[NAEMSP Dialog] EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Mic Gunderson]

From the time an AMI patient begins to have symptoms until they get
reflow through their coronary arteries restored, the 'time is muscle'
clock is ticking. This session of the NAEMSP Dialog is about the role
that EMS should (or could) play in keeping that symptom to reflow time
interval as short as possible. There are several important questions
that the EMS, ED and cardiology communities need to address in this
regard. Our intent is to facilitate discussion on these questions -
and thereby provide information that we can all use to help improve
care and guide further study in our respective systems.

I will get the conversation started by asking our invited participants
a few questions. That will help frame the issues we hope to address
and provide more specific items for you to reply to. So please, share
your viewpoints in this important discussion - and remember to 'sign'
your replies with your name and affilitation(s).

If you have any EMS, ED or cardiology colleagues you think should be
reading and/or participating in this discussion, please encourage them
to signup for Google Groups (http://groups.google.com) and the join
this NAEMSP Dialog group (ttp://groups.google.com/group/naemsp-
dialog).

Our invited participants for this session are:

Christopher Lee, MD - Chris is the lead author of the 'Early Cardiac
Cath Lab Activation by Paramedics for Patients with STEMI on
Prehospital 12 Lead ECGs' paper recently published in Prehospital
Emergency Care (see the 'Papers and Resources' section below). Chris
is a clinical instructor in emergency medicine at the Yale University
School of Medicine. He graduated from the University of Vermont
College of Medicine and completed his residency in emergency medicine
at Yale-New Haven Hospital. He is currently completing his fellowship
in EMS and pursing a PhD in investigative medicine at Yale.

Carin Van Gelder, MD - Carin is also one of the authors for the 'Early
Cardiac Cath Lab Activation by Paramedics for Patients with STEMI on
Prehospital 12 Lead ECGs' paper. She is an Assistant Professor in
emergency medicine at the Yale University School of Medicine, which is
where she also did her EM residency and EMS fellowship. She has had a
research focus on the heat physiology of firefighters and directs the
EMS Curriculum for the EM Residency at Yale - New Haven Hospital. She
also serves as the EMS Medical Director for the New Haven Sponsor
Hospital Program. Carin serves on the editorial board of Prehospital
Emergency Care.

David Cone, MD - Dave is another one of the authors for the paper
cited above. He serves as EMS Section Chief at the Yale University
School of Medicine, where he holds the rank of Associate Professor in
the departments of Emergency Medicine, and Epidemiology and Public
Health. He is the Immediate Past President of the National Association
of EMS Physicians, and Editor-in-Chief of Academic Emergency Medicine,
the journal of the Society for Academic Emergency Medicine. An active
EMS field provider since 1984, he has served as medical team manager
for two urban search and rescue task forces, is an active-duty
volunteer firefighter, and is the service chief of Connecticut’s only
physician response team.

Nick Nudell, REMT-P - Nick is has been involved in EMS for over 10
years, having worked as a volunteer EMT in rural EMS systems as well
as a paid paramedic in both rural and large urban systems. With more
than 15 years of experience in researching, supporting, and developing
emerging technologies, Nick is also a rising star in the field of
health care technology in the areas of data systems design and
analytics. Nick is the founder of the popular EKG Club online
discussion group. For the last few years, Nick has traveled the
country as a Senior Field Clinical Engineer for Angel Medical Systems
providing support services the cardiologists involved in clinical
trials of a medical device designed to detect precursors to acute
myocardial infarctions.

Tom Bouthillet, REMT-P - Tom is a Lieutenant / Paramedic with Hilton
Head Island Fire & Rescue. He has taught nationally in the University
of MAryland - Baltimore County's Critical Care Transport (CCEMT-P). He
also serves on the EMS Advisory Committee of the South Carolina
Chapter of the AHA's Mission: Lifeline, and is the editor of the
Prehospital 12 Lead ECG blog. His writings have been referenced in the
American Heart Journal, the Journal of the American College of
Cardiology: Cardiovascular Interventions, and the EP Lab Digest.

David Carter, RN, MBA - Dave is the Administrator for Sarasota
Memorial Healthcare System's freestanding Emergency Healthcare Center
in North Port, FL. In addition to a clinical background as a paramedic
and RN, he served as the EMS Director for FirstHealth of Carolinas,
based in Pinehurst, NC. He is also a site reviewer for the Society of
Chest Pain Centers.

Thanks,

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

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[Mic Gunderson]

Let me begin by asking our invited participants to jump right into one
of the questions that we hope to address over the next several weeks.
Has ECG transmission become the "million dollar solution to a 5 cent
problem"? Transmission can involve thousands of dollars of computer
equipment, expensive modems, recurring monthly subscriptions,
restrictive licensing agreements, and a lack of interoperability
between defibrillator/monitor and ePCR platforms. All of this is in an
age when a picture can be emailed around the globe in seconds from a
handheld device at a minimal cost.

Chris, Carin, Nick, Tom, Dave (Cone) and Dave (Carter) - what do you
think?

[medicnick]

Hi Mic,
I think it depends on the system and what it is intended to do. Does
the transmission of EKGs improve patient outcomes?

The equipment required to acquire a diagnostic quality 12 lead EKG is
not very complicated nor particularly expensive. What is complicated
and expensive are the platforms used to present the data for viewing
and archival. Many of today's popular platforms combine a number of
different sensors, therapies, and capabilities and are somewhat
sophisticated. There are even algorithms built into the devices that
do a decent job of interpreting the EKG for tell tale signs of STEMI.

In some areas of the country paramedics are required by protocol to
transmit the EKG for overreading while in other areas it is not
required. This is often a reflection of the local history of the
adoption of EMS initiated hospital protocols and specifically for
concerns with false positive/negative rates for paramedic
interpetation, computer interpretation, or a combination such as the
theme paper discusses.

