To ECG or not to ECG (opinion thread)

[TheGodfather]

The answer is, it really all depends. It depends on the Pt, the hx, the findings and the comfort level of the BLS provider. There are way too many variables to give this one a simple yes or no answer.

DAMN YOU VARIABLES!!!!!!!!! lol

at least the answer wasn't, "NO, you idiot!" -- I guess that is something I can live with

 

[DrankTheKoolaid]

re

Not exactly wrong per se. But earlier you had mentioned not wanting to waste time if it was a cardiac event. You could already have been enroute while performing the twelve lead saving time. This patient is obviously going to get a blood draw in the ED for labs. Instead of looking fror a way to dump your patient on a BLS provider. Be a patient care advocate and take care of your own patients. By the time you get to the ED, she could have had the 12 lead, IV and blood draw already done along with a complete history to aid the ED staff in getting things going.

Now this can also be charge and reimbursed as a ALS level call making it worthwhile for your company also

 

[WuLabsWuTecH]

It does really depend on the level of comfort of the BLS provider. Around here, what you did would have been ok. Even had you done more medic level interventions, as long as the basic was providing only basic level interventions in the back, then there is no issue. It still counts as a medic run and you are still in charge however. At the end of the run, you sign the report.

There are some cases where you need the paramedic to drive for whatever reason, and we are allowed to do that, but it still counts as a medic run.

 

[TheGodfather]

Not exactly wrong per se. But earlier you had mentioned not wanting to waste time if it was a cardiac event. You could already have been enroute while performing the twelve lead saving time. This patient is obviously going to get a blood draw in the ED for labs. Instead of looking fror a way to dump your patient on a BLS provider. Be a patient care advocate and take care of your own patients. By the time you get to the ED, she could have had the 12 lead, IV and blood draw already done along with a complete history to aid the ED staff in getting things going.

Now this can also be charge and reimbursed as a ALS level call making it worthwhile for your company also

Makes a lot of sense! I work with a partner who, like me, enjoys providing patient care, so I hate to step on him and take these "normal" appearing patients from him... 12-lead will nearly always be performed (for me at least) either in a non-moving ambulance, or while obtaining history and packaging... but i can see the time wasted with IV starts and fussing about what level of care the patient requires.. good stuff! ill start putting my foot down more on these "iffy" calls... thanks for the input everyone!

 

[DrankTheKoolaid]

It does really depend on the level of comfort of the BLS provider. Around here, what you did would have been ok. Even had you done more medic level interventions, as long as the basic was providing only basic level interventions in the back, then there is no issue. It still counts as a medic run and you are still in charge however. At the end of the run, you sign the report.

There are some cases where you need the paramedic to drive for whatever reason, and we are allowed to do that, but it still counts as a medic run.

Sign the report why? If you dont take a run why would you be writing and then signing a chart?

Care you show us your protocols where it is allowed to hand off a patient to a BLS provider after ALS interventions have been performed.

 

[WuLabsWuTecH]

Sign the report why? If you dont take a run why would you be writing and then signing a chart?

Care you show us your protocols where it is allowed to hand off a patient to a BLS provider after ALS interventions have been performed.

I'm sorry, I think we're talking about different things here. I was under the impression his basic was on his truck and with his department. In my case, you would sign the report because the truck is still a medic truck even if the medic is not in the back. There are many times that I have taken a run on a medic truck, even though I am not a medic. If any medic skills were performed by my partner on scene, generally he will ride and I will drive, but there are times where that may not be the case. In that case, he remains the in-charge, even though he is not the primary attendant. If only basic skills were performed, it doesn't matter who is the in-charge on the paperwork.

And gladly:

"2.6.3.6 Paramedics are directed to allow their EMT partners to do as much of the patient care as possible. This includes having the EMT ride in charge"

Please note that in-charge here is defined as being in-charge of the patient care (i.e. the attendant) and not in-charge on the paperwork which is defined as being a medic:


2.6.1.1 Fully Staffed Medic (ALS)
2.6.1.1.1 The minimum crew for (redacted) (ALS) shall be: 1 non-provisional EMT-P with in-charge status, and one non-provisional EMT-B (although EMT-I Preferred).

 

[DrankTheKoolaid]

I'm sorry, I think we're talking about different things here. I was under the impression his basic was on his truck and with his department. In my case, you would sign the report because the truck is still a medic truck even if the medic is not in the back. There are many times that I have taken a run on a medic truck, even though I am not a medic. If any medic skills were performed by my partner on scene, generally he will ride and I will drive, but there are times where that may not be the case. In that case, he remains the in-charge, even though he is not the primary attendant. If only basic skills were performed, it doesn't matter who is the in-charge on the paperwork.

And gladly:

"2.6.3.6 Paramedics are directed to allow their EMT partners to do as much of the patient care as possible. This includes having the EMT ride in charge"

Please note that in-charge here is defined as being in-charge of the patient care (i.e. the attendant) and not in-charge on the paperwork which is defined as being a medic:


2.6.1.1 Fully Staffed Medic (ALS)
2.6.1.1.1 The minimum crew for (redacted) (ALS) shall be: 1 non-provisional EMT-P with in-charge status, and one non-provisional EMT-B (although EMT-I Preferred).

