# Do you have a cardiac monitor on a BLS rig?



## patzyboi (Feb 3, 2013)

And why would you use it?

To determine rate and rhythm of the heart? EMT's can only interpret if a rhythm is regular or irregular? 

And just wondering, if a patient went into cardiac arrest, would you look at the monitor or check carotid artery?


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## EpiEMS (Feb 3, 2013)

We do have them. It's good to have it if there's a medic intercept and they don't even need to bother moving their monitor to the transporting unit. Additionally, having the monitor is helpful - if unnecessary - for SpO2 monitoring, heart rate monitoring, and BP (auto cuff after taking an initial pressure manually -- useful if there's other trauma care being done, say). Additionally, I can acquire a 12-lead if it's helpful to have monitoring (not that I'm by any means qualified to interpret one, but I can surely place one, which means I can transmit for STEMI activation if my system one day gets its act together).

Having a monitor isn't necessary, but it's certainly helpful.

If the patient arrested, I'd pull out the AED, start BLS measures, and call for a medic.


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## DesertMedic66 (Feb 3, 2013)

AED are all that are carried on BLS around here.


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## EpiEMS (Feb 3, 2013)

firefite said:


> AED are all that are carried on BLS around here.



What do you use for SpO2 monitoring on your BLS units?


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## DesertMedic66 (Feb 3, 2013)

EpiEMS said:


> What do you use for SpO2 monitoring on your BLS units?



They are optional in my county. So my ambulance company does not carry them. 

Other companies and our ALS 911 units carry an SpO2 monitor that is seperate from the monitor. Our ALS monitors don't even have auto BP.


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## EpiEMS (Feb 3, 2013)

firefite said:


> They are optional in my county. So my ambulance company does not carry them.
> 
> Other companies and our ALS 911 units carry an SpO2 monitor that is seperate from the monitor. Our ALS monitors don't even have auto BP.



Gotcha -- It's a feature used too often out of laziness, which, I suppose, could be problematic.


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## ATFDFF (Feb 4, 2013)

All the BLS units in my system have our old LP12s.  They will routinely transmit 12-leads to the hospital prior to meeting up with an ALS intercept, that's the main reason they have them.


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## Clare (Feb 4, 2013)

All ambulances in New Zealand carry a manual monitor/defibrillator either an MRx or LP12

Emergency Medical Technicians can acquire a 12 lead ECG and do basic interpretation of a rhythm strip while Paramedic and Intensive Care Paramedic can interpret 12 leads.

First Responders at events and in rural locations carry an AED because all they do is advanced first aid


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## EpiEMS (Feb 4, 2013)

ATFDFF said:


> All the BLS units in my system have our old LP12s.  They will routinely transmit 12-leads to the hospital prior to meeting up with an ALS intercept, that's the main reason they have them.



I can't help but think that this could be very useful, especially in areas where BLS is the only EMS available. Could -- potentially -- become the standard of care eventually.



Clare said:


> All ambulances in New Zealand carry a manual monitor/defibrillator either an MRx or LP12
> 
> Emergency Medical Technicians can acquire a 12 lead ECG and do basic interpretation of a rhythm strip while Paramedic and Intensive Care Paramedic can interpret 12 leads.



Do your EMTs transmit 12-leads to the ED for MD evaluation? (And can EMTs manually defibrillate?)


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## Outbac1 (Feb 4, 2013)

All ambulances in our system have LP12 monitors. In fact all units have the exact same equipment and meds on board. Our PCPs do 12leads and basic interpratation. They can then use that to call for ALS backup or if no ALS prenotify the hospital. 

 The only differences in equipment carried are on the units in and around Halifax. They don't carry TNK as they are within an hour of the cath lab. 
All units the same is one of the benefits of a single province wide provider.


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## EpiEMS (Feb 4, 2013)

Outbac1 said:


> All ambulances in our system have LP12 monitors. In fact all units have the exact same equipment and meds on board. Our PCPs do 12leads and basic interpratation. They can then use that to call for ALS backup or if no ALS prenotify the hospital.



By basic interpretation, do you mean that the PCPs are doing a 12-lead so as to determine "This is normal, we can transport" versus "This is abnormal, let's contact ALS for an intercept (or alternatively pre-notify)"? Or is it in greater depth?


