12-leads

[nsom9ac]

Hello all, i'm a new medic and work full time for a private and part time for a primary response district with 10-15 minute transport times to the closest facility. Many of the veteran medics at the primary response district seem to be overly eager to do 12-lead ekg's on patients. We don't carry thrombolytics and the hospitals around here don't care to see our strips if we do run a 12-lead. My thought is that if the patient has s&s that would suggest MI I would do a 12-lead enroute if time allows, otherwise I won't worry about it. I've had different medics tell me to run one on abd pain patients (once in nsr once in sinus tach). The only benefit I can see is that it would allow us to notify the cath lab prior to our arrival. I would like to hear what some of you might think of this and how often you run 12-leads.

 

[reaper]

You always need to run a 12 lead on pt's with S&S of a MI, not just if time allows. How are you gonna know what type of MI they are having, without one? Remember that a 3 lead only tells you rate and rhythm, Not much else.

I preform one on anyone I think needs one. You may find a problem that no one else has. It does not hurt to run one and is just lazy, not to.

Listen to the veterans, they will teach you a lot. Don't be a new medic that thinks they know more, then the guy that has been doing it for 20 years.

I also do a BGL on almost all my pt's. You just never know if someone is diabetic and has not been diagnosed yet!

 

[Ridryder911]

Old dogs are hard to train. Unfortunately; when attempting to discuss the need of twelve lead many do not understand. When, I approached my Director of the reason why, we were not using twelve leads (upon my employment) I received the usual responses.. " There will be no difference in treatment, costs will go up, it will increase scene time, etc. ".....

I rebutted several times with literature and facts, as well as references from AHA national standard of care. It took me time and finally comparisons of those that with simple leads, and those with a XII lead. Amazing, the difference one can see! I finally added to my final comment to him after an lengthy and heated discussion, I concluded with ...." I will no longer, the need. If you really understood cardiac care, we would not have this discussion"

After presenting a case of a 23 year old EMT student that was "shrugged off" as atypical chest pain, with the simple leads revealed no indications, no PMHX, etc. then upon arrival a XII lead revealed "tombstone" ST segment, with thrombo's administered to him immediately. I had a geriatric NH patient, that the nursing staff presumed was pneumonia & adm. Tylenol (low grade fever, crackles, diaphoresis), otherwise asymptomatic- monitoring leads SR, XII lead ischemia in inferior and septal wall involvement... he had a silent AMI.. hence the low grade temp, diaphoresis. Something, one would not seen on simple leads. Yes, it can convince many. As well, immediately changed my DX., and treatment

It still is a hard habit for many.... maybe, because I have always either changed leads (multi) using even simple lead format, or my experience in CCU and understanding that not performing a twelve lead is being negligent.

As renown author and EMS cardiac instructor Bob Page describes.."those that view in three... do not see; and in Lead II; you have no clue!"....

Twelve leads should be performed in any potential or related cardiac emergency. I personally perform them on all COPD, diabetic emergencies (remember diabetics have no to different symptoms), CVA, chest wall trauma, etc. It only takes a few seconds to perform... why would one not to really assess their patient? Again, only looking in simple leads or monitoring, you are only seeing a small portion, and actually half-arsing it!

If they usually need to be monitored, then they usually need a XII lead. Now, use some common sense associated with this.. like every thing else, nothing is black & white.

I cannot tell how many missed AMI's, ischemia that occur because no one takes the time and REALLY assess their patient.

Show me a person that does not want to perform XII leads, and I will show you one that is ignorant in cardiac care, treatment and knowledge. Treatments can change with findings (No NTG in inferior or right wall involvement). With accurate assessment and interpretation, physicians will start listening, but it has to be accurate and consistent, not a hit and miss. I know, when I call in with an significant ECG, I am taken very seriously, and treatment is totally different, from those that did not.

R/r 911

 

[nsom9ac]

I want to thank you r/r 911 for your reply with extra knowledge and thoughts on the subject as opposed to someone merely telling me that i'm being a new medic that thinks I know more than someone who has been doing it for 20 years, as so many on these forums are so eager to do. If that were the case I wouldn't be searching for others expert opinions on the subject. In my original post I don't think I was as clear as I could have been due to attempting to keep it brief. I do agree with running a 12-lead on patients complaining of chest pain, I was really more referring to other reasons for running one. Such as anyone with any type of abd pain. Not epigastric but lower quad tenderness with diarrhea for example. I can say with some degree of certainty that I am one of few from my medic class that read the texts enough to know about not giving ntg in inferior and right wall involvement, so yes most anyone with chest pain I will run a 12-lead on. Like you said it's not always black and white i realize. I never thought about it that way with diabetic emergencies but I see the reasoning. Why for CVA? I never saw that during my internship and I did see several CVA patients. The other thing is that during my program we did not go over 12-leads much at all, infact only one evening did we even talk about interpretation. However I did take the extra time to completely read through the 12-lead book and feel I could determine what type of MI it is. In addition, as soon as I can I do plan on getting into a 12-lead class. Thank you again for your insights on this as I know that I don't know it all and am just looking to improve my knowledge base.

