To ECG or not to ECG (opinion thread)

[fire87l2]

Concerning

This concerns me as a medic. I feel that if an ALS assessment is performed, even if that assessment is negative, then the patient should be transported by a paramedic and not an EMT-B. Where I work, if I start an IV or a saline lock (even though EMT's can monitor those), I must maintain patient care. EMT-B's are only allowed to monitor IV's and saline locks after the patient has been evaluated by a physician and then are being transferred to another facility.

The fact that you allowed your partner to maintain patient care after an ALS assessment and intervention has been performed is downgrade of care and subsequently can be looked at as abandonment of patient care. This call should have never been billed as ALS if the medic was not in the patient compartment.

 

[systemet]

My opinions:

* Failure to perform a 12-lead on this patient would be poor and potentially negligent patient care. I think you were right to do the 12-lead.

* As many others have said, you can't use a 12-lead to rule out acute MI. You need serial ECGs to rule out STEMI, and you need (likely serial) enzymes to rule out NSTEMI.

I agree that this patient is probably unlikely* to be an acute MI presentation [*unlikely as in improbable, not impossible]. Most likely, there's some sort of underlying infection, or medication intolerance / interaction. But, as I think you probably understand, we can't rule out an AMI with the technology in most ambulances without sitting on scene for a few hours.

* I think your supervisor is worried about the potential liability if the patient ends up arresting / having some sort of cardiac event, or even an unrelated severe pathology, and there's documentation that the patient was transferred to BLS after being assessed with a 12-lead.

This seems like a bad reason to be worried. A better reason to be worried would be because of the potential harm to the patient, not the potential legal liability.

* Your system is set up to allow you to downgrade to BLS. I'd imagine this criteria would be pretty well-defined. If it's not.. then, I'd be riding a lot of BLS patients in ALS.

There's a reality here, that if you've downgraded this patient without following the letter of your written protocol, you're going to get crucified if something happens. It might not be fair, but ask yourself how many of your managers or medical directors or local area physicians would truely be there backing you up in a court of law, or in front of a professional competency committee?

If you've decided this patient doesn't require ongoing ALS care (and I'll assume that monitoring the IV is a BLS intervention), then that's a decision you have to be able to defend. Is anyone going to support you? Because it sounds like your immediate supervisor isn't.

Maybe you need to sit back and have a think about whether you're happy with the decision you made, and whether you need to change your behaviour in the name of simple self-preservation. You can get away with making risky decisions for a long time, but if you do it for long enough, the chance of a decision going the wrong way is going to increase.

 

[WuLabsWuTecH]

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.

I should qualify that a bit more. He may write the whole thing but he consults with me while writing it. In one particular instance, he did the assessment and 12 lead on scene, showed nothing (it was a call for an ill person), and decided to forgo the IV. This was back when I was still not allowed to drive in inclement weather, and he saw no need to take another medic or engine out of service, so he drove. Still an ALS run, he was still in-charge on the documentation.

Actually no he did not address it, he showed a generic protocol that was not specific and appears to be for BLS patients. I have searched dam near every LEMSA in the nation over the last few days and have yet to find a wtritten protocol where a ALS care needing patient can be given to a BLS care provider especially a paramedic deemed it neccessary
To start an IV. If the patient is truely BLS why are they starting any IV at all. Still waiting to see a protocol in writing the explicitly states this is deemed appropriate by a medical director.

I absolutely could be wrong... But do please back up your knowledge with a verifiable referance

Please not that the quote I gave was from my department. I am not the OP, I am merely saying that in my area it is acceptable. And while corky may disagree with my citation, it's the best I can find at the moment. I know we can do this because it was specifically covered in our training.

you are taking this to the extreme... in no case where there is any risk of death would i ever BLS a patient in to the hospital... we're talking about patients with local injuries, or common BLS problems (IE; my foot hurts, i stubbed my toe, i ran out of medication and i didnt feel like making a doctors appointment, im 25 and have a fever without other symptoms, etc. etc..) --this specific patient we were speaking of, may have been a little borderline, but that's as high of "risk" i'll go

i do this to be courteous... the nurses are busy enough then to have to spend time doing IV sticks that i can easily perform... not to mention i have faith that my partner can do his job (including monitoring IV locks) without any kind of issue...

Right, these ALS runs are usually borderline ALS. We're not talking about even borderline serious, the risk here to these patients is no more than a BLS run, hence why it's not that big of a deal to let a basic ride.