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## VirginiaEMT (Feb 4, 2013)

EpiEMS said:


> We do have them. It's good to have it if there's a medic intercept and they don't even need to bother moving their monitor to the transporting unit. Additionally, having the monitor is helpful - if unnecessary - for SpO2 monitoring, heart rate monitoring, and BP (auto cuff after taking an initial pressure manually -- useful if there's other trauma care being done, say). Additionally, I can acquire a 12-lead if it's helpful to have monitoring (not that I'm by any means qualified to interpret one, but I can surely place one, which means I can transmit for STEMI activation if my system one day gets its act together).
> 
> Having a monitor isn't necessary, but it's certainly helpful.
> 
> If the patient arrested, I'd pull out the AED, start BLS measures, and call for a medic.



So are you saying your monitor and AED are separate units?


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## EpiEMS (Feb 4, 2013)

VirginiaEMT said:


> So are you saying your monitor and AED are separate units?



There's an LP15 and there's Phillips HeartStart FRx AED in the rig. Usually, we're not BLS-only (usually EMT-P/EMT staffing). When we are BLS staffed (EMT/EMT, or AEMT/EMT), the FRx is intended for the BLS providers (though the LP15 does have an AED mode, I've not used it for a BLS-managed arrest).


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## NomadicMedic (Feb 4, 2013)

None of the BLS ambulances in my county have a monitor. Since we are totally an intercept service, all of the paramedics carry their own life pack 15 and ALS gear that is brought on to each BLS ambulance for patient care.


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## EpiEMS (Feb 4, 2013)

n7lxi said:


> None of the BLS ambulances in my county have a monitor. Since we are totally an intercept service, all of the paramedics carry their own life pack 15 and ALS gear that is brought on to each BLS ambulance for patient care.



For a cardiac arrest, do you usually meet BLS on scene?

(quasi-related question)


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## NomadicMedic (Feb 4, 2013)

We are dispatched simultaneously and usually arrive first or just as BLS does. It's very, very rare that BLS will be on scene at an arrest for any significant amount of time (read: more than 3 or 4 minutes) without ALS. 

Unless, of course, the patient is an "alpha" sick person that arrests while BLS is there, or if its right next door to the fire station where the ambulance is.


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## EpiEMS (Feb 4, 2013)

I'm liking this Delaware system more and more.

Y'all use LP 15s?


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## NomadicMedic (Feb 4, 2013)

EpiEMS said:


> I'm liking this Delaware system more and more.
> 
> Y'all use LP 15s?



That's correct. We carry two on each medic unit, with a third "spare" at each station. 

Anyway, to get back on topic, some BLS units I've worked on in the past used Zoll monitors locked into AED mode. If a medic got on, he could enter a code to make it a manual defib.


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## EpiEMS (Feb 4, 2013)

n7lxi said:


> Anyway, to get back on topic, some BLS units I've worked on in the past used Zoll monitors locked into AED mode. If a medic got on, he could enter a code to make it a manual defib.



I'm fairly sure the LPs have a similar option. Not sure about any other manufacturers, though. 

For a BLS service, it might be cheaper (hence, preferable, if cost is a major concern) to have a single-role AED, let the intercepting ALS unit stock the monitor. I'd imagine this is standard practice for many services, given the cost of a monitor/defibrillator.


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## Trashtruck (Feb 4, 2013)

patzyboi said:


> And why would you use it?
> 
> To determine rate and rhythm of the heart? EMT's can only interpret if a rhythm is regular or irregular?
> 
> And just wondering, if a patient went into cardiac arrest, would you look at the monitor or check carotid artery?



No, the BLS units do not have cardiac monitors. They carry AED's, not cardiac monitors. They do not have a pulse ox, either. 
I suppose if they did have monitors on the BLS units, they could use the NIBP, pulse ox, and place it in AED mode. The CPR metronome is helpful, too. 

I would look at the monitor AND check for a pulse simultaneously


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## Tigger (Feb 4, 2013)

EpiEMS said:


> I'm fairly sure the LPs have a similar option. Not sure about any other manufacturers, though.
> 
> For a BLS service, it might be cheaper (hence, preferable, if cost is a major concern) to have a single-role AED, let the intercepting ALS unit stock the monitor. I'd imagine this is standard practice for many services, given the cost of a monitor/defibrillator.



An MRx can be locked out as well. Seems like this might work well for your agency so you don't need two devices?

Of note, every ambulance in South Dakota has a cardiac monitor on board as a result of a 8.4 million dollar grant. BLS crews are placing twelve leads and transmitting them for interpretation to allow for early cath lab activation or potentially helicopter transport if in a very rural area. ALS is few and far between out there. Here's an article, I used to have some more info about the program but I can't find it.


