Tell me a time a 12-lead actually mattered for you....

[ExpatMedic]

Everyone loves telling war stories, so with that said, I'd like to hear some calls you've ran where a 12-lead actually made any difference in your patient care. If you have the actual strip to post, that'd be great.

 

[VentMedic]

Just one time? Actually made a difference? War story? Are you kidding?

A 12-lead is an invaluable tool and it is a shame not all EMS agencies have that capability or know what to do with it if they do have it.

 

[EMSLaw]

Wouldn't it make a difference any time there was a patient with an MI?

 

[reaper]

Countless times that you are called for a minor problem and revel major ones, just by doing a 12 lead.

I will preform a 12 lead on lots of Pt's that may not normally call for one. just out of gut feeling, that something else is going on.

The expense of a few electrodes is worth a Pt's health.

 

[TomB]

In no particular order:

* Within a regionalized system of care, identifying acute STEMI in the prehospital setting allows paramedics to bypass the local non-PCI hospital so the patient can receive primary PCI.

* Even when bypass is not an issue, early notification allows the cath team to be called in from home during off hours (nights, weekend, holidays). That parallel processing leads to significant time savings which translates into decreased mortality.

* A prehospital 12-lead ECG taken with the first set of vital signs establishes a baseline so that changes can be identified with serially obtained ECGs. These changes in QRS/ST/T morphology suggest the dyanamic supply vs. demand characteristics of ACS, which can help establish the diagnosis of acute STEMI in the presence of confounders like LBBB and paced rhythm.

* Sometimes MONA "cleans up" a 12-lead ECG, leaving the prehospital 12-lead ECG as the only evidence that the patient was in fact experiencing cardiac-ischemic chest discomfort. This could prevent inappropriate early discharge from the hospital.

* 12-lead ECGs can be instrumental in the differential diagnosis of arrhythmias, and especially tachycardias. Capturing the rhythm in 12-leads is essentially a "fingerprint" of the arrhythmia which can be useful to the cardiologist after the arrhythmia breaks (or is successfully converted by the paramedic).

* 12-lead ECGs can help identify certain drug overdoses or electrolyte derangements, which might change treatment decisions. For example, sodium bicarb for TCA overdose or calcium gluconate for hyperkalemia.

* Oftentimes syncope patients don't want to be transported to the hospital. A careful screening that includes a 12-lead ECG allows the paramedic to look for signs of long QT syndrome, Brugada's syndrome, hypertrophic cardiomyopathy, acute ischemia, or other cardiac problems allows the paramedic to assess the risk of the refusal so the patient can make a more informed choice.

* An underlying prolonged QT interval is the only way to distinguish between polymorphic VT and Torsades de Pointes, for which you may wish to give magnesium sulfate and lidocaine instead of amiodarone.

Hows that for a start?

Tom

 

[Akulahawk]

Wouldn't it make a difference any time there was a patient with an MI?

12 Leads are good, and not just for diagnosing MI. There are other conditions that can be picked up by a 12 Lead. If all you have is a 3 lead, they can be easy to miss. A former partner of mine used to claim that all she needed to see could be seen in lead II. With our "old" LP-10's, I'd use the MCL's to get a "poor man's" 9-lead... (no AVL/AVF/AVR) but at least I'd have more of an idea what I'd be dealing with, and perhaps see if RVI was occurring.

She and I went rounds on that one... She was my supervisor, so... :blink: you can guess what happened (ultimately) there.

Oh, and thanks for posting TomB!! I know you could go on from there!

 

[Medic744]

45 year old male new onset chest pain while digging post holes, no medical history but family history with dad dying of MI at age 45. 12 lead= very beginning of MI. Doing that immediately and hauling booty got him to the cath lab within the window to save his life and minimize damage.

 

[ExpatMedic]

In no particular order:

* Within a regionalized system of care, identifying acute STEMI in the prehospital setting allows paramedics to bypass the local non-PCI hospital so the patient can receive primary PCI.