This still does not say that a patient who has received ALS intervention by a Paramedic with duty to act can be given to the BLS partner. This just simply says if the call is BLS let the BLS partner get it for the experience is how i read that.

As to the paperwork. Gotcha you mean the medic signs off on your chart... And does not actually write it him/herself


Side note I love how on the Ohio EMS website they list all the sanctioned people and what the offense punishment was. California needs to do the same, not just the little bit they do do. I always love the back of the nursing rags I get how anyone with an RN license that gets in trouble has their name smeared for all to see. Peer pressure can be a very good motivator to not screw up.

 

[medic417]

Many services allow basics to do IV's and to even capture ekg.

Do not forget that an ekg does not rule out a cardiac event, additional testing is required to rule out. If you feel an ekg is needed as a Paramedic you should probably keep the patient in case it is one of the 50-75% of cardiac events that are not captured on a 12 lead.

 

[18G]

I think your supervisor was a little harsh in calling you incompetent.

A 12-lead was certainly warranted but I don't think the call should have been BLS'd. You initiated IV access for a reason. Why? If you didn't feel the patient was all that sick or need IV access for possible deterioration or intervention, than why was an IV started? That is my number one question and I think where other's are coming from also. You must have been thinking in your head this patient may need fluid or a med possibly. And besides the IV you performed another ALS skill which was phlebotomy. Did you send the blood along with the EMT's?

If you did the 12-lead as part of your assessment and used it as a triage tool and did not perform any other ALS interventions, than I would see where your coming from with downgrading to BLS.

But once you start down the ALS path you can't hand over to BLS with an ALS intervention in place. Around here we would have had to contact medical command and get the okay to release to BLS.

It doesn't sound like a big deal what happened... just keep it in mind for next time and all is good

 

[Handsome Robb]

You'd get reviewed and dinged here. You preformed an ALS technique.

"If you're suspicious enough to capture a 12-lead or put someone on the monitor you will attend that patient all the way to the hospital." -Our medical director.

I might get burned at the stake but I agree with him. Don't dish your partners calls after you started ALS interventions/assessments/techniques, it's not fair to your partner or your patient.

 

[Aidey]

We have both Bs and Is here. If the emt is a B you can't start an IV and hand off the pt, even if it is a lock. With an I you can because it is within their scope. However you can't give meds out side of the I's scope and then hand the pt off. The reasoning is that they can't be expected to monitor the pt for the effects of a medication that isn't in their scope.

As for the 12 I suspect it would be highly frowned upon by our MD. As other people have said, if you suspect cardiac enough to do a 12 lead you should probably be taking the pt yourself.

Did the pt have any advanced directives? Where I am at the ekg may or may not have been done based on their level of care status. People on palliative care are limited to palliative measures only, and almost nothing invasive. You can start an IV to give meds, but only if the meds are for the pts comfort. Fluids depend on whether or not they have elected to receive artifical nutrition. So they rarely receive 12 leads unless they are obvious cardiac pts.

 

[Handsome Robb]

We have both Bs and Is here. If the emt is a B you can't start an IV and hand off the pt, even if it is a lock. With an I you can because it is within their scope. However you can't give meds out side of the I's scope and then hand the pt off. The reasoning is that they can't be expected to monitor the pt for the effects of a medication that isn't in their scope.

As an Intermediate an also as a medic student who is 2 weeks away from finishing the didactic portion of my class I have to be really careful about what medics dish down to me. I have felt pretty comfortable with nearly every patient I have encountered to the point of at least having a general idea or list of differentials. I'm guessing this comes from knowing that I have someone to fall back on if I'm wrong

All the medics I have worked with have been really good about not dishing me calls however we have had some pretty good discussions about treatment options.

 

[Tigger]

I've seen the above happen where I work in CO before and it's generally accepted. The difference there is that basics can start IVs and hang fluids as well as do blood draws (not done often if ever), so if the 12 lead revealed nothing this patient would often be attended by the basic, which I see no issue with.

 

[medic417]

I've seen the above happen where I work in CO before and it's generally accepted. The difference there is that basics can start IVs and hang fluids as well as do blood draws (not done often if ever), so if the 12 lead revealed nothing this patient would often be attended by the basic, which I see no issue with.

Really? Again the 12 lead rules nothing out. If you suspect cardiac involvement Paramedic needs to keep patient.

 

[Outbac1]

Oh I am so glad I work in the Great White North. You Americans get so wound up over the letter of the protocol, state rules etc. Fortunatly we have much more leniency here in our interpretation of that stuff.
A 91f with that hx, every sunrise is a bonus. My opinion is a proper assessment was done. Maybe the blood and urine tests will show something. Anyone could have sat with this lady on the way to hospital. My question is what was the pacemaker set to run at? Constantly or only if the rate drops below ? number? That info was not likely available on scene. Either way there was no indication of anything bad about to happen.
The supervisor was a) not medically educated, b) scared of lawyers etc. c) concerned about the detailed billing to the pt. You have rules to follow. You don't have to like it but you do have to, at least somewhat, toe the line. Work towards getting bad rules changed.
I would imagine there as well as here the highest registered person on the unit is responsible for all the patients all the time no matter who attends. Here we go turn for turn until a pt needs more than my partner can do. Then I will take a call from my partner (a PCP) as required.