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## mrg86 (Feb 5, 2013)

My agency has a LP12 on our BLS unit. Our EMTs are trained to set up 12 leads and use it in AED mode on arrests. If the call starts off BLS and gets balanced to a medic response, the arriving medic will usually get handed a 12 lead strip when they walk in.


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## Clare (Feb 5, 2013)

There is no transmission of ECG for interpretation here, this should not be occurring, if you cannot interpret an ECG then something is very wrong.


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## MidwestEMT (Feb 5, 2013)

our local service carries the LP15 on both our BLS and ALS rigs. They have the previously mentioned lockout for manual defib. As basics, we use it mainly for spO2, pulse, and transmitting 12's to the receiving facility if requested or if thought necessary. 

Most of our Basics are very good at continuing education, and learning because they want to, not need to. That being said, almost all of us are able to interpret at least a few common rhythms, and while we aren't 'trained' to diagnose different rhythms, we can give incoming medics a heads up.


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## Handsome Robb (Feb 5, 2013)

Clare said:


> There is no transmission of ECG for interpretation here, this should not be occurring, if you cannot interpret an ECG then something is very wrong.



Or you work as a lower level provider in a region where providers educated in 12-lead interpretation are few and far between so BLS ends up managing and transporting these patients. 

I agree that the Medic should be interpreting the 12-lead but in areas where there isn't always a medic available how is acquiring and transmitting a 12-lead in patients with suspected ACS a bad thing?



Only BLS crews in the county I work in are special events crews. They carry Philips AEDs. All ambulances are ALS and carry the MRx. Some special events crews are ILS and they will usually have an MRx they can use in AED mode and for pulse oximetry and to capture 12-leads for the incoming ALS crew since they have a few extended protocols over ambulance Intermediates after they request ALS backup.


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## EMT B (Feb 5, 2013)

my system we use lp15 on the trucks. all of our trucks are als equipped. it is very very rare that we have no als on duty though.


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## EpiEMS (Feb 5, 2013)

Clare said:


> There is no transmission of ECG for interpretation here, this should not be occurring, if you cannot interpret an ECG then something is very wrong.



What are the BLS providers expected to interpret? Normal vs. not normal? Or identify specific rhythms, etc.?



Tigger said:


> An MRx can be locked out as well. Seems like this might work well for your agency so you don't need two devices?



That'd be preferable, I would think -- may as well already have the monitor/defibrillator all ready to go when ALS shows up.


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## systemet (Feb 6, 2013)

Clare said:


> There is no transmission of ECG for interpretation here, this should not be occurring, if you cannot interpret an ECG then something is very wrong.



In an ideal world, BLS providers would be taught to capture and interpret a 12-lead.  Unfortunately in some places the training programs are so short that this becomes problematic.  I would rather have them capture, check whether the rhythm strip says "Acute MI suspected", and be able to transmit, that not be able to apply a 12-lead at all.  This is a skill that really should be available on every ambulance.

At an ALS level, it's really nice to be able to send a borderline ECG past a physician.  We're fortunate enough to have access to a team of physicians that can direct us to bypass the ER and go direct to cathlab, or to give TNKase, depending on the patients condition, risk factors, and the availability of local cathlab suites.  This is invaluable.  I think, as paramedics, we can do a very good job of calling obvious STEMIs.  The problems occur when the changes are borderline, or when we need to start assessing more complex risk/benefit issues, like the relative benefit of PCI vs. lysis in grey situations.


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## Christopher (Feb 6, 2013)

patzyboi said:


> And why would you use it?
> 
> To determine rate and rhythm of the heart? EMT's can only interpret if a rhythm is regular or irregular?
> 
> And just wondering, if a patient went into cardiac arrest, would you look at the monitor or check carotid artery?



We carry cardiac monitors on our industrial fire brigade, but to do 12-Leads, NIBP, SpO2, and EtCO2.

If necessary, paramedics (who utilize the same brand) in our county can unlock the full ALS features.

At my fire department our BLS/ILS crews also carry the same cardiac monitor as our ambulance does, this way if a medic hops onto their truck they can roll with what they have.


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## Christopher (Feb 6, 2013)

EpiEMS said:


> That'd be preferable, I would think -- may as well already have the monitor/defibrillator all ready to go when ALS shows up.



All major brands of cardiac monitors can be locked out for BLS providers.


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## VFlutter (Feb 6, 2013)

Clare said:


> There is no transmission of ECG for interpretation here, this should not be occurring, if you cannot interpret an ECG then something is very wrong.



You do not transmit STEMI EKGs? I do not necessarily agree with that. It is nice for the cardiologist to have a copy of the EKG in hand before the patient arrives in the ER or cath lab.


