# Lazy EMT'S



## CobraIV (Sep 8, 2013)

I work in an ER and about 98% of the nurses hate basics. When a radio patch comes in for a medical patient the nurses always question why BLS?  In any event I bring up a scenario that happen while I was working in the ER.

911 call for 34 year old female with chest pain. Patient states pain on left side, in her chest, pain shoots down left arm. Patient has no allergies,  no meds besides over the counter sleepaids and no cardiac history. Patient had some discomfort before going to bed. Patient woke up to more pain and called 911. Patient is warm pink and dry. Blood pressure is 132/90. Pulse is 112 and her respirations are 20......

Patient arrives to ER, the patient was able to give her full name and social security number. Patient was loaded off strecher to bed. 

Now, the nurses had a problem with this picture. Besides it being late in the shift 4:40am, the crew had not placed oxygen on the patient nor was any asprin given. Now as an EMT myself I felt this was a good question since the chief complaint was chest pain. I was taught o2 was like chicken noodle soup when you had a cold(obviously not all patients are the same I know this) I don't know if it was lazyness by the crew since it was early in the morning or bad judgement. This patient wasn't a "frequent flyer".  The crew left as fast as they came. The patients ekg came back normal sinus rhythm. Iv fluids were started. Her blood pressure went up and another ekg was preformed revealing a stemi. The patient was ALS to a cath lab. I don't know what the end result was. 

My experiences are diffrent from one and others just curious to some other ones insight.


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## NomadicMedic (Sep 8, 2013)

Did the PT have an IV? Did the patient get any nitro from the medics? Did the medics do a 12 lead? What was the PTs Spo2 on ambient air?

Sorry. Strike all of that. I misunderstood. I thought the PT was turfed by medic to BLS.


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## rmabrey (Sep 8, 2013)

There really isn't much excuse for not giving ASA or O2. There are  good reasons why that came in BLS. The main one being, hospital is closer than ALS care.


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## NomadicMedic (Sep 8, 2013)

There are good reasons for not giving O2. Like a room air sat of 98%.


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## Carlos Danger (Sep 8, 2013)

CobraIV said:


> I work in an ER and about *98% of the nurses hate basics. When a radio patch comes in for a medical patient the nurses always question why BLS?*  In any event I bring up a scenario that happen while I was working in the ER.



Probably, like many people, these nurses (quite mistakenly, IMO) believe that ALS is always better and should always be initiated anytime a patient is the least bit sick. I don't see how that indicates that they "hate" basics.



CobraIV said:


> 911 call for 34 year old *female with chest pain. Patient states pain on left side, in her chest, pain shoots down left arm. * Patient has no allergies,  no meds besides over the counter sleepaids and no cardiac history. Patient had some discomfort before going to bed. Patient woke up to more pain and called 911. Patient is warm pink and dry. Blood pressure is 132/90. Pulse is 112 and her respirations are 20......
> 
> Patient arrives to ER, the patient was able to give her full name and social security number. Patient was loaded off strecher to bed.
> 
> Now, the nurses had a problem with this picture. Besides it being late in the shift 4:40am, *the crew had not placed oxygen on the patient nor was any asprin given.* Now as an EMT myself I felt this was a good question since the chief complaint was chest pain.



Of course I can't explain the actions or inactions of these EMT's, but if this is representative of how basics typically perform here, it is no wonder the nurses would rather patients not be brought in BLS.


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## rmabrey (Sep 8, 2013)

DEmedic said:


> There are good reasons for not giving O2. Like a room air sat of 98%.



Yeah, but most EMT's still do it.


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## J B (Sep 8, 2013)

DEmedic said:


> There are good reasons for not giving O2. Like a room air sat of 98%.



This pt was transported by emt-b's, who are taught to automatically give O2 to everyone.  So in this case, she should have been on O2.  It's possible that protocols are different in OP's state, I don't know.



rmabrey said:


> Yeah, but most EMT's still do it.



As they should, because their protocols indicate it...


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## NomadicMedic (Sep 8, 2013)

J B said:


> This pt was transported by emt-b's, who are taught to automatically give O2 to everyone.  So in this case, she should have been on O2.  It's possible that protocols are different in OP's state, I don't know.
> 
> 
> 
> ...



And that you STILL believe this is okay is a shining example of what's wrong with EMS.


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## jrm818 (Sep 8, 2013)

J B said:


> This pt was transported by emt-b's, who are taught to automatically give O2 to everyone.  So in this case, she should have been on O2.  It's possible that protocols are different in OP's state, I don't know.
> 
> 
> 
> As they should, because their protocols indicate it...