* Even when bypass is not an issue, early notification allows the cath team to be called in from home during off hours (nights, weekend, holidays). That parallel processing leads to significant time savings which translates into decreased mortality.

* A prehospital 12-lead ECG taken with the first set of vital signs establishes a baseline so that changes can be identified with serially obtained ECGs. These changes in QRS/ST/T morphology suggest the dyanamic supply vs. demand characteristics of ACS, which can help establish the diagnosis of acute STEMI in the presence of confounders like LBBB and paced rhythm.

* Sometimes MONA "cleans up" a 12-lead ECG, leaving the prehospital 12-lead ECG as the only evidence that the patient was in fact experiencing cardiac-ischemic chest discomfort. This could prevent inappropriate early discharge from the hospital.

* 12-lead ECGs can be instrumental in the differential diagnosis of arrhythmias, and especially tachycardias. Capturing the rhythm in 12-leads is essentially a "fingerprint" of the arrhythmia which can be useful to the cardiologist after the arrhythmia breaks (or is successfully converted by the paramedic).

* 12-lead ECGs can help identify certain drug overdoses or electrolyte derangements, which might change treatment decisions. For example, sodium bicarb for TCA overdose or calcium gluconate for hyperkalemia.

* Oftentimes syncope patients don't want to be transported to the hospital. A careful screening that includes a 12-lead ECG allows the paramedic to look for signs of long QT syndrome, Brugada's syndrome, hypertrophic cardiomyopathy, acute ischemia, or other cardiac problems allows the paramedic to assess the risk of the refusal so the patient can make a more informed choice.

* An underlying prolonged QT interval is the only way to distinguish between polymorphic VT and Torsades de Pointes, for which you may wish to give magnesium sulfate and lidocaine instead of amiodarone.

Hows that for a start?

Tom

Yup, thats a decent start. The kind of answer I was looking for.

Not so much with the 'are you kidding me' or 'To diagnose an MI!' responses.

For the MI responses... Assuming you have ruled out other possible causes, such as SVT, would your treatment have changed with no STEMI present? Studies are conflicting, but I've read more than one article that suggests as little as 50% of patients presenting with an active MI, actually show any sort of ST elevation what so ever. It's been a couple years, but I can do some digging for those articles if anyone is interested.

Point is, there are people and studies that claim (statistically speaking) actual patient outcome and quality of life does not change due to the presence or absence of pre-hospital 12 Lead EKG's. I would like to make a solid and educated argument against those claims. So, again, I thank the above poster for his response.

 

[ExpatMedic]

45 year old male new onset chest pain while digging post holes, no medical history but family history with dad dying of MI at age 45. 12 lead= very beginning of MI. Doing that immediately and hauling booty got him to the cath lab within the window to save his life and minimize damage.

The chest pain is present, as well as the risk factor, as such, I would be hauling booty and following a chest pain protocol, regardless of what my monitor suggested.

"Treat the patient, not the monitor."

EDIT - With that said, in the presence of a STEMI, does your system allow you to bypass the ED and head directly to the cath lab? We don't have that option, unfortunately.

 

[VentMedic]

The chest pain is present, as well as the risk factor, as such, I would be hauling booty and following a chest pain protocol, regardless of what my monitor suggested.

"Treat the patient, not the monitor."

What do you for patients that do not present with the classic EMT textbook "having an MI chest pain"? That includes the elderly, diabetics and women. There are many times where a 12-lead EKG can show what the patient is not.

If your monitor "suggested" an MI, even if the patient is not "text book" it still requires further evaluation.

And yes of course if the patient has chest pain, it would be prudent of you to follow your protocols for that also.

 

[ExpatMedic]

What do you for patients that do not present with the classic EMT textbook "having an MI chest pain"? That includes the elderly, diabetics and women. There are many times where a 12-lead EKG can show what the patient is not.