 

[WuLabsWuTecH]

This still does not say that a patient who has received ALS intervention by a Paramedic with duty to act can be given to the BLS partner. This just simply says if the call is BLS let the BLS partner get it for the experience is how i read that.

As to the paperwork. Gotcha you mean the medic signs off on your chart... And does not actually write it him/herself


Side note I love how on the Ohio EMS website they list all the sanctioned people and what the offense punishment was. California needs to do the same, not just the little bit they do do. I always love the back of the nursing rags I get how anyone with an RN license that gets in trouble has their name smeared for all to see. Peer pressure can be a very good motivator to not screw up.

The medic might or might not write the chart himself. There have been plenty of times on a busier run where both me and a medic have been in the back (running a three man crew) and I've written the entire thing only to have her read it and sign it at the hospital. There have also been times where the medic may have had to drive for whatever reason, and I've been in the back alone on a medic run and he ends up writing the entire thing at the hospital.

That may not be the applicable part of the SOP, I'll have to keep looking, but I know it is allowed because it was covered in my official training and not just something that everyone does and gets away with it. We were told that it is allowed, but that if the lower level provider ever feels uncomfortable with the situation, then we could refuse it and the medic could not appeal or even try to make an argument as to why it should be ok, but had to take it himself.

And yes, the monthly actions are pretty cool. You know exactly who has been behaving badly! I'm always surprised at the number of random audits that they immediately revoke the licenses of people for. They only do that when it is blatantly obvious that you made no attempt at recertification. This is not a, well he for got a class, or came up 10 hours short type deal. When they take it away with no plan on how to keep it, that's generally a "he said he took CEUs but didn't really do any of it" situation. Shame.

You'd get reviewed and dinged here. You preformed an ALS technique.

"If you're suspicious enough to capture a 12-lead or put someone on the monitor you will attend that patient all the way to the hospital." -Our medical director.

I might get burned at the stake but I agree with him. Don't dish your partners calls after you started ALS interventions/assessments/techniques, it's not fair to your partner or your patient.

It depends. Here capturing a 12-lead is a basic skill. Technically interpretation is not allowed, so you send it off to medical control, and they tell you what to do about it. I'm not saying, blanket statement, this is always ok, or it's always not, but I am saying that there are situations in which it could be ok, especially if there are other factors outside of patient care you have to be aware of.

 

[Epi-do]

The medic might or might not write the chart himself. There have been plenty of times on a busier run where both me and a medic have been in the back (running a three man crew) and I've written the entire thing only to have her read it and sign it at the hospital. There have also been times where the medic may have had to drive for whatever reason, and I've been in the back alone on a medic run and he ends up writing the entire thing at the hospital.

That may not be the applicable part of the SOP, I'll have to keep looking, but I know it is allowed because it was covered in my official training and not just something that everyone does and gets away with it. We were told that it is allowed, but that if the lower level provider ever feels uncomfortable with the situation, then we could refuse it and the medic could not appeal or even try to make an argument as to why it should be ok, but had to take it himself.

And yes, the monthly actions are pretty cool. You know exactly who has been behaving badly! I'm always surprised at the number of random audits that they immediately revoke the licenses of people for. They only do that when it is blatantly obvious that you made no attempt at recertification. This is not a, well he for got a class, or came up 10 hours short type deal. When they take it away with no plan on how to keep it, that's generally a "he said he took CEUs but didn't really do any of it" situation. Shame.




It depends. Here capturing a 12-lead is a basic skill. Technically interpretation is not allowed, so you send it off to medical control, and they tell you what to do about it. I'm not saying, blanket statement, this is always ok, or it's always not, but I am saying that there are situations in which it could be ok, especially if there are other factors outside of patient care you have to be aware of.

How on earth does that work? If you aren't in the back with the patient, how can you know everything that was said and done? Having a medic sign off on a lower providers report is one thing. Having them write the report when they weren't the transporting provider seems like something entirely different to me.

 

[Fish]

Bring it up to your medical director or clinical practices team, is this a field supervisor who was telling u this?

 

[TheGodfather]

Bring it up to your medical director or clinical practices team, is this a field supervisor who was telling u this?

It was a LT/Medic in charge of QA
I addressed the issue with my MCP yesterday; Results:

1) any indication that patient may possibly be ALS should just be taken ALS. In the case of that specific patient, he stated that just doing a 12-lead to be proficient (if no real clinical s/s or risk factors present), I may perform an ECG and transmit prior to BLS transport.

2) for BLS patients (whom of which will most likely still require lab work) he stated as a form of courtesy to the ER, I may initiate an IV and lock/titrate to KVO rate. (state protocol allows this) --- He was unsure about the billing aspect of doing this.

 

[tssemt2010]

if you have to question it like this, then do the 12 lead, its not going to hurt anything