Where transmission of the EKG is required, the cost of acquiring the
capability to transmit is a given. In areas where not required, as an
optional cost for the system, the capability may not purchased.
Requiring all system participants to use a single vendor reduces
competition and may increase the costs. Requiring all vendors to use a
common data and/or communications protocol may reduce costs and
improve interoperability.

Cheers,
Nick
medi...@gmail.com
(714) 699-3549

PS: My comments are mine and not the opinions of my employer.

[tbouthillet]

Compare our current situation to one of the solutions proposed for the European Union where ECGs are converted to DICOM format and transmitted to existing PACS systems already in place at the hospital. It's incomprehensible that a hospital should have to purchase 3 different computer systems to receive ECGs from Physio, ZOLL, and Philips (although General Devices CAREpoint can receive from multiple vendors and I have recently been made aware of a system in Texas where Physio-Control's LIFENET has been modified to allow ECGs from another vendor).

In Issue 4 of the STEMI Systems newsletter (2007) "Optimizing prehospital wireless ECG transmission: new data, new ideas" Landman, Rokos, et al. propsed the CAPTURE method (CAmera Phone Transmission and Universal Routing of prehospital Electrocardiograms) where paramedics simply take a photograph of a diagnostic quality 12-lead ECG and email it to a dedicated email account at the receiving hospital for the cost of a minimum cell phone data plan.

One the one hand, the paramedic profession has left itself open to exploitation by not embracing 12-lead ECGs fully in our scope of practice. There's still not broad agreement on what paramedics should be taught, or even what paramedics are capable of being taught. Clearly it's not enough to "recognize ST-elevation on the 12-lead ECG" as so many studies have measured, because false positives continue to be a problem. Having said that, a "false positive" can mean the ED physician canceled the STEMI Alert or it can also mean that the patient was cathed and had no culprit artery, so I think it's important to clarify what is meant when we speak about false positives.

I definitely see value in transmitting the ECG for expert consultation (although there is significant variability in physician interpretation) and I have personally witnessed occasions where the ED physician "stood down" the STEMI Alert after pulling an old ECG for comparison while the patient was still in the field. Even when paramedics are appropriately trained, I see nothing wrong with an extra set of "critical eyes" screening patients before the cardiac cath lab is activated. Diverting to a STEMI Receiving Center is another issue, and there are certainly times that marginal cases should probably be diverted even if the cath lab isn't activated while the patient is still in the field.

At a minimum, I think EMS and paramedic organizations and associations should promote the principles of interoperability (non-proprietary formats) and access to data at the local, regional, state, and national level. To answer the question, yes I think ECG transmission has become the "million dollar solution to the 5 cent problem" but I also think the monster has already been born. At this point our best hope may be to help steer the medical device industry in the direction we'd like them to go, and the top of that list needs to be interoperability so we're not locked into one vendor. Competition is good and monopolies are bad.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

[Mic Gunderson]

The recent paper in PEC by Lee, Van Gelder and Cone, 'Early Cardiac Cath Lab Activation by Paramedics for Patients with ST_Segment Elevation MI' brings up several questions - directly and indirectly.

In order to make good clinical decisions are on the basis of the interpretation of the prehospital ECG, the false positive and false negative rates need to be within some sort of acceptable limits. What are those acceptable limits? Are those acceptable limits the same for all decisions? For example, does an ambulance decision decision to bypass the closest ED in favor of a hospital with 24/7 PCI need the same level of false positives and false negatives as the decision to activate the cath lab?

The answers to those questions may help frame the question of who, how and when the ECG is interpreted.

Let me begin this line of discussion by asking Drs. Lee, Van Gelder and Cone for their perspectives on the acceptable limits for false positives and negatives and if those limits vary with type of decision.

--- Mic

Mic Gunderson 
Editor/Moderator, NAEMSP Dialog;
President, IPS

---

From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of tbouthillet
Sent: Saturday, May 01, 2010 8:06 AM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Lee, Christopher]

I would first like to thank Mic Gunderson and NAEMSP for providing this opportunity to discuss a very important and contemporary issue in EMS.

As we all know, faster times to the cath lab in STEMI save lives. It is logical that if a STEMI is recognized by a paramedic in the field, earlier activation of the cath lab would translate to earlier time to coronary reperfusion. However, at many hospitals across the country, the cath lab is only activated once the patient arrives in the ED, despite proper recognition by EMS. Dave Cone, Carin Van Gelder, and myself, along with our cardiology colleagues, have used our research to support the implementation of EMS cath lab activation in our own hospital.

As Mic and Tom both mention, this leads to several questions:
1. Can paramedics even recognize STEMI on prehospital ECG?
2. If not, can we transmit the image to a physician, and then, is ECG image transmission the "million dollar solution to a 5 cent problem"?
3. What are acceptable false positive rates, and how do we define a false positive?
4. Should we worry about false negatives?

As pointed out, very real technological and financial limitations currently exist for the majority of EMS agencies to implement ECG image transmission to an emergency physician or cardiologist from the field. The "million dollar solution" may be irrelevant because the "5 cent problem" isn't actually the problem we should be focusing on. ECG image transmission should occur if paramedics can not reliably recognize STEMI, but the paper by Trivedi, Schuur, and Cone (Can Paramedics Read STEMI on Prehospital 12-Lead ECG? PEC, 2009;13(2):207-214) showed that paramedics in our system were able to recognize STEMI accurately and reliably. This certainly needs to be evaluated in each individual EMS system, and continuing education and training for rhythm recognition needs to be incorporated into any paramedic program.

I agree with Tom that there is definitely value in expert consultation and having "another set of eyes" read a difficult ECG. However, protocols to activate the cath lab should be established only for clear-cut cases of STEMI. If a paramedic is faced with a borderline or difficult ECG in the field, one can argue that by taking the patient to the ED without activating, then there is no change in clinical care than what is currently being done. If the ED physician activates the cath lab on EMS arrival, the system has simply defaulted to the system currently in place. This is what would occur during a false negative, and therefore isn't as concerning.