If your monitor "suggested" an MI, even if the patient is not "text book" it still requires further evaluation.

And yes of course if the patient has chest pain, it would be prudent of you to follow your protocols for that also.

In the case of the elderly, diabetic, female who is feeling 'down and out', I would obviously hope that my monitor shows me a STEMI. That is, assuming she is experiencing an MI.

I already had that on my list of examples, but you do bring up a good possible use. Thanks.

 

[EMTinNEPA]

Like VentMedic said, only one time?

If STEMI's negative, the patient still gets MONA... nitro and oxygen help with angina too. At the same time, the patient could be experiencing an NSTEMI, which wouldn't present with the tell-tale ST elevation. If the 12-lead DOES show ST elevation, the location of the infarction could effect your treatment as well, especially when it comes to giving nitro to inferior STEMIs.

In my student ride time, I've seen four STEMIs, one of which was a "silent" MI (no chest pain). If it weren't for 12-lead capabilities, a keen eye, beginner's luck, and a gut feeling, it would have gone completely unnoticed and the patient would have arrived at his preferred destination (a little "Doc In a Box"). He would have sat there for 45 minutes while the doctor did his assessment, the hospital performed their own 12-lead, the doctor interpreted it, arranged transfer to the hospital with an interventional cath lab, then called us to transport him. In the meantime, he would have been sitting there and myocardium would continue to die. Instead, we bypassed the Doc In a Box and the emergency room and went straight to the cath lab.

Every time an ambulance bypasses a local hospital in favor of one with an interventional cardiologist, the 12-lead was worth its weight in gold and more. Every time someone has chest pain and calls an ambulance, the 12-lead makes a difference.

 

[Medic744]

The chest pain is present, as well as the risk factor, as such, I would be hauling booty and following a chest pain protocol, regardless of what my monitor suggested.

"Treat the patient, not the monitor."

EDIT - With that said, in the presence of a STEMI, does your system allow you to bypass the ED and head directly to the cath lab? We don't have that option, unfortunately.

I was the student and I was the one that caught it confirming it with a 12 lead. I have yet to treat a monitor other than smack it when it gets in my way. That was a quick recap of what happened not the whole 3 page narrative that I turned in.

And yes, every system in the area of a 24hr, we never close Cath Lab only has to call, give report and they have the team and the elevator waiting for us. It is a very nice perk of being so close to a few of the top cardiac centers in the state.

 

[JPINFV]

In the case of the elderly, diabetic, female who is feeling 'down and out', I would obviously hope that my monitor shows me a STEMI. That is, assuming she is experiencing an MI.

I already had that on my list of examples, but you do bring up a good possible use. Thanks.

If the patient is having an atypical MI presentation ("silent MI") that is confirmed by 12 lead, wouldn't treating it be treating the monitor and not the patient?

 

[reaper]

Hahaha That is good!

 

[firemedic1563]

Yup, thats a decent start. The kind of answer I was looking for.

Not so much with the 'are you kidding me' or 'To diagnose an MI!' responses.

For the MI responses... Assuming you have ruled out other possible causes, such as SVT, would your treatment have changed with no STEMI present? Studies are conflicting, but I've read more than one article that suggests as little as 50% of patients presenting with an active MI, actually show any sort of ST elevation what so ever. It's been a couple years, but I can do some digging for those articles if anyone is interested.

Point is, there are people and studies that claim (statistically speaking) actual patient outcome and quality of life does not change due to the presence or absence of pre-hospital 12 Lead EKG's. I would like to make a solid and educated argument against those claims. So, again, I thank the above poster for his response.

I have not seen the statistics, or met a critic, but I know one patient who benefited from a 12 lead with his life:

Patient presents with chest pain only, otherwise asymptomatic. C/O "I am having a heart attack". Followed standard C/P protocol, 12 lead just prior to leaving scene. I do have a copy somewhere, when I can dig it up one day I will scan it. Classic inferior. As I am moving leads to check right side, pt goes into VF. Through pads on and defib within 30 seconds, converted to NSR, and spoke to me. Went with him to cath lab, watched him go into VT w/ pulse there, complete RCA blockage, opened up, was back at work in a month.