OP is in boston....from MA ACS protocols

"ASSESSMENT / TREATMENT PRIORITIES
1. Ensure scene safety and maintain appropriate body substance isolation precautions.
2. Maintain open airway and assist ventilations as needed.
*3. Avoid hyperoxygenation; administer oxygen using an appropriate oxygen delivery device, as
clinically indicated. If pulse oximetry is available, give supplemental oxygen only if the oxygen
saturation level is less than 94%.*
4. Obtain appropriate assessment, (O-P-Q-R-S-T), related to event.
5. Obtain appropriate (S-A-M-P-L-E) history, related to event.
6. Monitor and record ECG and vital signs.
7. Initiate transport as soon as possible, with or without ALS. Do not allow patients to exert themselves and properly secure to cot in position of comfort, or appropriate to treatment(s) required."

ASA is another issue....but perhaps in general ED nurses or an ED based EMT aren't the best ones to be determining the appropriateness of field treatment....


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## Carlos Danger (Sep 8, 2013)

Is it possible that the EMT's in question simply didn't suspect a cardiac origin for the chest pain? Right or wrong, that would probably explain their actions.



jrm818 said:


> perhaps in general ED nurses or an ED based EMT aren't the best ones to be determining the appropriateness of field treatment....



Laypersons in many cases even know that nitroglycerin, aspirin, and expeditious transport to the ED are appropriate prehospital treatments for a suspected heart attack.

So I think it'd be a pretty tough sell that ED nurses - who have far more training than EMT-B's, receive patients from EMS all day long, and work alongside ED physicians and cardiologists every day - actually know _less_ about appropriate BLS treatment than do many laypersons.


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## jrm818 (Sep 8, 2013)

Halothane said:


> Is it possible that the EMT's in question simply didn't suspect a cardiac origin for the chest pain? Right or wrong, that would probably explain their actions.
> 
> 
> 
> ...



I agree the crew may have failed to consider the diagnosis...wouldn't surprise me in the least.


That said, in my experience many ED RN's, although wonderful in many ways, have limited knowledge of EMS protocols, and certainly tend to not keep up with protocol changes (e.g. Massachusetts change to the O2 administration portion of the protocol.)  I don't know if the OP works outside the ED, but if he's indeed in MA, he seems to have missed a protocol revision or two... I would think a medical control physician would probably be a better evaluator of EMS performance relative to their protocol-ized expectations.

I agree that ASA should have been administered given the history in the post by the OP, although I wonder if the EMS crew heard the same version of the history (either due to poor history taking or patient's irritating habit of changing stories just when it is most likely to make the original history-taker look like an idiot).  That said, the nurses seemed to have four criticisms of the  EMS crew (no O2, No ALS, its 5AM and I want to go home, and no ASA) and only one seems possibly legitimate.


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## J B (Sep 8, 2013)

jrm818 said:


> OP is in boston....from MA ACS protocols
> 
> *3. Avoid hyperoxygenation; administer oxygen using an appropriate oxygen delivery device, as
> clinically indicated. If pulse oximetry is available, give supplemental oxygen only if the oxygen
> ...



Do basics have pulse ox on their trucks in MA/Boston?  Given that it's talking about ECG's in the same bullet list, might that be written for paramedics?

I suppose the phrase, "administer oxygen ... as clinically indicated" gives you room to use your discretion, so kudos to MA.  I know many places just give everybody O2, though...



DEmedic said:


> And that you STILL believe this is okay is a shining example of what's wrong with EMS.



Not saying it's good that many people get O2 when they shouldn't, I'm saying it's not the place of the guy who took a 1-semester EMT-B course to ignore protocols put in place by a committee of people with vastly superior knowledge and experience.  

Obviously we are patient advocates and sometimes you need to use your judgement and go outside the box.  However, I think it's a bit of a stretch to call people following their protocols a "shining example of what's wrong with EMS."  

Overuse of O2 and spinal precautions frustrates me, too, but if you want to effect a change you need to go higher up the food chain.


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## rmabrey (Sep 8, 2013)

J B said:


> As they should, because their protocols indicate it...



My protocols as an EMT at my employer are curriculum.  

Does that mean im going to put every patient on high flow O2 via NRB?

No


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## Jim37F (Sep 8, 2013)

Around here EMTs don't carry ASA, NTG, epi, or Pulse Oxs on BLS ambulances. (Not even blood sugar meters). 

The standing field treatment protocol for chest pain here, as far as oxygen goes, simply says give oxygen. Not give oxygen prn, or if SpO2 is XX, just give oxygen. So for an EMT-B here, this patient is supposed to be on O2 15LPM NRB since that's how we're trained. Although I suppose if you honestly don't think your patient needs high flow you could give 2L via nasal cannula and still be technically within protocol. 