Mic and Tom also raise interesting points regarding false positives. Tom is absolutely correct that a false positive can mean one of two things: either an EMS activation that was cancelled by the ED physician, or a cath lab activation of a patient that ultimately was found to have clean coronaries. In discussions with our cardiology colleagues, it was established that a false positive rate of approximately 10% was acceptable and expected. It is understood that a false positive rate of 0% would imply that there are cases that are being missed. In other words, interventional cardiologists expect to find a certain number of clean coronaries in order to ensure capture of the largest number of occluded coronaries. Therefore, even if realistic image transmission were to occur, there would still be a 10% false positive rate. In our study, our false positive rate was comparable to the standard and deemed acceptable by our cardiologists.

Activation of the cath lab by EMS should not mean that EMS needs to recognize every single patient requiring reperfusion therapy. This is difficult without old ECGs and records to compare, and in the setting of more nuanced ECG interpretations such as a new left bundle branch block in a patient with chest pain. However, for patients who have a unequivocally recognized STEMI, EMS activation can save their lives. EMS activation doesn't have to capture "all or none" in order to be of benefit overall.

Chris

------------------------------------
Christopher H. Lee, MD
Clinical Instructor, Fellow - EMS and Disaster Medicine
Yale University Department of Emergency Medicine
464 Congress Avenue, Suite 260
New Haven, CT 06519
ph 203.785.4710

On May 3, 2010, at 1:31 PM, Mic Gunderson wrote:


The recent paper in PEC by Lee, Van Gelder and Cone, 'Early Cardiac Cath Lab Activation by Paramedics for Patients with ST_Segment Elevation MI' brings up several questions - directly and indirectly.


In order to make good clinical decisions are on the basis of the interpretation of the prehospital ECG, the false positive and false negative rates need to be within some sort of acceptable limits. What are those acceptable limits? Are those acceptable limits the same for all decisions? For example, does an ambulance decision decision to bypass the closest ED in favor of a hospital with 24/7 PCI need the same level of false positives and false negatives as the decision to activate the cath lab?


The answers to those questions may help frame the question of who, how and when the ECG is interpreted.


Let me begin this line of discussion by asking Drs. Lee, Van Gelder and Cone for their perspectives on the acceptable limits for false positives and negatives and if those limits vary with type of decision.

--- Mic

Mic Gunderson
Editor/Moderator, NAEMSP Dialog;
President, IPS

________________________________

From: naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com> [mailto:naemsp...@googlegroups.com] On Behalf Of tbouthillet

Sent: Saturday, May 01, 2010 8:06 AM

To: naemsp...@googlegroups.com<mailto:naemsp...@googlegroups.com>

Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

Compare our current situation to one of the solutions proposed for the European Union where ECGs are converted to DICOM<http://en.wikipedia.org/wiki/Digital_Imaging_and_Communications_in_Medicine> format and transmitted to existing PACS<http://en.wikipedia.org/wiki/Picture_archiving_and_communication_system> systems already in place at the hospital. It's incomprehensible that a hospital should have to purchase 3 different computer systems to receive ECGs from Physio, ZOLL, and Philips (although General Devices CAREpoint can receive from multiple vendors and I have recently been made aware of a system in Texas where Physio-Control's LIFENET has been modified to allow ECGs from another vendor).

In Issue 4 of the STEMI Systems<http://stemisystems.com/> newsletter (2007) "Optimizing prehospital wireless ECG transmission: new data, new ideas" Landman, Rokos, et al. propsed the CAPTURE method (CAmera Phone Transmission and Universal Routing of prehospital Electrocardiograms) where paramedics simply take a photograph of a diagnostic quality 12-lead ECG and email it to a dedicated email account at the receiving hospital for the cost of a minimum cell phone data plan.

One the one hand, the paramedic profession has left itself open to exploitation by not embracing 12-lead ECGs fully in our scope of practice. There's still not broad agreement on what paramedics should be taught, or even what paramedics are capable of being taught. Clearly it's not enough to "recognize ST-elevation on the 12-lead ECG" as so many studies have measured, because false positives continue to be a problem. Having said that, a "false positive" can mean the ED physician canceled the STEMI Alert or it can also mean that the patient was cathed and had no culprit artery, so I think it's important to clarify what is meant when we speak about false positives.

I definitely see value in transmitting the ECG for expert consultation (although there is significant variability in physician interpretation) and I have personally witnessed occasions where the ED physician "stood down" the STEMI Alert after pulling an old ECG for comparison while the patient was still in the field. Even when paramedics are appropriately trained, I see nothing wrong with an extra set of "critical eyes" screening patients before the cardiac cath lab is activated. Diverting to a STEMI Receiving Center is another issue, and there are certainly times that marginal cases should probably be diverted even if the cath lab isn't activated while the patient is still in the field.

At a minimum, I think EMS and paramedic organizations and associations should promote the principles of interoperability (non-proprietary formats) and access to data at the local, regional, state, and national level. To answer the question, yes I think ECG transmission has become the "million dollar solution to the 5 cent problem" but I also think the monster has already been born. At this point our best hope may be to help steer the medical device industry in the direction we'd like them to go, and the top of that list needs to be interoperability so we're not locked into one vendor. Competition is good and monopolies are bad.

Tom

--
Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)

ems12lead.blogspot.com<http://ems12lead.blogspot.com/>

On Fri, Apr 30, 2010 at 5:22 PM, Mic Gunderson <mic.gu...@gmail.com<mailto:mic.gu...@gmail.com>> wrote:
Let me begin by asking our invited participants to jump right into one
of the questions that we hope to address over the next several weeks.
Has ECG transmission become the "million dollar solution to a 5 cent
problem"? Transmission can involve thousands of dollars of computer
equipment, expensive modems, recurring monthly subscriptions,
restrictive licensing agreements, and a lack of interoperability
between defibrillator/monitor and ePCR platforms. All of this is in an
age when a picture can be emailed around the globe in seconds from a
handheld device at a minimal cost.