Honestly though, who cares? In his area it is allowable.

For arguments, it is in my area too, not sure how you want me to prove it. I am trained to start and monitor IVs, and I am a basic. You can look on page 17 of this to find this to be an allowable skill for EMT-Basics with approval from their medical director.

I firmly believe that ideally, every patient should be assessed by a paramedic. That doesn't mean they must always be treated by one though.

In tiered systems, this is how it works, the medic gets there, does the assessment, and if there is truly nothing ALS about the run, the turf it to the BLS crew such that the ALS guys can remain in service.

 

[firecoins]

this is a direct copy from my state protocols:



How would what I did be an unacceptable action based on how that is written? I deemed that the patient was not in any type of acute coronary syndrome... how would I then not be able to deem the patient BLS?

That is not a full protocol. You deemed it necessary to do a 12 lead and start a line, its an ALS patent that warrents you taking it in.

 

[DrParasite]

I get the feeling you've never had that patient who was "fine" crap out in a 10 minute transport because you weren't paying close enough attention. It's an eye opener when it happens.

You'll find that as your assessment skills grow diagnostics often simply confirms what you know from a good history and physical exam.

I've not a newbie by any stretch, and I have experienced patients that say they are fine one minute and we are doing CPR on next. I've also had patients who looked like crap that ALS released, who we ended up bagging or doing CPR to halfway to the hospital (and often these releases were done over my objections, as the patient looked like crap).

Doesn't mean every patient needs a monitor and IV during the trip to the hospital. Also doesn't mean that the patient is having an atypical or silent MI, or some cardiac abnormality that isn't presenting normally.

Plus is it really gonna hurt to throw some stickies on the patient and fire up the lifepak for a minute? just to make sure everything looks good before your turf the patient to the EMT?

This concerns me as a medic. I feel that if an ALS assessment is performed, even if that assessment is negative, then the patient should be transported by a paramedic and not an EMT-B.

this concerns me as a provider. are you nuts???? please tell me you are joking.

This also concerns me as a potential patient of yours. If I am on an ALS/BLS truck, I expect the ALS provider (who is more skilled, more educated and more experienced) to be the one conducting the assessment. I want the best care and best assessment possible. Then, once the ALS provider has determined that I don't need his help, than the BLS person can monitor my stable self to the hospital. But I don't want an ALS bill just because the ALS provider had to take a look at me and determined that I didn't need his help.

The fact that you allowed your partner to maintain patient care after an ALS assessment and intervention has been performed is downgrade of care and subsequently can be looked at as abandonment of patient care. This call should have never been billed as ALS if the medic was not in the patient compartment.

absolutely wrong. you didn't abandon your patient, you assessed your patient, determined your services were not needed, and left them in the capable hands of the BLS provider.

The whole IV thing aside (which may constitute abandonment, depending on your local protocols and medical director's opinion), just doing an assessment doesn't automatically make it an ALS patient.

Ride in on the borderline jobs, but if the patient is stable, and you have ruled out everything using your assessment tools, let the EMT babysit for the ride in. And if something does happen enroute, pull over, and the EMT will drive while the medic deals with the emergency.

 

[flanaganj]

I don't know about you guys, but a 12 lead is routine ALS. If they get an assessment that includes the monitor they get a 12 lead. Period. Doesn't cost money and ill be damned if I'm called anything less then thorough.

A 12 lead is always justified if you, as a medic, want to do one. What NEEDS to be justified is when you DONT do a 12 lead on am als assessment.

Sent from my Nexus S 4G using Tapatalk

 

[tacitblue]

I don't know about you guys, but a 12 lead is routine ALS. If they get an assessment that includes the monitor they get a 12 lead. Period. Doesn't cost money and ill be damned if I'm called anything less then thorough.

A 12 lead is always justified if you, as a medic, want to do one. What NEEDS to be justified is when you DONT do a 12 lead on am als assessment.

Sent from my Nexus S 4G using Tapatalk

I don't know that a 12 lead is justified every time a patient is placed on a monitor. If you preform 12 lead electrocardiograms on every ALS patient you take without a pretest suspicion of something, you may very well wind up with data that you don't know how to use. You may also increase your liability on some runs.