However, that's a moot point as fire department ALS is dispatched to every call, whether cardiac arrest or stubbed toe, so unless you're doing an event standby and can see the ED entrance from where you are, the chances of a chest pain patient being transported BLS is slim to nill here.


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## Mariemt (Sep 8, 2013)

I have yet to give o2 for a cardiac call since their o2 has always been satisfactory for me. I always give ASA for suspected cardiac but that is protocol.  
Of course I can also run a strip and give nitro too. 

Only chest pain I have needed o2 for as of yet is after auscutating crackles. Pts had pneumonia.


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## Akulahawk (Sep 8, 2013)

If the BLS crew isn't allowed to give ASA (not in protocol/scope for them), then the patient won't get ASA by the EMTs. If the O2 protocol states give if <94% and the patient's SpO2 is 97%, the patient won't get O2. I've met many nurses that don't know there actually IS a difference between an EMT and a Paramedic... or they think that ASA is so basic that everyone can give it, when that may not actually be the case. 

I'm not faulting the nurses, it's just that they get about ZERO education about other providers, including EMS, as to what their scope of practice actually is.


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## DrParasite (Sep 8, 2013)

please allow a step by step resonse to your post





CobraIV said:


> I work in an ER and about 98% of the nurses hate basics. When a radio patch comes in for a medical patient the nurses always question why BLS?  In any event I bring up a scenario that happen while I was working in the ER.


ehhh, don't really care if the nurses hate basics.  I work in the field, and 98% of the basics and medics hate nurses.  For some reason, I don't see the nurses losing sleep over it, and I would hope your EMS aren't losing sleep over it either.  BTW, in my experience, most nurses barely know the difference between ALS and BLS, and if BLS gives a good report, they don't care.


CobraIV said:


> 911 call for 34 year old female with chest pain. Patient states pain on left side, in her chest, pain shoots down left arm. Patient has no allergies,  no meds besides over the counter sleepaids and no cardiac history. Patient had some discomfort before going to bed. Patient woke up to more pain and called 911. Patient is warm pink and dry. Blood pressure is 132/90. Pulse is 112 and her respirations are 20......


Based on the MPDS, this would be dispatched as an Alpha response, BLS only.


CobraIV said:


> Patient arrives to ER, the patient was able to give her full name and social security number. Patient was loaded off strecher to bed.


doesn't sound like the patient is in any distress...





CobraIV said:


> Now, the nurses had a problem with this picture. Besides it being late in the shift 4:40am, the crew had not placed oxygen on the patient nor was any asprin given. Now as an EMT myself I felt this was a good question since the chief complaint was chest pain. I was taught o2 was like chicken noodle soup when you had a cold(obviously not all patients are the same I know this) you were taught wrong; modern medicine says not everyone needs oxygen, despite what the EMT curriculum says I don't know if it was lazyness by the crew since it was early in the morning or bad judgement. This patient wasn't a "frequent flyer".  The crew left as fast as they came. The patients ekg came back normal sinus rhythm. Iv fluids were started.


normal ekg?  so I'm guessing the patient appeared not sick?  or at least not acutely sick and in need of emergent interventions?  yes, something changed, but at least initially the patient seemed to be in no distress





CobraIV said:


> Her blood pressure went up and another ekg was preformed revealing a stemi. The patient was ALS to a cath lab. I don't know what the end result was.
> My experiences are diffrent from one and others just curious to some other ones insight.


sounds like new oneset of an undiagnosed cardiac condition that even the receiving nurse didn't find until the BP spiked.

Not for nothing, but I have heard plenty of really good things about Boston EMS, as well as Boston EMTs.  I would imagine (and this is only a guess, no first hand knowledge) that being a busy urban system, they see a lot of patients, and know the difference between sick and not sick.

Patient's conditions change all the time.  If the patient was in N/S, a medic would have probably turfed it to BLS, esp with normal vitals.  Maybe this was just a freak thing?  a completely unanticipated event, and one no one could have predicted?

I'm sure your nurses have never given a report about a stable patient during shift change and the next shift they come in found the patient died or ended up needed surgery to fix something.


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## randomfire (Sep 8, 2013)

Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.


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## Akulahawk (Sep 8, 2013)

randomfire said:


> Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.


According to my drug book, it's onset time is between 5 and 30 minutes. I would imagine that it might be a bit faster if it's chewed and swallowed vs just swallowed. Also, the sooner you get it onboard, the sooner it takes effect. Waiting for it to be given at the ED just lengthens the time before administration. Remember, you're giving it for it's antiplatelet effects. You don't want the clot to become bigger.