 

[reaper]

I said it the way I did due to what you wrote!

Hello all, i'm a new medic and work full time for a private and part time for a primary response district with 10-15 minute transport times to the closest facility. Many of the veteran medics at the primary response district seem to be overly eager to do 12-lead ekg's on patients.

I would never consider doing to many 12 leads overly eager. Be happy that the older medics are doing them at all. Most don't like technology.

We don't carry thrombolytics and the hospitals around here don't care to see our strips if we do run a 12-lead.

Don't worry about what the hospitals do with them. You do your job right, then you know that you did all you could for your pt.

My thought is that if the patient has s&s that would suggest MI I would do a 12-lead enroute if time allows, otherwise I won't worry about it.

You stated "if time allows, otherwise I won't worry about it". As I stated before. All S&S pt's of MI should have a 12 lead preformed on them.

I've had different medics tell me to run one on abd pain patients (once in nsr once in sinus tach). The only benefit I can see is that it would allow us to notify the cath lab prior to our arrival.

That is a major reason to do a 12 lead. To notify the cath lab. That is why a lot of systems are doing code STEMI's. It does save lifes.

I would like to hear what some of you might think of this and how often you run 12-leads.

If this is not what you meant to say, then I apologize. I was just responding to what you wrote.

 

[Ridryder911]

I agree, the part of about diarrhea, but remember again not all is black & white.. i.e. electrolyte imbalance, induced hyperkalemia etc. For example, the CVA can be caused by an arrhythmia (A-fib) throwing a clot, as well multi-fragments again may be either producing or released causing potential problems.

Even in traumatic patients such as chest wall injuries, one may want to be sure there is not gross enlargement related to pericarditis.

Attempt to think of it this way, it is another tool to help aid in your diagnosis skills. Thus allowing you to possible see another view to rule out, or possibly to consider a differential diagnosis. All this for a few more seconds.

You will find by learning more and more ECG (particularly XII lead) you can find out a lot about a patient.

For example; I had a slurred Q-T segment (indicative of Dig tox) on a bradycardiac patient with a Hx. of syncopal episode. Thus, treatment may be altered from the regular treatment, since the culprit could be Beta Blocker induced. Something, that the "usual Paramedic" may not look at, but; something the physician agreed was important in finding the cause, then treat the effect.

I highly suggest purchasing Bob Page's ECG book. Not, only will it help you understand the reason for knowing in the prehospital arena, but re-enforce and go into great detail of XII lead interpretation. It is written by a Paramedic for a Paramedic, but not watered down nor over the head of most. Very simplistic and to the fact, with plenty of practice portions. Very, reasonable price too. Definitely, will teach you interpretation skills in a short period of time.

http://astore.amazon.com/medical-bookstore-20/detail/013022460X

You may find one at a more reasonable price, somewhere else. As well, if you get a chance to attend one of his courses or conferences, I highly recommend this motivated educator.

The other book of course, is the ECG bible of medicine. Dubin's ECG interpretation. http://www.emergencyekg.com/ Which every Paramedic should have read and keep as a reference.

Again, from an "old dog"; try to keep an open mind and realize everyone (including myself) learns something new every day. This is what makes this job interesting, similar to an investigation. The more I learn, the more I learn how stupid I am, but attempt to apply to my clinical practice
to make more aware what is going on with my patient and potential treatment modalities.

Good luck!
R/r 911

 

[nsom9ac]

I said it the way I did due to what you wrote!



If this is not what you meant to say, then I apologize. I was just responding to what you wrote.

I appologize for that. Reading back over it, I didn't quite say my original post as I meant. Many of the veterans in the district are pretty new with several (including the ones I was referring to) having around 5 years as a medic. So they're not really so much old school as in some areas. However, the one partner I had that seemed overly eager with 12-leads would run it and not really be able to interpret it, so then basically it was wasted time. I felt he was doing it just because it's cool medic toys. I have a somewhat different view after hearing some things that you and rid have said, which is really why I turned to this forum to hear more expert opinions. Thank you and sorry about the crappy original post.

 

[reaper]

No problem.

Yes, if the medic can't read it, then he has no reason to do it. He is probably one that only looks at what the monitor interprets the rhythm as. The monitor can be right sometimes, but they are more often wrong!