 

[DrParasite]

I don't know that a 12 lead is justified every time a patient is placed on a monitor. If you preform, my 12 lead electrocardiograms on every ALS patient you take without a pretest suspicion of something, you may very well wind up with data that you don't know how to use. You may also increase your liability on some runs.

huh? please explain how a paramedic, who is an expert in 12 leads, and is trained on what to look for, and what do if it looks abnormal, is created increased liability if he or she 12 leads everyone?

if anything, the argument could be made (not that i would make it, only to argue the other side) that failing to to a 12 lead that could show a potential cardiac episode that is presenting abnormally, increases your liability because you are willingly failing to use a diagnostic tool that is readily available to you that would have detected the problem.

just saying in response to your post, nothing else.

 

[triemal04]

Way to start the new year off with a bang. I had a nice, long responce all thought out and about half written, with each innacurracy, falsehood and just plain silly statement pointed out and corrected when I realized that a) that would take a very long time to write, and b) it would be pointless.

This is just another prime example of how lacking medical education is in the US for ALL prehospital providers, and how even a "paramedic" here can prove that they don't know squat.

TheGodfather-
I'll go out on a limb and say that you did a complete assessment of this patient to the best of your abilities and just didn't post every minute detail. If that is the case, you did nothing medically wrong. It may have been against your companies policy, and that is something you'll have to live and deal with (or move on or try and change), but from a medical standpoint...you did fine.

Everyone else-
Please explain why this patient needed a paramedic in constant, direct attendance. And bear in mind when answering that the only real answer must be based on medicine; no "because my protocols say so" no "because it's "the law,"" no "because it's policy," no "because all patients need a paramedic with them," no "paramedics aren't smart enough to make that decision," nothing like that. I would like to hear an honest medical reason why this patient, as presented, and going off the assumption that there was nothing else untoward found in the physical or history, could not be transported by a lower level of care.

You should also bear in mind what will happen to this patient when they arrive at the ER. At some point in the first 30 minutes or so they will get their BP checked, labs drawn, probably an IV started, and an EKG (12lead) done. The doctor (or PA or NP if they go to a fastrack type unit) will come in and do a cursory exam. And that's all. Nothing acute or hurried until their test results are in.

So please, tell me: what was the medical reason that this patient needed a paramedic in constant attendance, and why has everyone flipped out?

 

[tacitblue]

huh? please explain how a paramedic, who is an expert in 12 leads, and is trained on what to look for, and what do if it looks abnormal, is created increased liability if he or she 12 leads everyone?

if anything, the argument could be made (not that i would make it, only to argue the other side) that failing to to a 12 lead that could show a potential cardiac episode that is presenting abnormally, increases your liability because you are willingly failing to use a diagnostic tool that is readily available to you that would have detected the problem.

just saying in response to your post, nothing else.

Whenever you preform a diagnostic test, you should have a pretest suspicion and the test you are performing is ether to confirm your hunch or help rule it out. You will also need to take into account the specific test's sensitivity and specificity for identifying the suspected pathology.

Would you also fault the emergency physician for not ordering an abdominal CT scan on a post roll over MVA trauma patient with multiple benign abdominal exams? Even though that test is readily available to him and he is an "expert" in it's interpretation? Do you know how sensitive a CT o the abdomen is in locating a surgical problem even if one exists? It's not as high as you might think.

I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?

 

[DrankTheKoolaid]

Way to start the new year off with a bang. I had a nice, long responce all thought out and about half written, with each innacurracy, falsehood and just plain silly statement pointed out and corrected when I realized that a) that would take a very long time to write, and b) it would be pointless.

This is just another prime example of how lacking medical education is in the US for ALL prehospital providers, and how even a "paramedic" here can prove that they don't know squat.

TheGodfather-
I'll go out on a limb and say that you did a complete assessment of this patient to the best of your abilities and just didn't post every minute detail. If that is the case, you did nothing medically wrong. It may have been against your companies policy, and that is something you'll have to live and deal with (or move on or try and change), but from a medical standpoint...you did fine.

Everyone else-
Please explain why this patient needed a paramedic in constant, direct attendance. And bear in mind when answering that the only real answer must be based on medicine; no "because my protocols say so" no "because it's "the law,"" no "because it's policy," no "because all patients need a paramedic with them," no "paramedics aren't smart enough to make that decision," nothing like that. I would like to hear an honest medical reason why this patient, as presented, and going off the assumption that there was nothing else untoward found in the physical or history, could not be transported by a lower level of care.

You should also bear in mind what will happen to this patient when they arrive at the ER. At some point in the first 30 minutes or so they will get their BP checked, labs drawn, probably an IV started, and an EKG (12lead) done. The doctor (or PA or NP if they go to a fastrack type unit) will come in and do a cursory exam. And that's all. Nothing acute or hurried until their test results are in.