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## Christopher (Feb 6, 2013)

Chase said:


> You do not transmit STEMI EKGs? I do not necessarily agree with that. It is nice for the cardiologist to have a copy of the EKG in hand before the patient arrives in the ER or cath lab.



We've got a system that works exceedingly well without transmission. Only necessary if the providers cannot interpret the ECG's.


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## NomadicMedic (Feb 6, 2013)

We also do not transmit ECGs. Our system works very well without it. 

The medial directors are very involved with our education, know all the medics by name and since we all see them frequently, it's not uncommon for one of the docs to just flip you a 12 lead and say "what is this?"


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## Tigger (Feb 6, 2013)

Clare said:


> There is no transmission of ECG for interpretation here, this should not be occurring, if you cannot interpret an ECG then something is very wrong.



I don't know how your rural ambulances are staffed, are ambulances nation wide crewed by at least one paramedic or do units exist with only EMTs staffing them? 

Seems like an EMT only ambulance could benefit from transmitting EKGs to the hospital since they already have the monitor...


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## WolfmanHarris (Feb 6, 2013)

Our BLS trucks and American ones are quite different. All Primary Care Paramedic (BLS) trucks are equipped with a monitor with 12 lead capability. All PCP's are trained to interpret and no transmission is done. One of the medical direction programs I'm aware of emphasizes machine interpretation over medic for their STEMI program, but they are the exception. We are required to bypass on our own interpretation only. It's a weird quirk of the system where almost every directive is the same across the province save STEMI since those are regional agreements with the PCI lab.


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## Bullets (Feb 7, 2013)

Our ambulances only carry AEDs, Cardiac Science. Town got a grant and got an AED for every PD (20), FD (14), EMS (20), OEM/Hazmat (5) vehicles and the schools. Near on a hundred AEDs in town.

Our day to day EMS takes BPs manually, checks pulses manually, though we do carry Rad-57s to measure Oxygen and CO

We have 2 MCI units, one has 4 Welch Allyn monitors that do NIBP, Pulse Ox, and 3 leads. Our MCI bus had 10 of these new ATHENA GTX wireless monitor, also do NIBP, O2 and 3 leads and can transmit them over bluetooth to a central monitoring station.


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## EpiEMS (Feb 7, 2013)

Any use in having the AEDs that give a 3-lead rather than just the regular AED?


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## Tigger (Feb 7, 2013)

EpiEMS said:


> Any use in having the AEDs that give a 3-lead rather than just the regular AED?



Most of the AEDs that are 3-lead capable are also marketed as tougher than your "average" AED. That's why we have Zoll AED Pros instead AED Plus models I am told. 

Besides that I can't come up with much. If a BLS unit is getting an intercept I would expect ALS is bringing a monitor. I suppose ALS could use the three lead function during an already "in progress" arrest to save time and check for  rhythm. If someone arrests in front of me the AED is going on immediately and staying on even if it doesn't shock, so all they would have to do is unlock and voila, three lead. Of course we have Zoll monitors too so they could just plug in our pads to their monitor...


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## EpiEMS (Feb 7, 2013)

Tigger said:


> Most of the AEDs that are 3-lead capable are also marketed as tougher than your "average" AED. That's why we have Zoll AED Pros instead AED Plus models I am told.
> 
> Besides that I can't come up with much. If a BLS unit is getting an intercept I would expect ALS is bringing a monitor. I suppose ALS could use the three lead function during an already "in progress" arrest to save time and check for  rhythm. If someone arrests in front of me the AED is going on immediately and staying on even if it doesn't shock, so all they would have to do is unlock and voila, three lead. Of course we have Zoll monitors too so they could just plug in our pads to their monitor...



Yeah, I can't quite see where it'd be useful, barring the 3-lead capable AEDs actually being tougher.

ALS comes, ALS uses an ALS monitor, that's really all there is to it, I suppose.


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## Outbac1 (Feb 8, 2013)

EpiEMS said:


> By basic interpretation, do you mean that the PCPs are doing a 12-lead so as to determine "This is normal, we can transport" versus "This is abnormal, let's contact ALS for an intercept (or alternatively pre-notify)"? Or is it in greater depth?



  Sorry for the delay in replying I've been working or away.

  Our PCPs will interpret sinus rhythms, a-fib, v-fib, v-tach, and look for ST elevations on 12 leads. Most do rely more on the monitors interpretation than their own. And lets face it most of the time the monitor is right. They will use that info to call for ALS backup or to notify the hosp that they are bringing in a probable STEMI. With advance notice the door to drug time can be as little as 10 min. Our nearest cath lab is 100 miles away. 