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## chaz90 (Sep 8, 2013)

randomfire said:


> Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.



People are wrong. How long have you been in EMS that you've not once seen ASA administered for chest pain?


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## mycrofft (Sep 9, 2013)

Back to OP.

Many nurses hate other nurses, as well as techs. Many nurses see techs as a way to move patients (ambulance drivers) and chafe when they stop to stabilize before driving.

It's a cultural thing, and their boss ought to be aware. But he or she might be aware, and be part of that whole thing.

Booger it.


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## JPINFV (Sep 9, 2013)

rmabrey said:


> Yeah, but most EMT's still do it.




The standard of care (what the average person at that level/area does) should not be confused with evidenced based (what the evidence says should be done). 

Personally, I feel that "standard of care" should be a dirty word. I don't want to do what the average provider does. I want to do what the evidence says should be done.


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## JPINFV (Sep 9, 2013)

Halothane said:


> Is it possible that the EMT's in question simply didn't suspect a cardiac origin for the chest pain? Right or wrong, that would probably explain their actions.



When it comes to something like ASA, unless there's a blatantly obvious alternative (patient with PNA coughing up a lung, or taking a baseball bat to the chest), chest pain is cardiac until proven otherwise.


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## JPINFV (Sep 9, 2013)

Jim37F said:


> The standing field treatment protocol for chest pain here, as far as oxygen goes, simply says give oxygen. Not give oxygen prn, or if SpO2 is XX, just give oxygen. So for an EMT-B here, this patient is supposed to be on O2 15LPM NRB since that's how we're trained. Although I suppose if you honestly don't think your patient needs high flow you could give 2L via nasal cannula and still be technically within protocol.



Can I give the patient an FiO2 of 22% and still be compliant with the cookbook-ocol?


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## JPINFV (Sep 9, 2013)

randomfire said:


> Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.




Does it matter? I never got this train of thought. "Well, it won't take effect till after we get to the hospital, so we'll delay it taking effect by even longer because we'll let the hospital deal with it."


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## rmabrey (Sep 9, 2013)

JPINFV said:


> The standard of care (what the average person at that level/area does) should not be confused with evidenced based (what the evidence says should be done).
> 
> Personally, I feel that "standard of care" should be a dirty word. I don't want to do what the average provider does. I want to do what the evidence says should be done.



Im in agreement with you. My first post was based on the assumption that the EMT's would follow protocol. 

I personally, as an EMT have put exactly one patient on O2 in the last year. Only because I had a gut feeling she would complain and the report would get reviewed (she did and it did). 

As a student I reluctantly do it since most medics in my system follow cookbook - ocols, but I argue every time.


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## Carlos Danger (Sep 9, 2013)

JPINFV said:


> When it comes to something like ASA, unless there's a blatantly obvious alternative (patient with PNA coughing up a lung, or taking a baseball bat to the chest), chest pain is cardiac until proven otherwise.



Well, just because you and I and most of the rest of the folks on here know that, doesn't necessarily mean the EMT's in question knew that.

Perhaps the EMT's felt they had GOOD reason to suspect a non-cardiac origin; maybe the patient related an element of her history that didn't make its way to this discussion (i.e., maybe she DID take a baseball bat to the chest the day before). Or maybe the patient said something that led them to believe she had an aspirin hypersensitivity. Or maybe the patient told them that she didn't want to take any medicine. Or maybe you are wrong, and the EMT's were taught that in a young, healthy female, a cardiac origin for chest pain is so unlikely that it should be dismissed as a possibility.

I don't know - obviously I'm just speculating. But there had to be some reason the EMT's in question didn't administer ASA.


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## Christopher (Sep 9, 2013)

rmabrey said:


> There really isn't much excuse for not giving ASA or O2. There are  good reasons why that came in BLS. The main one being, hospital is closer than ALS care.



Aspirin is the only one of those two with any evidence to support its routine usage in chest pain.

The other one does not have support for routine usage.


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## Christopher (Sep 9, 2013)

Jim37F said:


> So for an EMT-B here, this patient is supposed to be on O2 15LPM NRB since that's how we're trained. Although I suppose if you honestly don't think your patient needs high flow you could give 2L via nasal cannula and still be technically within protocol.



Good news, many programs no longer teach this nonsense!


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## Christopher (Sep 9, 2013)

randomfire said:


> Does anyone know how long it takes for baby aspirin to start working? We carry it but I have literally never seen anyone give it because every station around is within a 10 minute drive of a cardiac center so people say there is no point.



