BLS Services and 12 Lead Defibs

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Luv2rsq

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Just wondering what BLS services out there are using 12 leads and what the pros/cons are. I am a member of a BLS Service in rural Wisconsin. Some of the members on the service would like to look into purchasing one. Because we are a rural service our funds are limited- just looking for input as to how valuable this would be to our patients. There is some concern about transmission to our recieving hospitals as well as delay in transportation time. Thanks in advance for your opinions/advice!
 
IF you're a very rural service there is no reason you should be playing on scene really. My minimum transport time out here is 20 minutes and I do damned near everything while we're moving. To be honest, talk to your local hospitals and your medical director and find out what they think of you having 12 lead capability. A monkey can be taught how to place a 12 lead correctly, but the auto interpret is not always accurate, and unless all you plan on doing is transmitting it to your receiving facility, I'm not sure what benefit it would give.
 
TransportJockey said:
IF you're a very rural service there is no reason you should be playing on scene really. My minimum transport time out here is 20 minutes and I do damned near everything while we're moving. To be honest, talk to your local hospitals and your medical director and find out what they think of you having 12 lead capability. A monkey can be taught how to place a 12 lead correctly, but the auto interpret is not always accurate, and unless all you plan on doing is transmitting it to your receiving facility, I'm not sure what benefit it would give.
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I agree with most of what you have said here, but I would say that the algorithms in our monitors these days actually provide very good interpretations generally. Of course they aren't perfect, but neither are the cardiologists or emerg docs! Here is a recent study that may be of interest: http://www.ajconline.org/article/S0002-9149(10)01618-8/abstract
 
As useful as 12 leads are, for BLS to be using them, about the only utility they'd add is to "fax" the strip to the receiving facility. They'd add zero to your on-scene decision-making and unless the crews are proficient in electrode placement, they could very easily result in extending on-scene times unnecessarily. In my County, we do not base treatment decisions on the 12-lead, but the 12-lead can alter our destination decision.
 
Luv2rsq said:
Just wondering what BLS services out there are using 12 leads and what the pros/cons are. I am a member of a BLS Service in rural Wisconsin. Some of the members on the service would like to look into purchasing one. Because we are a rural service our funds are limited- just looking for input as to how valuable this would be to our patients. There is some concern about transmission to our recieving hospitals as well as delay in transportation time. Thanks in advance for your opinions/advice!
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Just curious, what county?
 
Why do you feel you need a 12 lead?


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We're a hybrid BLS/ALS service so a BLS providers can do a 12 lead but it makes no difference in their treatments or destination. Our nearest cath lab is 2 hours away. When used in concert with our cardiac trop tests we will transport direct to the cath lab if we have positive trops and suspected NSTEMI. Otherwise everyone else goes directly to our local hospital for further investigation prior to continuing on to the CCU.
 
BEorP said:
I agree with most of what you have said here, but I would say that the algorithms in our monitors these days actually provide very good interpretations generally. Of course they aren't perfect, but neither are the cardiologists or emerg docs! Here is a recent study that may be of interest: http://www.ajconline.org/article/S0002-9149(10)01618-8/abstract
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The 12 lead interpretation algorithms on most modern cardiac monitors are specific but not particularly sensitive. Which is why you should be able to interpret your own 12 leads and not go solely off what the machine says.
 
usalsfyre said:
The 12 lead interpretation algorithms on most modern cardiac monitors are specific but not particularly sensitive. Which is why you should be able to interpret your own 12 leads and not go solely off what the machine says.
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They wouldn't be usable for a BLS crew around here for determining STEMI or other infarct, because the hospitals won't activate the cath lab without elevation and reciprocal depression, so the LP15s at least will yell STEMI for a lot of things that aren't, and some that might be but won't get a cath anyways.
 
usalsfyre said:
The 12 lead interpretation algorithms on most modern cardiac monitors are specific but not particularly sensitive. Which is why you should be able to interpret your own 12 leads and not go solely off what the machine says.
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Fair point... sensitivity for the LP15 would be 78% compared to 85% for the cardiologist in that study I cited. The thing I have trouble wrapping my head around is how much training paramedics will need to be able to do 12 lead interpretation anywhere near as good as the cardiologist (which they would need to get pretty close to to be better than the algorithm).