So please, tell me: what was the medical reason that this patient needed a paramedic in constant attendance, and why has everyone flipped out?

And what if this patient has another syncopal episode. Remember this wasn't a fall, this was a syncopal episode causing the fall. Under a paramedics care while being monitored if the patient had another episode of the arrhythmia (if thats what it was) it would be captured and identified and treated accordingly.

Simply put, a syncopal episode his cardiac in origin until proven otherwise by a physician. And there is no excuse not to have this patient cardiac monitor for the trip into the ED.

Being a paramedic means being a strong patient advocate. And would a true patient advocate allow an elderly syncopal episode patient to be fast tracked or triaged out of the ambulance into the waiting room the way a lot of patients are when BLS'ed into the ED, No. Any patient advocate is going to assure this patient is cared for and monitored while enroute to the highest level needed / warranted and also to the best of his ability at least formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle. If a BLS provider unsure of how or simply doesn't know enough to paint a good enough picture or a don't give a damn paramedic can not convey the need for immediate evaluation in a busy ED system that is exactly what is going to happen.

 

[Shishkabob]

...Even the most critical of ICU patients don't have a healthcare provider with direct eye contact them every second they are there.



Just sayin'.

 

[systemet]

Whenever you preform a diagnostic test, you should have a pretest suspicion and the test you are performing is ether to confirm your hunch or help rule it out. You will also need to take into account the specific test's sensitivity and specificity for identifying the suspected pathology.

I agree with this, but I think you would accept that the OP has an indication for the 12-lead here, right? He has a weak old lady. This weakness could result from an arrhythmia, or could be an anginal equivalent, and might be symptomatic of cardiac ischemia. There's also a remote possibility that there may be some sort of electrolyte abnormality that might be detectable (even if the ECG is pretty insensitive here).

Would you also fault the emergency physician for not ordering an abdominal CT scan on a post roll over MVA trauma patient with multiple benign abdominal exams? Even though that test is readily available to him and he is an "expert" in it's interpretation? Do you know how sensitive a CT o the abdomen is in locating a surgical problem even if one exists? It's not as high as you might think.

I actually have no idea about the sensitivity. I'm not trying to be argumentative, but if you have a decent reference handy, I'd love to take a look. I can also pubmed this myself, so don't kill yourself looking for it.

I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?

But what if the LBBB meets Sgarbossa criteria? Or there's a clear STEMI? In these situations, we might have to accept that the patient has both a severe headache and a cardiac event occuring simultaneously, that may be related or coincidental.

I remember reading some time ago (and I don't have a reference at hand), that there's a fair incidence of MI in patients experiencing a CVA. I think a 90 year old having a severe headache will probably be getting a 12-lead in the ER. Why not in the ambulance? [I accept that a 19 year old female with no CV risk factors, might not].

There also (albeit fairly insensitive) ECG changes that can occur with increased ICP. While it's not going to mean a whole lot if they're absent, surely if we see them, it might be interesting in the differential diagnosis of the headache.

 

[DrankTheKoolaid]

re

disregard my last post, mixed up threads

 

[epipusher]

You could argue that the majority of our patients do not require a paramedic in direct patient contact. It does not take away, imo, why this run, as with others, are ALS runs.

 

[triemal04]

You could argue that the majority of our patients do not require a paramedic in direct patient contact. It does not take away, imo, why this run, as with others, are ALS runs.

Ok...but why? I'm being serious here; if EMS is ever going to be thought of as a serious medical profession and paramedics as true, educated medical providers, then this needs to be answered. Using the criteria I laid out above. Why, in your medical opinion, did this patient need a paramedic, and not an EMT?

The patient, as presented, needed to be seen by either a doctor or midlevel provider (PA/NP) who could order and interpret the needed tests, and then prescribe any needed medications and/or refer the patient to the appropriate level of follow-up care. That's all.

And...you're right, many of the patients that are taken in by paramedics DO NOT need that level of care. There is a group of patients when a prehospital intervention will make a difference in the patient's overall outcome. There's another group that a prehospital intervention will make a difference in the patient's immediate level of comfort. And there's another group that could benefit from a good, competant paramedic taking them in as their report to the recieving facility could speed up the care given. But, for the vast majority, it really doesn't make a difference.*

disregard my last post, mixed up threads

Thought I'd missed something for a second. But, since you did respond...what do you think? Why did this patient need a paramedic?