A number of folks have already made this point, but I'm going to reiterate it because of how important it is...

I really loathe pharmaceutical companies and their studies, but Aspirin is one of the drugs which actually, sincerely, by all evidence known works. It also is cheap and readily available.

The only other pre-hospital intervention for acute coronary symptoms known to improve M&M is an early 12-Lead ECG with activation of a cath lab if indicated.

Aspirin, 12-Lead, and activation if indicated. That is _maximally aggressive_ chest pain therapy by known evidence.


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## Mariemt (Sep 9, 2013)

Many argue about basics doing 12 leads as they can not read them. I have picked up on some things but I feel the best benefit is sending it ahead to be read.  The ed can get a read on them before we get there.


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## patzyboi (Sep 9, 2013)

Like most basics here, I was taught to give O2 to almost every patient. 
But my instructors emphasized to treat the patient, not the number. If this patient did not have any trouble breathing, whether slight or severe, then they would not need O2. However, O2 may or may not help.


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## Tigger (Sep 9, 2013)

patzyboi said:


> Like most basics here, I was taught to give O2 to almost every patient.
> But my instructors emphasized to treat the patient, not the number. If this patient did not have any trouble breathing, whether slight or severe, then they would not need O2. *However, O2 may or may not help.*



What does the bolded part mean?


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## rmabrey (Sep 9, 2013)

Tigger said:


> What does the bolded part mean?



Probably referring to the infamous "O2 for pain" or "O2 calms people"


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## Tigger (Sep 9, 2013)

That's what I am guessing. However I am trying to give him the benefit of the doubt before we go down that road.


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## Hellsbells (Oct 15, 2013)

Its a bad idea to have emt b's obtaining 12 leads they cant read, as you cant have an ER physician walking up to the fax to read every 12 lead that is taken, at least not in a busy urban setting.


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## Medic Tim (Oct 15, 2013)

Hellsbells said:


> Its a bad idea to have emt b's obtaining 12 leads they cant read, as you cant have an ER physician walking up to the fax to read every 12 lead that is taken, at least not in a busy urban setting.



You can at least use it for trending and changes. Not all places can transmit either.


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## VFlutter (Oct 15, 2013)

Medic Tim said:


> You can at least use it for trending and changes. Not all places can transmit either.



+1, an initial prehospital EKG can expedite care regardless if it wasn't read until the patient arrived in the ER. It can mean to difference between a emergent cardiac cath and having the patient sit in the ER with an evolving MI.


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## Tigger (Oct 15, 2013)

Hellsbells said:


> Its a bad idea to have emt b's obtaining 12 leads they cant read, as you cant have an ER physician walking up to the fax to read every 12 lead that is taken, at least not in a busy urban setting.



Not every patient needs a 12 lead. I cannot imagine that a physician could not take the time to read 12 leads transmitted from crews with patients presenting ACS symptoms. Would there be a work increase? Yes absolutely, but I don't see it as something that can be overcome, especially by committed STEMI centers. 

On a somewhat related note, South Dakota recently finished implementing an AHA Mission: Lifeline grant that saw nearly every agency and non-PCI capable hospital receive cardiac monitors and the needed peripherals to transmit 12 leads. Many of these agencies are volunteer BLS with long transport times. Having med control say "yup it's a STEMI" gets the ball rolling at the receiving facility and also helps to properly utilize alternative transport means (fixed or rotor wing).


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## Christopher (Oct 15, 2013)

Hellsbells said:


> Its a bad idea to have emt b's obtaining 12 leads they cant read, as you cant have an ER physician walking up to the fax to read every 12 lead that is taken, at least not in a busy urban setting.



As mentioned, all of SD does EMT 12-Leads, and they do it well.

It is really only a _bad_ idea if you don't like appropriate destinations for patients. Or if you feel like waiting for the paramedics to arrive to have a 12-Lead acquired. If your service can't afford it, that is another story.

But why wouldn't you acquire 12-Leads at first medical contact? (rhetorical, because you should...and I'd rather not hijack this further)

And who cares if nobody overreads it immediately, especially in an urban setting where you've just made the door to ECG negative and transport times are short.


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## Jay (Nov 2, 2013)

rmabrey said:


> There really isn't much excuse for not giving ASA or O2. There are  good reasons why that came in BLS. The main one being, hospital is closer than ALS care.



Sad part here is that in Pennsylvania, basics are not aloud to give ASA. We can however give O2 and assist with Nitro if they have a valid Rx. The only "work around" with ASA is that we can "suggest" to the family of the PT that they should give it however we are banned from doing this ourselves.


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