Chris, Carin, Nick, Tom, Dave (Cone) and Dave (Carter) - what do you
think?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

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[Mic Gunderson]

Thanks for your excellent reply Chris.

I'd now like to open the Dialog up to discussion with everyone's
participation. Please feel free to ask questions, offer your comments and
observations, or reply to previous questions. Our objective here is to tap
in the collective wisdom of all the people on the list and information in
the literature to pose and answer, as best as we can, the key questions that
we are now facing in advancing our policies and protocols to reduce the time
lag between the onset of symptoms and restoring coronary flow in patients
with AMI.

A couple of reminders:
- Include your name and affiliation in the 'signature' at the end of your
posts.
- Please keep the same subject line in your replies
- Because this list is moderated, expect a delay between submitting your
reply or comment and it being sent out to all list members. I will do my
best to keep those delays as short as possible.

Thanks,

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

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[Mic Gunderson]

The false positive rate for the field interpretation seems to be a
pivotal issue. Is there consensus around this definition? How do the
various EMS provider organizations and hospitals represented on this
listserv operational define false positives in their systems?

[Laurie Romig, MD, FACEP]

I would argue that from an EMS perspective, the false positive rate would
reflect those patients who are being declared EMS STEMI Alerts who don't go
to the cath lab and not necessarily those who have clean arteries on cath,
especially where patients don't go to the cath lab without overread of the
12 lead or a quick reevaluation upon arrival. Of course we know that there
are a number of reasons that candidate patients don't go to cath that don't
reflect that EMS has "wrongly" called a STEMI Alert and we have to expect
those. In our area (the supposed "Land of the Newly Wed and the Nearly
Dead") it's very common for ECG changes to be old or for patients and/or
families to decide against cath due to chronic illness, age and/or debility.
Even though we've been doing differential PCI transport since 2002, we're
still very much a STEMI System in evolution, utilizing 12 lead transmission,
relatively rarely going directly to the cath lab and only now beginning to
get detailed outcome info on our STEMI Alert patients. We rarely miss
calling a STEMI Alert on an EMS patient who goes to cath, but are still
working with about a 40% cath rate and are trying to sort out some of the
contributors that we can impact with education, medical control guidance and
quality management. The recent statement about 10% being a reasonable false
positive rate is the first I've heard of a potential benchmark to work
towards.

Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County (FL) EMS

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com]
On Behalf Of Mic Gunderson
Sent: Wednesday, May 05, 2010 8:48 AM
To: NAEMSP Dialog
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[Marc Berenson]

Out of curiosity Dr. Lee, did the 10% false positive rate come from the literature or the opinions of the Cardiologists that you spoke with? (I'm not necessarily negating the validity of that benchmark, but in the age of EBM it's hard - not impossible, but hard - to convince folks of anything that isn't supported concretely).
 
I think you all make excellent points regarding the necessity of reducing intervals to reperfusion. I personally am an advocate for Paramedic interpretation of 12 Lead EKGs and subsequent activation of the Cath Lab as appropriate. I actually think E2B times should be tracked along with D2B times and used as a performance benchmark.
 
Here's my question: If we really want to reduce reperfusion times, then designating STEMI receiving centers and bypassing non-PCI capable hospitals is imperative. However, not all areas have the luxury of having those facilities within a reasonable distance. Therefore, should be we consider using Medevac to bypass local facilities (where significant delays to PCI can occur) if the patient can not be driven there in a reasonable distance?
 
One other note: It is important to remember that while reducing E2B times are well within the abilities of EMS systems, reducing symptom onset to balloon time requires a much broader and more lateral approach that requires participation from the primary care, cardiology and public health communities. EMS can have an impact here too; although I'd venture a guess that most systems have not adopted a public health role as part of their operations.

 

--
Marc Berenson
MICU Paramedic
Holy Name EMS
Hackensack University Medical Center
beren...@gmail.com

[Paul Rostykus]

We are working to clearly define false positives and false negatives
for our STEMI system.

We define a false positive as when our STEMI protocol (requiring both
clinical and ECG criteria) is not met and the cath lab is activated by
the EMS radio call of "STEMI Activation", such as > 12 hours of
cardiac chest discomfort, no cardiac chest comfort (such as syncope or
nausea only), presence of a LBBB or a paced rhythm, or no ST
elevation. These are relatively easy to track.

In a similar fashion, a false negative is when our protocol criteria
are met and the cath lab is not activated by EMS. These, we find
harder to track.

About 97% of STEMI patients go to the cath lab. About 95% get PCI or
stent.

EMTs call "STEMI Activation" in the field - we do not transmit.

Paul S. Rostykus, MD, MPH
Jackson County (OR) EMS Supervising Physician

[Mic Gunderson]

(Posted on behalf of Marv Wayne, MD)

5 years of data have been reviewed in a system that does not transmit
EKG due to geography. Our worst year was 8% over call and 4% under.
Door to balloon time is actually shorter on EMS Cath Code
activations. Results continue to be excellent. Transmission is
helpful where it is cost effective but I think this shows medics can
be trained to read EKGs well. Just my 2$ (cents are worthless in
today’s economy)

Marv Wayne, MD
Associate Clinical Professor, University of Washington;
Attending Physician, Emergency Department, St Joseph Medical Center;
EMS Program Director, City of Bellingham, WA

[DW...@schertz.com]

Mic,

In San Antonio, we have struggled with this "definition" and we are
carrying forward a suggesting to adopt the following language:

1. TRUE: Patient met Pre-Hospital Heart Alert Criteria, hospital was
notified, patient went to cath lab (or didn't due to contra-indications)
2. FALSE: Patient DID NOT meet Pre-Hospital Heart Alert Criteria,
hospital was notified that they did, patient did not go to the cath lab
emergent
3. MISSED: Patient met Pre-Hospital Heart Alert Criteria, hospital WAS
NOT notified, patient went to cath lab (or didn't due to
contra-indications)

We feel the measurement we need to focus on is whether or not the
patient met the criteria in the pre-hospital environment that warranted
bringing in personnel to the cath lab (team and interventionalist). We
were getting all tangled up in the pre-hospital feedback on whether or
not the patient went to the cath lab and honestly, that is not purview
of the pre-hospital personnel. We look at it similarly to trauma, did
the patient meet our regions definition of "Trauma Alert" and if so, the
accuracy of the pre-hospital efforts should not be judged on whether or
not the patient was taken to surgery by the trauma surgeon.