 

[Guardian]

Hello all, i'm a new medic and work full time for a private and part time for a primary response district with 10-15 minute transport times to the closest facility. Many of the veteran medics at the primary response district seem to be overly eager to do 12-lead ekg's on patients. We don't carry thrombolytics and the hospitals around here don't care to see our strips if we do run a 12-lead. My thought is that if the patient has s&s that would suggest MI I would do a 12-lead enroute if time allows, otherwise I won't worry about it. I've had different medics tell me to run one on abd pain patients (once in nsr once in sinus tach). The only benefit I can see is that it would allow us to notify the cath lab prior to our arrival. I would like to hear what some of you might think of this and how often you run 12-leads.

If done right, twelve leads can cut the time from 911 to cath lab or other definitive treatment. That's the bottom line. That's what makes it all worth it. With technology the way it is, emt-basics can be trained to put on the pads and read the machine's surprisingly accurate diagnosis. Am I advocating a decrease in paramedic education, NO!, but I point this out to re-enforce that there is absolutely no excuse not to do twelve leads. I think once you learn more about them, this will be obvious.

 

[medic755]

From one newer medic to another: GET THE DUBINS BOOK. I've had it for two years now, and when I was doing clinicals at our trauma/teaching center, I ended up explaining 12-Leads to medical students, and was able to keep up with residents and attending MD's. Read it, practice it, read it again, learn it, love it, UNDERSTAND IT (and then read it again). The only downfall of the book is that it doesn't have as many examples as I would have liked (and thus leading me to purchase Page's ECG's....thanks Rid)

Now that I'm off my soapbox, remember when you did clinicals in the ED, how often did the attending want 12-Leads? That is how we should be doing them. Classic CP, atypical CP with relevant history, ANY CP, dyspnea, brady/tachydysrhythmias, hypo/hypertension, syncope, near syncope, dizzyness, diaphoresis, weakness, palpitations. And that is just off the top of my head. I too came from a program that spent roughly 90 minutes through the entire program on twelve leads - but this is something I've taken it upon myself to focus on.

Learn not to rely on the print out, or computer diagnosis, and get as much practice as you can. Urge your employers/med directors/REMAC to develop standards for STEMI and direct cath lab transport

Besides, it may take awhile, but how will you get more respect: telling the doc that you have a pt with CP or that you have a STEMI patient with septal-anterior involvement?

 

[nsom9ac]

well after this discussion i went out and bought the bob page 12 lead book. i'm not finished with it yet, but what i have learned so far has brought my level of understanding and interpretation up to point where i understand the importance of 12 leads and i'm not afraid of running one. previously all i could read was patterns of depression or elevation. now i feel very confident with axis deviation, hemiblocks, and bundle branch blocks and what these things mean in terms of clinical condition of the patient.

one thing that does confuse me somewhat however is the topic on diagnosing v tach. i get the criteria that is taught for what constitutes vt such as erad + positive v1 or any negative v6 complex, etc.

correct me if i'm wrong, but the way i understand it is that just because the complex is wide does not necessarily mean it's vtach which is why you have to use these criteria to know for sure. it just goes against what i've been taught previously that anything wide is ventricular in origin.

also at the end of the month i'm attending a 12 lead class so i can hash out other questions i have there too.

 

[MSDeltaFlt]

<correct me if i'm wrong, but the way i understand it is that just because the complex is wide does not necessarily mean it's vtach which is why you have to use these criteria to know for sure. it just goes against what i've been taught previously that anything wide is ventricular in origin. >


You are absoutely right. You need to use all of the criteria so you won't mistake an abarent conduction for V-Tach. Lead II has an accuracy rate of about 34%. That means it's wrong 66% of the time.

 

[medic3]

In Calgary, Canada we're doing 12 leads, then if we're diagnosing it as a STEMI, we are transmitting our 12 lead via cell phone or land line (hooked up to our LP12) and sending the 12 leads to the hospital. While enroute we patch to a ER doctor, and if they agree it's a STEMI, they will make the arrangements for us to bypass the ER completely and go directly to the Cath lab. According to our medical director our stats for diagnosis of STEMI's are very high and the cardiologists are very happy with the protocol.

 

[Ridryder911]

all [/b] of the criteria so you won't mistake an abarent conduction for V-Tach. Lead II has an accuracy rate of about 34%. That means it's wrong 66% of the time.

Absolutely... Glad to see nsom9ac that you purchased Bob's book. I believe the more you will read and review the strips in the book, the more easier it will be for you. Look at recommended web sites that have been mentioned and test yourself. I believe you will be surprised on how much you have comprehended.

R/r 911