  Please keep in mind that most of our PCP (Primary Care Paramedic), programs are longer than many "Paramedic" programs in the US. The scope of practice of PCPs here is considerably more than a "Basic". It is not a fair comparison to try and compare our "BLS" to yours.


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## Handsome Robb (Feb 8, 2013)

Christopher said:


> We've got a system that works exceedingly well without transmission. Only necessary if the providers cannot interpret the ECG's.





n7lxi said:


> We also do not transmit ECGs. Our system works very well without it.



Same here. 

I can't transmit one even if I wanted to. Or at least I'm not aware of how to do it. Be nice to be able to if you were really stuck though. 



Tigger said:


> Most of the AEDs that are 3-lead capable are also marketed as tougher than your "average" AED. That's why we have Zoll AED Pros instead AED Plus models I am told.
> 
> Besides that I can't come up with much. If a BLS unit is getting an intercept I would expect ALS is bringing a monitor. I suppose ALS could use the three lead function during an already "in progress" arrest to save time and check for  rhythm. If someone arrests in front of me the AED is going on immediately and staying on even if it doesn't shock, so all they would have to do is unlock and voila, three lead. Of course we have Zoll monitors too so they could just plug in our pads to their monitor...



I've never understood why all the agencies we co-respond with don't carry monitors that are all the same brand as ours or why we don't carry an adapter. 

All the FDs here use Zoll monitors and we carry the Philips. I believe the few volly squads we have carry Zoll AEDs as well, never been to an arrest where they were the only fire unit on scene. Every time we go to an arrest that fire is already there we have to change the pads out. Not a huge deal but it'd be nice to be able to just plug in there pads and go from there. FWIW, I always put the pads on first then the 4-lead gets put on a little later. It's attached early on but pads give me a fine view of their initial rhythm.


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## Christopher (Feb 8, 2013)

EpiEMS said:


> Any use in having the AEDs that give a 3-lead rather than just the regular AED?



I don't know if there is any advantage, but we've got them now. We don't run ALS engines, but often have paramedics on the engine (which carries the 3-Lead capable AED). Sometimes more information is good, but hasn't made much of a difference in practice.


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## Christopher (Feb 8, 2013)

Robb said:


> I've never understood why all the agencies we co-respond with don't carry monitors that are all the same brand as ours or why we don't carry an adapter.



It hasn't been mandated in the past, but currently in the two counties I work all EMS agencies utilize the same brand of monitors/AEDs or carry adapters.

County 1: Philips. (IFT uses Zoll)
County 2: Zoll. (previously Physio-Control)

Our industrial fire brigade has 26 AED's on site, all brand-compatible with the county EMS system. Being able to swap 1:1 is awesome when rolling up on a code.


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## Handsome Robb (Feb 8, 2013)

Christopher said:


> Our industrial fire brigade has 26 AED's on site, all brand-compatible with the county EMS system. Being able to swap 1:1 is awesome when rolling up on a code.



That'd be nice. It definitely wouldn't be cheap to get fire all new monitors, especially when all they really use them for is the first, maybe second round in a cardiac arrest if they're way out in the middle of nowhere or if they're on scene for a while with an EMS patient and have run out of things to do if we're responding priority 3. 

Getting an adapter for every ambulance seems like an easy and relatively cheap (maybe not, everything medical is so damn expensive) way to solve this "problem". Like I said, it isn't a huge deal to swap the pads out, sometimes may be beneficial if they're really hairy and didn't get shaved before the pads went on. I've seen some really poorly placed pads though by both EMS and fire that needed to be changed even if we could just "plug and play".


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## ThirtyAndTwo (Feb 10, 2013)

We carry one because we have enough medics at the hospital to dispatch one with every call, most of the time. It saves him/her the time and trouble of lugging their own monitor back and forth, because we all know how much lifting the medics do .

Anyway, we are trained by our organization to hook it up and use the BP/pulse ox/heart rate functions so we get valuable information that we can actually make use of and the rhythm is already on the screen when the medic arrives.


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## NomadicMedic (Feb 10, 2013)

You can get that same valuable information with a BP cuff and your fingers and eyes.


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## bahnrokt (Feb 11, 2013)

I really want my BLS squad to start putting monitors on the rigs.  We average 15-20 minutes from on scene with a PT to when we see an ALS intercept.  Being able to hand a medic a strip as soon as they get out of the fly car is valuable.  My own personal want extends from having a monitor and can sync its data directly into our e-PCR system.


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