Paramedic insight into wireless ECG transmission

[ohword3]

Hey guys,

First post here, so forgive me if I mess something up! Some background, I'm 20yo, junior (premed) undergraduate bio major at a state school, and I work for our schools health center as an EMT-B.

I'm in the process of writing a textbook chapter on the role of telemedicine in the AMI patient. Essentially, were looking at how effective wireless ECGs are at reducing the door-to-repurfusion times and hoping to not only analyze current methods, but also suggest directions for future growth/research. Technically, the chapter is methods of ECG acquisition and interpretation and the role of automatic vs. paramedic interpretation.

I'd love to hear from some of you that actually use this technology on a day-to-day basis (we don't use it at our health center). Feel free to throw in anything pertinent, but just some general questions to get you guys thinking:

1. Do you feel that its useful? Assuming yes, what exactly is beneficial about it?
2. Along with #1, do you think that it's necessary to have a trained cardiologist view the ECGs, or would you feel confident accurately interpreting them in the field?
3. Any recommendations to improve the efficiency of wireless ECGs? I'm sure working with this stuff on everyday you have some pet peeves about it.
4. Anything interesting, cool, insightful you'd like to share?

Thanks in advanced! Hopefully this can be an interesting discussion for others as well!

 

[RocketMedic]

1. It's super-awesome useful, I think.
2. I'd like to have a trained cardiologist available for ECGs that we don't know what to make of, but if resources are limited, I'll settle for someone who knows more than I do.
3. Three things- replace the Lifepack wheel with a keyboard, add a notes/context/label function to the transmission, and make the modems we use better.

 

[Handsome Robb]

I might get hated on for this but we don't transmit ECGs and have excellent door to balloon times, it's all on the medic to interpret the ECG and activate our STEMI protocol if warranted. We are consistently <60 minutes and have been hitting <30 minutes more and more now that we do field blood draws on STEMI activations when going to a specific facility. Hoping to get the rest of the hospitals in the area onboard with us drawing labs for them. Supposedly it's going to start happening on more than just STEMIs but we will see. Also added Metoprolol into our STEMI protocol with strict parameters for it's administration but that's an entirely different argument for an entirely different thread.

To make this semi-on topic, I'm not sure ECG transmission is the golden ticket to faster door-to-balloon times. I'm not saying I know what that ticket is but I would think better prep by EMS would definitely help. I'm talking stripped and in a gown or covered with a sheet/blanket, shaved if necessary, defib pads in place if your pads are the same that the ER uses (any patient going to cath gets defib pads placed anterior/posterior not sure if that's the standard but I would assume so, bilateral lines, serial 12-leads including a current one (as you are arriving at the ER, they are going to do their own anyways but I know the cardiologists here love it when we have a serial 12s with a "current" one as well) and labs drawn (we do a rainbow plus an extra purple top).

For what it's worth it isn't uncommon for us to meet a cardiologist at the door, they look at our 12-leads, if they are clean and not the junk a lot of crews bring in, confirm STEMI, then we go straight to the lab completely bypassing the ER. Happens more during the day since everyone's on campus, at night we generally end up stopped in the ER.

I do agree with Rocket about being able to get a consult on those rhythms that you just don't know what to make of it rather than having to describe it to the MD on the phone or radio.

Like I said, I've never transmitted but we do sync our monitors (Philips MRx) with our ePCRs to electronically attach 4s and 12s to our chart. It's pretty dang easy to do, I'm assuming transmitting to the ER would be similar.

When it comes to automatic interpretation it's poor at best in my experience. When it prints I tear it off and fold over the interpretation and read the ECG myself then glance at the machine's thoughts to see if it potentially caught something I didn't (or to catch a laugh at whatever random garbage it throws out there) and also to look at measurements. The numbers are accurate as far as PRI, QRSd, QTc and axis, the interpretation on the other hand not so much.

Sorry for the novel, and I'm not really sure if I helped either...

 

[Outbac1]

We connect our LP12 to our tablet and send to the closest Reg. Hosp. We can also connect direct to the phone jack in the pts house and fax it that way as well. The on duty Dr confirms or not, and tells us to go ahead with TNK or not. We make the initial dx, call the hosp and speak to the Dr. If we can be at the only cath hosp in under 60 min we will do the same, no TNK, and go straight to the lab.
Overall it works pretty good. My co-workers have done two this week. Nevers rains but it pours.

 

[VFlutter]

Our area EMS transmit EKGs which I believe are interpreted by the EM physician who then consults cardiology after activating the cath lab. I will get a copy of our official data but our door to balloon time is usually sub 30mins.

 

[Christopher]

Hey guys,

First post here, so forgive me if I mess something up! Some background, I'm 20yo, junior (premed) undergraduate bio major at a state school, and I work for our schools health center as an EMT-B.

I'm in the process of writing a textbook chapter on the role of telemedicine in the AMI patient. Essentially, were looking at how effective wireless ECGs are at reducing the door-to-repurfusion times and hoping to not only analyze current methods, but also suggest directions for future growth/research. Technically, the chapter is methods of ECG acquisition and interpretation and the role of automatic vs. paramedic interpretation.