A great example from my agency was a patient we had, female, atypical
ACS symptoms (sudden on set weakness) who was showing ST elevation in
M1-M4. A Heart Alert was initiated and the patient delivered to our PCI
center. By our definition, the outcome was TRUE for this case even
though the cardiologist and family opted NOT to take this patient to the
cath lab since she was 104 years old. (age is not an indicator for our
criteria).

Dudley

"Do not follow where the path may lead. Go instead where there is no
path and leave a trail" - Ralph Waldo Emerson

Dudley Wait
EMS Director
City of Schertz EMS
1400 Schertz Parkway
Schertz, TX 78154
210-619-1400 (O)
210-619-1499 (F)
210-488-4243 (C)

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-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Mic Gunderson
Sent: Wednesday, May 05, 2010 7:48 AM
To: NAEMSP Dialog

Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[tbouthillet]

I think there are two take-home lessons here. First, we need to define exactly what we're talking about when we use the term "false positive". Second, we need to look at every single EMS-initiated "STEMI Alert" (or whatever you call it in your jurisdiction) and define exactly what caused the problem.

• Was it poor data quality or poor lead placement? This is extremely common.
• Was it an STE-mimic like LBBB, LVH, BER, or pericarditis? These are the best learning opportunities for a prehospital 12-lead ECG program.
• Did the patient not meet the clinical criteria? Certainly requiring a chief complaint of chest discomfort increases the specificity of EMS-initiated STEMI Alert, but are we missing atypical presentations? Should patients with abnormal neuro exams be excluded?
• Was the patient not cathed because they were a DNR or had an allergy to contrast dye (however, the ECG clearly showed acute STEMI). Does the prehospital criteria need to be modified?

It's also worth noting those situations where the patient did not meet the STEMI Alert criteria but ended up with a discharge diagnosis of STEMI or NSTEMI.

We have identified a handful of cases where an isolated posterior STEMI was missed, but the patient did not meet the "1 mm of ST-elevation (2 mm in leads V2 or V3) in 2 more more contiguous leads" criteria. In one case, the patient was not cathed until > 24 hours later and the discharge diagnosis was NSTEMI. One has to wonder how often that happens.

Additionally, I think we should attempt to identify patients who showed acute STEMI in the presence of LBBB or paced rhythm according to Sgarbossa's criteria (or the modified criteria that take into account the depth of the S-wave when measuring discordant ST-elevation) since those are high-risk patients.

I don't know if anyone saw Chang AM, Shofer FS, Tabas JA, et al. Lack of association between left bundle-branch block and acute myocardial infarction in symptomatic ED patients. Am J Emerg Med 2009;27:916-921 but "new LBBB" (previously undetected LBBB) may not be a particularly sensitive marker of AMI, and almost half of LBBB patients in the Larson study had no culprit artery.

Having said that, I worry about the "false negatives" that have marginal ECGs or baseline abnormalities that are triaged to non-PCI hospitals and end up receiving no reperfusion. These are very difficult to track.

I'm also not convinced that every patient who "receives a stent" in the cath lab is experiencing an acute thrombotic event in an epicardial coronary artery, but at some point you have to pick end point and there are some gray areas.

One thing I've suggested is that all the cards be placed on the table at our multi-disciplinary STEMI meetings. In other words, how many total patients (including walk-ins) were cathed and had no culprit artery? This is the only way to provide context for EMS-initiated STEMI Alerts. If 30% of patients fast-tracked to the cath lab by ED physicians have no culprit artery, then let's take that into account when we judge the number of "false positive" STEMI Alerts called by EMS.

I agree that a < 10% "false positive" rate for patients emergently cathed is a benchmark we should all be shooting for if we're defining "false positive" as "no culprit artery" but I suspect the actual number is much higher nationally.

I personally think the "false positive" rate for EMS-initiated STEMI Alerts that are canceled by the ED physician or cardiologist (patient is not emergently cathed) can and should be variable based on what the hospitals and physicians in a given locality are comfortable with.

One recent study from Southern California showed a 25.7% rate of "false positives" which sounds pretty bad, except that 22.9% were STEMI Alerts canceled by the ED physician. Only 2.8% had no culprit artery, which is pretty impressive, assuming there weren't a lot of missed STEMIs, which is not something the paper examined.

So if you look at it like a funnel where EMS puts potential STEMI patients in the pipeline and the ED physician acts as an additional filter, a 30% "false positive" rate might be perfectly acceptable.

In another community where the cath lab is being activated on nights, weekends, and holidays, and 30% of the time it's a false alarm (or a significantly higher rate of "no culprit artery" when compared to ED physicians) that could be a problem.

So I think we need robust data collection if we want to do apples-to-apples comparisons because every system is different and the devil's in the details.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

--

[David Carter]

The question is not can a well trained Paramedic accurately recognize
STEMI or even an acute NSTEMI, it is dealing with the inconsistently
across America. The Society of Chest Pain Centers has accredited over
580 Chest Pain Centers in the US. Somewhere around 10% have EMS
activating the cath lab from the field, bypassing the closest and taking
the patient directly to a waiting cath lab team. Sadly, about 30%
(perhaps more) of EMS services lack 12 lead capabilities (my stats are a
SWAG). It's great if you live in a community that is in the top 10%
until you go on vacation..... As leaders of EMS we need to raise the
minimum acceptable level of care across the US.