*Obviously this will vary by system and the type of calls that paramedics are dispatched on; one group may see many more patient's that truly need care than another.

 

[triemal04]

...Even the most critical of ICU patients don't have a healthcare provider with direct eye contact them every second they are there.



Just sayin'.

Well...a good ICU that really follows a 1:1 RN to patient ratio will come pretty damn close. And the more unstable that patient is the more time a RN will be in the room or very close by.

 

[DrParasite]

I remember reading some time ago (and I don't have a reference at hand), that there's a fair incidence of MI in patients experiencing a CVA. I think a 90 year old having a severe headache will probably be getting a 12-lead in the ER. Why not in the ambulance? [I accept that a 19 year old female with no CV risk factors, might not].

IIRC, it was 20% of CVA patients are also having a cardiac related problem or MI.

Being a paramedic means being a strong patient advocate. And would a true patient advocate allow an elderly syncopal episode patient to be fast tracked or triaged out of the ambulance into the waiting room the way a lot of patients are when BLS'ed into the ED, No.

and an EMT can't be a strong patient advocate? please explain why not?

Any patient advocate is going to assure this patient is cared for and monitored while enroute to the highest level needed / warranted and also to the best of his ability at least formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle.

exactly, the highest level of care that is warranted based on the situation. Sometimes that is an EMT. and maybe not in your state, but there are quite a few EMTs who can formulate a coherent verbal report to the ED staff to make sure they are not brushed off into a corner and left to dwindle. I know I've done it, and seen others give great reports to ER staff as well.

If a BLS provider unsure of how or simply doesn't know enough to paint a good enough picture or a don't give a damn paramedic can not convey the need for immediate evaluation in a busy ED system that is exactly what is going to happen.

and what if the BLS provider does know what he is doing and can paint the picture? does that mean there is no need for the medic?

I've been blown off by the nurse on a serious patient. She wanted to have me put the patient in the fast track section of the ER. A quick chat with one of the ER attendings was all I needed to do to move the patient back to the emergency section of the ER. So you don't need to be a medic in order to be a patient advocate.

Whenever you preform a diagnostic test, you should have a pretest suspicion and the test you are performing is ether to confirm your hunch or help rule it out. You will also need to take into account the specific test's sensitivity and specificity for identifying the suspected pathology.

do you test every patient's blood sugar? as part of their vital signs? if so, why not do 12 lead as part of your vital signs to look for any abnormality?

Would you also fault the emergency physician for not ordering an abdominal CT scan on a post roll over MVA trauma patient with multiple benign abdominal exams? Even though that test is readily available to him and he is an "expert" in it's interpretation? Do you know how sensitive a CT o the abdomen is in locating a surgical problem even if one exists? It's not as high as you might think.

if the patient was bleeding into his abdomen and subsequently died, and that injury could have been fixed if he had done the CT? yes, I think I might find a little fault in that.

I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?

will the CATH lab be able to fix the left bundle branch block? What if it shows a STEMI? gonna activate the CATH lab? what about new onset of AFib? would that warrant treatment? how about a pulse ox of 70? think that might warrant you doing some type of corrective action, even if it's asymptomatic or abnormal symptoms?

 

[Handsome Robb]

I I have a patiet with a headache which is severe, and I start a line and give morphine and zofran, it's an ALS call correct? Well, by the logic of the poster I was replying to in my first post, this patient would get a 12 lead. What if the 12 lead showed a left bundle branch block and this patient denies ever having one before? Are you going to activate the cath lab? No. Then why did you do the 12 lead?

Why wouldn't you activate the cath lab?

new onset LBBB needs diagnostic and possibly interventional catheterization. Where did the LBBB come from? Is it ischemic in origin and the LBBB is hiding the STEMI?

If you aren't going to cath them they at minimum need to go to the angio suite.

 

[tacitblue]

Why wouldn't you activate the cath lab?

new onset LBBB needs diagnostic and possibly interventional catheterization. Where did the LBBB come from? Is it ischemic in origin and the LBBB is hiding the STEMI?

If you aren't going to cath them they at minimum need to go to the angio suite.

I have a bundle branch block, I'm in my mid 20s. I wouldnt call in a cath activation for a patiet with a headache and an incidental LBBB on a 12 lead that I my self wouldn't have preformed. A lot of people walk around with them, and unless I'm working up a patient and ACS is in the differential, an LBBB is probably going to be treated as an incidental finding.