If you'd like to get a really good answer, you should talk to the South Dakota Mission Lifeline folks. They have an entire State onboard with this. If you PM me I can see about helping you get in touch with somebody from there.

I'd love to hear from some of you that actually use this technology on a day-to-day basis (we don't use it at our health center). Feel free to throw in anything pertinent, but just some general questions to get you guys thinking:

1. Do you feel that its useful? Assuming yes, what exactly is beneficial about it?

I love it on our monitors...but we don't send it to the hospital. We send it back to the station so we can attach a clean copy without scanning ECG strips.

2. Along with #1, do you think that it's necessary to have a trained cardiologist view the ECGs, or would you feel confident accurately interpreting them in the field?

I work in an area where paramedics activate the cath lab with a high accuracy, since probably 2008 (maybe 2009?). In fact, the entire State of North Carolina has a really high accuracy with EMS activation. The answer is clearly No a cardiologist overread is not required, and Yes we feel confident accurately interpreting them in the field.

3. Any recommendations to improve the efficiency of wireless ECGs? I'm sure working with this stuff on everyday you have some pet peeves about it.

It needs to be FREE. Free to send, free to receive. I shouldn't have to pay a $0.10 to send any data from a cardiac monitor these days. This is 2013, the internet has been around for far too long; wireless has been around for far too long.

4. Anything interesting, cool, insightful you'd like to share?

If you have any technical questions feel free to ask. I'm a software engineer by trade and have been involved in nearly every aspect of architecture design (networking, hardware, software, databases, etc). Most of these chapters I've read have had problems with technical correctness when it comes to the computer systems

 

[medicdan]

I hate to burst your bubble, OP, but a device already exists that allows for the capture and immediate transmission of an EKG, ostensibly by first responders or a BLS unit.
http://www.physio-control.com/ProductDetails.aspx?id=2147484996

There's an interesting discussion of EKG capture by BLS providers on KevinMD.com
http://www.kevinmd.com/blog/2013/01/allowing-emts-perform-ecg-controversial.html

 

[ohword3]

I hate to burst your bubble, OP, but a device already exists that allows for the capture and immediate transmission of an EKG, ostensibly by first responders or a BLS unit.

There's an interesting discussion of EKG capture by BLS providers on KevinMD.com

Thanks for the great replies guys! I'm on my phone now, I will post a more detailed response when I get a chance, but I just wanted to clarify. The mentor I work with is actually a cardiologist that works at a hospital which uses one of these devices. He's already written on the topic (I can pm you a link to a few of his articles if you'd like to check them out), but I'm just getting my feet wet with it all. I'm not looking to "invent" a device, I'm just trying to understand the current system so I can generate a thorough analysis; the suggestions are secondary to an accurate assessment, if that makes sense?

Thank you for the info though! I will certainly look into it when I get a moment.

 

[Aidey]

I'm confused. Your topic sounds like something that needs to be the subject of a research paper, not a chapter in a text book. Electronic transmission warrants mention, but why dedicate a chapter to it if you don't have strong research behind it?

 

[Christopher]

I'm confused. Your topic sounds like something that needs to be the subject of a research paper, not a chapter in a text book. Electronic transmission warrants mention, but why dedicate a chapter to it if you don't have strong research behind it?

I too thought this was strange...but you know, using the Internet means things are new and exciting. Why this isn't ubiquitous now is mind boggling.

 

[RocketMedic]

I also like it for refusals. I recently had a patient with vague complaints of chest pain associated with nausea/vomiting, probably linked to muscular activity. She had some hyper-acute T-waves in V3/V4, but an otherwise-clean ECG, and didn't want to go (really nice nursing home, good staff and a workable treatment plan in place for her flu). Our system requires geriatric supervisior consult if they refuse care, and I found it far easier to convince the FOS to use my assessment when I could include "and the ER doc at Southwest said it's a completely normal ECG in-context and that she probably isn't having an MI".

 

[ohword3]

I'm confused. Your topic sounds like something that needs to be the subject of a research paper, not a chapter in a text book. Electronic transmission warrants mention, but why dedicate a chapter to it if you don't have strong research behind it?

I too thought this was strange...but you know, using the Internet means things are new and exciting. Why this isn't ubiquitous now is mind boggling.

The book is on cardiovascular diseases, but this specific volume is prehospital management of the acute infarction patient. The various chapters touch on the importance of prehospital management, prehospital cpr in stemi, prehospital thrombolysis or transfer to primary pci center, regional approaches to prehospital management, etc. (Does that description help at all?)

We were asked to focus on the methods of ecg acquisition/interpretation, role of automatic vs paramedic interpretation, and telemedicine. Were also writing another chapter on novel techniques. Essentially, my mentor wants our focus to be on the three steps: 1. Machine 2. Paramedic 3. Physician. Theres plenty of aspects to talk about for each, I just wanted to make sure I understood telemedicine from the "on-the-ground" user's perspective.