-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Mic Gunderson

Sent: Wednesday, May 05, 2010 4:02 PM
To: NAEMSP Dialog
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[DW...@schertz.com]

The 2009 AHA EMS Survey showed that only 50% of EMS units across the
nation have 12-lead capability on at least 75% of their units. That is
very bothersome...especially where I like to vacation! :)

I agree with raising the minimum standard, and support that strongly,
however, I can tell you that within 60 minutes drive time from the 7th
largest city in the nation (San Antonio) there are EMS agencies that are
selling pancakes and sausage (not at the same time) just to put diesel
in the tanks. Asking them to have 12-lead capability when they have
this level of funding difficulty can get you some rather humorous looks
and comments.

We laugh in state meetings that there are trauma departments, cardiology
departments and neuro departments in hospitals and healthcare...yet when
someone is having chest pain, they do not get the "cardiac
ambulance"...they get the AMBULANCE. In our quest for better
reimbursement models, one of those has to be that agencies that invest
in these specific care issues must be able to be reimbursed at a higher
level than those that do not...and making it public like hospital core
measures probably wouldn't hurt either.

Dudley

"Do not follow where the path may lead. Go instead where there is no
path and leave a trail" - Ralph Waldo Emerson

Dudley Wait
EMS Director
City of Schertz EMS
1400 Schertz Parkway
Schertz, TX 78154
210-619-1400 (O)
210-619-1499 (F)
210-488-4243 (C)

[Launa Nielson]

I definately agree with you.
1) We need to raise the minimum standard of training for EMTs (yes,
volunteer too). The ones who usually complain the loudest are the fire/ems
agencies because they have to train in both fire and EMS. But a basic
firefighter class is 180 hr. EMT is 130 hrs. Something is wrong there.
Separate them so the EMTs CAN spend the extra time.
2) We are a rural paid volunteer agency (intermediate advanced) that reads
our 12 leads, calls the cath lab and bypasses our community hospital. We
sometimes goof and go straight to our local hospital if we aren't sure=1-2
hr delay. We are getting better however. The only reason we can do any of
this is because our medical director is extremely active in our agency.
Other agencies just laugh and say "our doc won't even come to one training a
year". He fights for us, trains us, and helps us with everything (for no
pay).
3) We have been very lucky and have been able to use the homeland security
grants for a number of purchases -- MANY EMS agencies aren't allowed any of
that federal money by their local law and fire departments.
4) EMS really needs the help of medical leaders. We are so busy with runs
and training we just don't have time for lobbying and "politicking". Yet I
know that is where we need to be.
5) We have had to fight so hard and long to be where we are today; EMS
agencies shouldn't have to fight to improve/advance, they should be
encouraged and helped.

Great information--thanks for having this discussion!
Launa Nielson
Wasatch County EMS
Heber City, UT

[Mic Gunderson]

(posted on behalf of David Carter)

If we were able to persuade CMS to increase reimbursement to an ALS 2
level for patients that received a medically necessary 12 lead, do you
think that would influence more services to acquire 12 lead capability
(and training)?

David Carter
Sarasota Memorial Health

[Launa Nielson]

Speaking for our agency and some other rural ones we have talked to, yes
there would be more interest if you could receive extra reimbursement for
doing a 12 lead. At the present time we supposedly cannot even bill for
them -- necessary or not--as we can't bill for reading them and we already
have a small fee for our cardiac monitor. We had to think long and hard
about spending the extra money for 12 leads when we can't even bill for
them. They ended up costing 9% of our annual budget (not including
training) BUT since we are all getting grey we decided it was worth cutting
some other areas. (-:

Can other areas of the country bill extra for doing and reading 12 leads? I
know the ED docs say they can't bill for reading them, only the
cardiologists get the money for that. Would that apply to us also? If
anybody knows how to legally and ethically bill for 12 leads we would
definately be interested.

Launa Nielson
Wasatch County EMS

----- Original Message -----
From: "Mic Gunderson" <mic.gu...@gmail.com>
To: "NAEMSP Dialog" <naemsp...@googlegroups.com>
Sent: Wednesday, May 05, 2010 7:30 PM
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[Nick Nudell]

This is an excellent question and the discussion so far has been great.

 

With our intense focus on STEMI's and 12lead machines, we run the risk, as STEMI systems continue to develop, to lose sight of the big picture. What is important to the patient? 30% of them die every year before we get to talk to them, so perhaps our sample is biased?

 

Is the STEMI presentation (by 12 lead EKG alone) really the best that can be done? Are there other factors that could reduce the false +/- transports, tests, procedures, medications, etc?

 

These are questions I think about every day as some of you know. I'm interested in the thoughts of this distinguished group.

Cheers,

Nick

 

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[Mic Gunderson]

Given the financial barrier of purchasing 12 lead capable machines in
systems where funding for such technology is a REAL issue, is anyone aware
of places where STEMI screenings are being done with MCL leads as surrogates
for the V leads using the older 3 lead machines recording in 'diagnostic'
mode?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com]

[Lee, Christopher]

I agree that maintaining (and expecting) a high standard of EMS care across the country is critical in advancing our specialty. Credibility in the public's eye and the potential for future financial reimbursement lies in our ability to provide standard "modern medicine" regardless of geographic location. However, this geographic fragmentation in medical care is not limited to EMS systems; a good recent example is therapeutic hypothermia for cardiac arrest survivors. Although the landmark studies for therapeutic hypothermia were published 8 years ago, only within the past year have many major medical centers finally started hypothermia protocols. This delay of close to 10 years seems to be typical for changing people's minds and behaviors, particularly in a traditional field such as medicine, which historically has been slow to accept change. Although many hospitals now have therapeutic hypothermia, any one of us may still be unlucky enough to vacation in a spot that simply doesn't have it...