So how did the 12 lead make the difference? Well, he was OBVIOUSLY unstable after going into VF and later VT. However our scene to balloon time, was only 72 minutes. Door to balloon was about 45. This was a Sunday night with the team on call. The closest member lived 30 minutes away (required to be within an hour). No team is going to be activated with/ every chest pain patient until it is confirmed by 12 lead or blood work. SOOOO, had the team not been activated 15 minutes prior to his arrival thanks to my 12 lead and consult, they probably would not have for at least 10 after arrival with time to get a 12 lead and/or bloodwork. So we would be looking at an additional 20-30 minutes delay in his cath at best, which quite possibly would not have been quick enough.

 

[MasterIntubator]

If the patient is having an atypical MI presentation ("silent MI") that is confirmed by 12 lead, wouldn't treating it be treating the monitor and not the patient?

Well... I suppose that is where your level of training should kick in, and figure out if these are acute changes. And yes, I have treated SOME pts based on what the monitor has told me. ( sometimes you gotta pick your battle.. again.. training ). Kinda like the 86 y/o with stroke symptoms, but then the machine tells me a BG of 24mg/dL. Yeah, I'm gonna treat the pt accordingly based on what the machine tells me.

Somewhere I have some 12 leads I will try to post up, showing an inferior MI occuring in real time. Basically, it was NsR as I was watching it, then pain would increase, then the ST segs starting increasing to about 3-4mv above isoelectric. Yes... it was transmitted enroute, which bought us a free ticket to the cath lab without any stopping in the ED. And THAT is one big reason 12 leads make the difference in the pt.

Thats some good stuff right thur.... yes sir.

 

[JPINFV]

Well... I suppose that is where your level of training should kick in, and figure out if these are acute changes. And yes, I have treated SOME pts based on what the monitor has told me. ( sometimes you gotta pick your battle.. again.. training ). Kinda like the 86 y/o with stroke symptoms, but then the machine tells me a BG of 24mg/dL. Yeah, I'm gonna treat the pt accordingly based on what the machine tells me.

So you used a tool as a tool to help make a proper assessment.

I think that saying "treat the patient, not the monitor" is just as extreme as becoming fixated on a tool without regard to what the patient's physical exam and history is telling you. Information from all sources (history, physical, diagnostic tools) should be combined to give the medical provider a more complete picture on what is occurring inside the patient.

 

[ExpatMedic]

If the patient is having an atypical MI presentation ("silent MI") that is confirmed by 12 lead, wouldn't treating it be treating the monitor and not the patient?

In that specific case, yes. But, I believe my response was to a scenario that involved chest pain, not a 'silent MI'. Valliant effort, though.

With that said, the common "silent MI" is often accompanied with some, and/or all of the following: difficulty breathing, nausea, vomiting, diaphoresis, and anxiousness. These symptoms, combined with the risk factors associated with diabetics, elderly, and/or females (as mentioned before) will automatically raise my suspicion of an occurring infarction. At that point, of course, I would use the tools available to not only help confirm my suspicion, but also to justify my treatment.

Generally speaking, I don't blindly apply a 12 lead to every patient with an upset tummy or bucket full of puke. As in the case above, I would treat the signs and symptoms of the patient, not the monitor.

Try not to read into my quote too literally. It's simply a phrase one can remember in order to not fall into tunnel vision, which many new EMTs do. Remember, there should be more tools in your box than the latest and greatest piece of electronics; those tools lie within your head. God forbid, your basic forgets to charge the batteries, right?

Semantics.

 

[MrBrown]

had a bunch of chest pains with ST changes on 12 lead ECG