I guess I am saying that I agree with what you're saying in principle, but surely this will take significant training resources when we're essentially trying to bring paramedics up towards cardiologist interpretation when they spent many years learning this type of stuff.

I'm sure there are many people on this forum who can give examples of times they identified a STEMI that the monitor (or even doctor) didn't, but we also need to remember that we're not representative of the profession as a whole.
 
Luv2rsq said:
Just wondering what BLS services out there are using 12 leads and what the pros/cons are. I am a member of a BLS Service in rural Wisconsin. Some of the members on the service would like to look into purchasing one. Because we are a rural service our funds are limited- just looking for input as to how valuable this would be to our patients. There is some concern about transmission to our recieving hospitals as well as delay in transportation time. Thanks in advance for your opinions/advice!
Click to expand...

I don't personally know of any BLS services doing 12 leads, but, I believe there are some in North Carolina that do it, though I am not completely sure.

I'd say that the use of 12 leads depends on the capabilities of the system in which you work. If you are in a tiered system then it could allow for a 12 lead to be performed while ALS is enroute. It could also be used on patients with vague, possible cardiac complaints that normally wouldn't warrant an initial ALS response (mild dyspnea, epigastric pain, pleuritic type chest pain, weakness/fatigue, etc.). If there is no ALS, then surely the 12 lead could be used to notify the receiving hospital and allow them to mobilize staff to manage the patients (PCI or thrombolysis or rapid transport to a more appropraite hospital).

I do not think it would significantly extend scene times. It takes a couple minutes to do and I do not think that is a big deal whether for ALS or BLS. I do think you should only perform 12 leads if you can transmit to a hospital for interpretation. As others have pointed out the computer algorhythms tend to be quite specific, but lack in sensitivity of STEMIs. My personal experience has been that if it says "Acute MI suspected", its usually right. However, I have caught a few that did not get such an interpretation from the computer that I interpreted as an acute MI. (I can say that every time I caught it, I was right; however, that doesn't mean I caught every one.)

Anyhow, even for ALS, 12 leads are best employed as part of STEMI "system" in order to have the best impact. To perform the 12 lead in and of itself doesn't help the patient - it is the response of EMTs all the way to the cardiologists that matters.

So, ultimately, if you (BLS) can't transmit, you're wasting your time and money. Or, if you can and the receiving hospital doesn't act on it, then, again, you are wasting your time and money.

...my 2 cents
 
It all depends on your service area

Working in a heavily metropolitan area, 12 Leads would be invaluable. I may be 1 mile from the nearest hospital but 10 miles from the nearest STEMI center / PCI Hospital. Now, according to local protocols this doesn't matter for me as a BLS provider, but for a critically thinking person, it would be the difference of requesting ALS response or transporting a patient with a STEMI to a hospital not equipped to handle the situation. But what's your service area? If, for example, you have only two hospitals in a 100 mile radius and both of them are STEMI centers, what difference would a 12-Lead make? The two minutes it takes the ED staff to place a 12 Lead? Furthermore, what does your protocol state? Even if you know it's a STEMI, can you (as a BLS provider) take a patient to a further away hospital with the intent of transporting to a STEMI center? I know I'm focusing on STEMI a lot and 12 Leads yield much more information, but from a BLS perspective it seems like STEMI identification would be the only true benefit to the patient as far as interventions are concerned. Seriously though, it's all up to Medical Direction.
 
We don't have any BLS units, but if one were staffed up, the LPs would most likely be programmed for AED mode, ALS can override it with a code.

We teach our BLS folks to attach 12 leads to assist the ALS crews, and it works out good. But the chances of having a solo BLS crew on scene for any length of time would be slim to none, so their skills would be better spent doing good pt assessment, initial treatment and so forth.
 
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