Just as paramedics are now entrusted with the responsibility of ECG STEMI interpretation, it wasn't that long ago when cardiologists weren't so quick to give that responsibility to emergency physicians either. Times definitely change, albeit slowly.

In response to Marc's excellent question regarding a 10% false positive rate, this rate was not based in the literature. One of the reasons we approached our cardiology colleagues regarding this was that we simply did not know what an "acceptable" false positive rate would be. And they admitted as much that as a group, they came to the consensus that "around 10%" was going to be acceptable. Certainly this is very location specific. As we've seen in this discussion forum, the rates vary widely across our systems. Marc also brings up an excellent point that evidence based medicine will give us the most credibility when proposing protocol and patient care changes. Only by conducting sound scientific research can we legitimately advance EMS care and support multi-disciplinary early goal directed therapies (STEMI, sepsis, trauma, etc). My hope is that as we continue to collect data as a whole, a gold standard false positive rate can be identified.

I just saw the posting from Launa about ECG billing. I know that emergency physicians in our hospital definitely bill for ECG interpretation nor should this be limited to cardiologists. In fact we are often hounded for this very reason when we forget to sign the appropriate place for ECG interpretation in our charts...Whether or not paramedics can bill for interpretation is an excellent question that I would also be curious to know the answer.

Chris
------------------------------------
Christopher H. Lee, MD
Clinical Instructor, Fellow - EMS and Disaster Medicine
Yale University Department of Emergency Medicine
464 Congress Avenue, Suite 260
New Haven, CT 06519

ph 203.737.5090

[David Carter]

Currently EMS payments are limited to a all inclusive fee schedule.  CMS does not allow itemized charges such as 12 lead, thrombolitics, CPAP, ect.  Our revenue stream does not encourage good patient care.  Example, if you place a patient on CPAP and prevent an intubation, the patient wins and EMS looses:  Intubation=ALS 2, CPAP=ALS 1 a $150 loss of net revenue, the CPAP cost approximately $50 so the net loss is approximately $200...  The hospital wins by reducing the patients length of stay by approximately 2-3 days... We have multiple areas we need to address to affect culture shift and improve the overall system. 
 
There is a larger group becoming aware of issues such as the ones I described above.  As a group, EMS has a weak voice.  We need our hospitals, cardiologist, EM Doc's to help give us a voice.  Regional meetings with our hospitals is a excellent place to raise awareness.  Our state medical directors are another strong group we need to solicit help from.  They are in a pickle because they can not issue an unfunded mandate such as all ALS units must have 12 lead or CPAP capability.... 

---

Hotmail is redefining busy with tools for the New Busy. Get more from your inbox. See how.

[Cone, David]

Not to take this discussion off on a tangent, but I'm worried about this snippet from the below post:

"But a basic firefighter class is 180 hr. EMT is 130 hrs. Something is wrong there."

What do you mean?

Dave
--
David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Launa Nielson
Sent: Wednesday, May 05, 2010 8:26 PM
To: naemsp...@googlegroups.com

[Launa Nielson]

The basic ff class is 180 hrs yet the basic EMT course is only 130 hrs.
Much of the pressure to shorten the basic EMT course came from national fire
groups because their volunteers didn't have time to take a longer EMS course
. I think its sad we currently think a house is more important than a
human life.

The new nationally recognized EMS levels (in my VERY humble opinion) blew it
also. They 'dummied' down the intermediate class. When you take your
vacation in rural America, chances are the highest level you will find in
the future is an extremely limited "advanced" EMT. Shouldn't we be
encouraging (pushing) increased education for volunteer EMS, not making it
easier just so other groups can easily obtain an ems certification too?

We are only an hour from a trauma one facility yet MANY areas in my state
are 6-7 hours away from one. I am referring to roads, not backpacking
areas. One frequently can not call a helicopter due to weather so you may
be with a volunteer crew for a long time. (3-4 hrs from ANY hospital is not
uncommon)

As volunteers we find it almost impossible to put in 1200 hrs of
training/education all at once. Yet we could do it if we could slowly build
on class after class. With the new levels that is impossible. Its pretty
tough to mandate 12 leads if EMTs are only taught to recognize v-fib,
v-tach, asystole, sinus brady and sinus tach. I am our agency's training
officer. While we do have a few who don't want to learn more, most eat it
up and beg for more. But it has to be doable (small amounts) with a family
and full time job.

Sorry for the long reply, as you can tell this is a sore spot with me.

Launa Nielson
Wasatch County EMS

[Mic Gunderson]

Dave and Launa,

I allowed the question from Dave and thank you Launa for the reply
below. This is off-topic, so let's leave this line of discussion off
here.

Thanks,

--- Mic

Editor / Moderator, NAEMSP Dialog;
President, IPS

[Gary....@memphistn.gov]

Thank you Mic since we all know that the National Standard Curriculum is developed by all stakeholders involved in EMS, not just fire organizations.
Gary Ludwig

----- Original Message -----
From: naemsp...@googlegroups.com <naemsp...@googlegroups.com>
To: NAEMSP Dialog <naemsp...@googlegroups.com>

Sent: Thu May 06 09:54:03 2010
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Derek Isenberg]

How would the discussants response to those people who say that the cost of implementing 12-lead ECGs in the field is not cost efficient.

For example, if a system runs:
100,000 calls per year
2% of those calls are chest pain calls=2,000 calls a year and
1% of those calls are STEMIs-20 patients a year.

How do we justify the cost of the equipment and training of our medics for 20/100000 patients?

Sincerely,

Derek Isenberg, MD
EMS Medical Director
Mercy Fitzgerald EMS
Darby, PA

[Margaret Keavney]

Regrding billing extra for 12 lead application and interpretation:

A certain percentage of our patients are Medicare beneficiaries, and we would have to change the law to be allowed to bill for that.  Not impossible, but a very heavy lift.