 

[Christopher]

The book is on cardiovascular diseases, but this specific volume is prehospital management of the acute infarction patient. The various chapters touch on the importance of prehospital management, prehospital cpr in stemi, prehospital thrombolysis or transfer to primary pci center, regional approaches to prehospital management, etc. (Does that description help at all?)

We were asked to focus on the methods of ecg acquisition/interpretation, role of automatic vs paramedic interpretation, and telemedicine. Were also writing another chapter on novel techniques. Essentially, my mentor wants our focus to be on the three steps: 1. Machine 2. Paramedic 3. Physician. Theres plenty of aspects to talk about for each, I just wanted to make sure I understood telemedicine from the "on-the-ground" user's perspective.

I highly recommend looking at the RACE program for insight into regional approaches.

We're benchmarked on acquiring an ECG within 10 minutes of first medical contact and providing a STEMI alert as soon as possible after that ECG. We've gotten into the habit of doing it in the living room or while walking to the truck if others are packaging the patient.

Requirement to use machine interpretation is a symptom of a disease, to put it into medical terms. The disease is inconsistent human interpretation and the addition of a rule-based computer provides some consistency into the mix. As an added bonus, there is zero cost in using it if you already have 12-Leads in the field. Education requires an expense, so most systems with interp have decided to forgo it. Machine interp is a bridge to a better system, but is not a functioning system.

 

[ohword3]

I highly recommend looking at the RACE program for insight into regional approaches.

We're benchmarked on acquiring an ECG within 10 minutes of first medical contact and providing a STEMI alert as soon as possible after that ECG. We've gotten into the habit of doing it in the living room or while walking to the truck if others are packaging the patient.

Requirement to use machine interpretation is a symptom of a disease, to put it into medical terms. The disease is inconsistent human interpretation and the addition of a rule-based computer provides some consistency into the mix. As an added bonus, there is zero cost in using it if you already have 12-Leads in the field. Education requires an expense, so most systems with interp have decided to forgo it. Machine interp is a bridge to a better system, but is not a functioning system.

Thanks for the solid advice! The RACE program came highly recommended from my mentor, as well as the Mission Lifeline and the Denmark experiment (excellent cellular signals + a cardiologist on every bus)- does anyone have a little more information on the Denmark one, perhaps a link to either for some further reading?

Also, does anyone know of a place to start with the literature on this one? Information is nice, but I need some solid sources to pull from. I think our introduction is going to stem around the government mandates for reperfusion time - I'm totally lost on that one haha. Anyone have more experience with that side of it?

 

[Christopher]

Thanks for the solid advice! The RACE program came highly recommended from my mentor, as well as the Mission Lifeline and the Denmark experiment (excellent cellular signals + a cardiologist on every bus)- does anyone have a little more information on the Denmark one, perhaps a link to either for some further reading?

Also, does anyone know of a place to start with the literature on this one? Information is nice, but I need some solid sources to pull from. I think our introduction is going to stem around the government mandates for reperfusion time - I'm totally lost on that one haha. Anyone have more experience with that side of it?

Jollis JG, et al. Implementation of a statewide system for coronary reperfusion for ST-segment elevation myocardial infarction. (2007)

Garvey JL, et al. Rates of Cardiac Catheterization Cancelation for ST Elevation Myocardial Infarction after Activation by Emergency Medical Services or Emergency Physicians: Results from the North Carolina Catheterization Laboratory Activation Registry (CLAR).

Jollis JG, et al. Expansion of a regional ST-segment-evelation myocardial infarction system to an entire state.

Munoz D, et al. Transport time and care processes for patients transferred with ST-segment-elevation myocardial infarction: the reperfusion in acute myocardial infarction in Carolina emergency rooms experience.

Glickman SW, et al. Care processes associated with quicker door-in-door-out times for patients with ST-elevation-myocardial infarction requiring transfer: results from a statewide regionalization program.

Jollis JG. Reperfusion of acute myocardial infarction in North Carolina emergency departments (RACE): study design.

Jollis JG. Systems of care for ST-segment-elevation myocardial infarction: a report From the American Heart Association's Mission: Lifeline.

These should get you started on RACE.

 

[ohword3]

These should get you started on RACE.

Thank you! I'm not sure how long it took you to compile all of those links, but regardless I really appreciate it. It'll probably take me a day or two to get through all those with the amount of school work I have, but I will certainly come back and let you know how it went!

 

[downunderwunda]

There is plenty of research on this subject.

The research indicates that on average patients having a STEMI with onset times within 4 hours are in the cath lab 2-3 hours faster, ballooned & stented faster with better outcomes.

Evidence based practice. I encourage you to consider pre hospital treatment of chest pain 30 years ago. It was in essence DRIVE FAST. Until more recent times the treatment evolved to ASA (aspirin) a nitrate, either a spray or sublingual tablet, morphine & urgent transport.

Today, the EVIDENCE says start the above, straight to cath lab. The next generation of this, & there are some places already doing it as well as some with trials happening, pre hospital thrombolyasis.

Evidence based practice. That's what it's all about.