scope. The way to address your concern is to already have an ALS intercept on the way if the EMT feels an EKG is warranted. That should be protocol anyway, both for the dispatcher at the time of the call and for the EMT to verify that is happening. No triage decision on scene need be necessary.

      What do you suggest? A particular protocol? Online medical control only? Other? Thanks for joining the conversation!

  4. In Alabama, capturing a 12-Lead is in the EMT protocol. Interpretation is left up to the Medic on the rig. No problems with any of our EMT’s. They have all received training and it saves me time on scene.

    • Thank you for contributing to the conversation, Mr. Reynolds. I didn’t mention it before, but I have always worked with my EMT’s to know how to properly apply a 12-lead EKG and capture it. I learned this as an EMT in 1997 and was already teaching interpretation classes to the Paramedics and Nurses I worked around and at the local college two years later, after having worked in ICU’s and telemetry units to get experience. My medics always complemented me on exceeding my skillset to augment their care on scene so I could do the tech work while they focused on the patient care management, issued orders, and gave reports.

  5. As I said at Dr Dillon’s blog, there is no reason that an EMS provider, regardless of their level of certification should not be able to perform a 12 lead EKG and transmit it to the receiving facility. Paramedics aren’t anointed with defib gel and given the right and responsibility of placing a patient on a 12 lead EKG. (12 leads weren’t really an option when I went through Paramedic school. All my 12 lead training came afterwards) We are responsible for interpreting them, however. That’s not what is being asked for here. If we really want what’s best for our patients, then we need to be sure that everyone EMS provider knows how to properly place a 12 lead EKG, hit the Analyze button and then know how to transmit it to the appropriate facility. We have had “Time is Muscle” for 20+ years. Here is a simple way to save some time, thus saving muscle.

    • Mr. Hooper, thank you for contributing. Personally, I think you are spot on in your comments. As far as the comment below, I am still inclined to agree, as long an there is no significant delay in transporting the patient to a hospital as a result of obtaining the diagnostic adjuncts.

  6. I forgot to add: I work primarily in a service in which from the time we get call we can have the patient to the hospital in less than 30 minutes, and I still believe that there isn’t a reason for BLS personnel to not be able to obtain and transmit 12 lead EKGs.

  7. I have no problem with an EMT getting a 12 lead. Nor do I have a problem with them transmitting an ECG to a hospital. I think it is a good idea to divert to a cath capable facility based on an automated reading. I stop short, however, of activating a cath lab based on a computer read. That really requires a trained reading. The specificity simply isn’t there for that expenditure of resources.

    • Thanks for contributing, Dr. Mell. I wholeheartedly agree with your comments. I think it was the old Marquette interpretation software I referred to in a previous reply that was completely wrong about 80% of the time. Even though the new HP and other interpretation software is at least partially correct more in modern days, it is still not worthy of a trained human’s interpretation. In my personal experience, it requires several months of regular use on real patient’s (not just simulators) to become truly proficient enough to recognize MOST rhythms.

      Activation of a cath lab should be based on the good clinical judgement of either a physician’s or paramedic’s interpretation of a good quality 12-lead (or better yet, serial 12-leads), in concert with patient symptoms and presentation at a minimum, and if available, field testing of biomarkers would add weight to the decision to activate.

      As far as EMT’s, they needn’t necessarily learn interpretation. Just acquisition and transmitting to the proper clinician and/or facility.

  8. In Quebec (Canada) we use the Zoll M serie with 12 leads and a software to “read” the EKG. It’s like that for about the 3 last years. It’s a great overall experience for both rural and urban regions.

    Mainly, we do EKGs on all kind of chest pain even on atypic presentations. If we get a STEMI, we will give ASA and put on “tension” the closest Cardiac center by radio. When we get to the emergency, they confirm the EKG and we go straight to the hemodynamic departement.

    We sometimes have “false STEMI” from the machine but we are trained to mention that possibility on the radio to the cardio center. Many of them are caused by bad EKG quality BTW.

    On the formation side, we had about 2 days of training with the 12 leads. First day was Zoll’s new serie with leads’ positionnning and second was theory about how to get a good quality EKG as well as a crash course in EKG, STEMI oriented, reading.

    With our experience here, I can say that EVERY ambulance crew should have 12 leads in it. Our experience is telling us that we save more lives by a getting the good patient to the right place at first than bringing the patient to the closest emergency room and then transfert it.

  9. The idea of an EMT taking a 12 lead ECG is a great idea and when they have limited experience in interpreting the ECG in the field, the benefit of being able to transmit it to a cardiologist is an excellent resource. Why would anyone not want them to take a 12 lead?

    It is a simple question to me with all roads leading to…. yes, of course the concept should be embraced and supported from every level both in the community and also in the healthcare organization.

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