In every commercial insurance contract I've ever seen for ambulance services, the insurance company takes an ancillary provider or physician contract, substitutes the work "ambulance" and plops in the HCPCS codes from the ambulance fee schedule with a rate.  In order to be able to bill those payors for those services, we need to change that model.  You can negotiate with an insurance company that they WILL pay for those services.  I imagine the conversation would go like this:

"When your member is having a STEMI, we can find out and bring them directly to the PCi hospital.  or, without this technology, we being them to the closest facility for a 12 lead.  When they find what we would have found in the field,they will discharge the patient and call another ambulance to take them to the STEMI hospital.  You will incur another ambulance bill AND an extra ED visit bill, including the physician and lab portions.  So, would you like to pay us for the field 12 lead?"

Margaret A. Keavney, Esq.
732-610-7100

www.njemslaw.com
Twitter: @keavneylaw
Ambulance Law Update: http://njemslaw.com/posts/

[Tom Bouthillet]

Hilton Head Island Fire & Rescue does between 15 and 20 STEMIs a year
and our call volume is about 6500 calls/year between EMS and fire, so
I think your statistics are a bit skewed.

The cost efficiency argument is often used to justify writing off
cardiac arrest patients. At some point we have to acknowledge that
we're supposed to be saving lives and improving mortality.

Cardiovascular disease is the number 1 killer in the industrialized
world, so if we're not geared up to help these patients, what exactly
are we good for?

Tom

Sent from my iPhone

On May 6, 2010, at 9:01 AM, Derek Isenberg <derek.i...@gmail.com>
wrote:

[Cone, David]

What is your demographic like on Hilton Head? We get about 50 STEMI cases per year out of about 40,000 ambulance transports - or about 0.13%, a factor of 2.5% different. We also get another 50 walk-in cases, and maybe your walk-in STEMI volume is lower, reflecting a smarter population -

Dave
--
David C. Cone, MD
EMS Section Chief
Yale Emergency Medicine
Editor-in-Chief
Academic Emergency Medicine
www.aemj.org

-----Original Message-----
From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Tom Bouthillet
Sent: Thursday, May 06, 2010 2:32 PM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Tom Bouthillet]

Hilton Head Island has about 35,000 - 38,000 year-round residents, a
peak summer time population of about 200,000, and we see about 2.25
million visitors per year.

I'll check the exact STEMI numbers when I get home from Vegas. If
STEMI patients call 9-1-1 more on Hilton Head my gut feeling is that
it's because they're from out of town and don't know where the
hospital is.

Tom

--
Tom Bouthillet
Lieutenant / Paramedic

Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)

Sent from my iPhone

[Marc Berenson]

I'd like to underscore Tom's comment about improving morbidity/mortality as part of this discussion. Prehospital cardiac care was truly the reason for the evolution of early advanced life support systems. There is a substantial body of evidence to suggest that early activation of cath labs reduces D2B times and therefore M/M, making this worth our effort, time and money.

 

I would also be curious to see in systems that do 12 Lead EKGs already whether or not there is a significant number of "missed" STEMIs that do emergently receive a PCI - only to note if the true number of STEMIs per total call volume is higher than currently stated. The system that I work in collectively does somewhere in the neighborhood of 70,000 to 80,000 ALS dispatches annually and has a far higher number of STEMIs than quoted by Tom or Dr. Cone (Don't have an exact number because the concept of data sharing does not really exist in this neck of the woods, but anecdotally I'm very confident that it's substantially larger).

 

--
Marc Berenson, MICP, NREMT-P

MICU Paramedic
Holy Name EMS
Hackensack University Medical Center
beren...@gmail.com

[David Carter]

Question:  Of the services that are performing 12 leads, how manyare leaving the leads on and performing serial ECG's or just running one "negative" ECG and taking the leads off?  I know much of this depends on the transport times.  In NC our average transport time was 30 min.  Ocassionally we would have patients convert to STEMI during transport or a transient STEMI episode.  If we captured the episode on a ECG it was an immediate ticket to the cath lab. 
 
David Carter RN, MBA
Site Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza
 

---

The New Busy is not the too busy. Combine all your e-mail accounts with Hotmail. Get busy.

[Mic Gunderson]

Many communities do not have paramedics. Should EMTs being capturing
12 lead ECGs and using the machine interpretation to guide destination
decisions (i.e. go to an ED at a PCI hospital vs. a closer ED at a non-
PCI hospital)?

The paper by Lee, Van Gelder and Cone (Early Cardiac Cath Lab
Activation Activation by Paramedics for Patients with ST-Segment
Elevation Myocardial infarction. Prehosp Emerg Care 2010;14:153–158)
mentioned the use of the Acute Cardiac Ischemia Time-Insensitive
Predictive Instrument (ACI-TIPI) score (Daudelin DH, Selker HP.
Medical error prevention in ED triage
for ACS: use of cardiac care decision support and quality improvement
feedback. Cardiol Clin. 2005;23:601–14.) as an adjunct to the 12 lead
alone. Would this be something to further aid EMT only system in
making transport destination decisions? Is anyone else using the ACI-
TIPI scoring tool with their paramedic system?

--- Mic

Mic Gunderson

Editor / Moderator, NAEMSP Dialog;
President, IPS

[David Carter]

Since the reality is that most of the geographic US is not covered with ALS, I would agree this should be considered. I am aware of at leas one trial that was performed in a rural section of Ohio where EMT's applied the 12 lead and transmitted the results to the receiving facility and activated the cath lab (They published a paper on the trial, I will try to find it for reference). Some states allow EMT's to capture 12 leads some do not (thier is that consistency issue).
 
Colorado recently made some changes that allows their Intermediates to capture 12 leads...
 
Even if they only recognize obvious STEMI's, that is better than nothing...  especially if its me!

 
David Carter RN, MBA
Site Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza
 
 

> Date: Fri, 7 May 2010 06:02:02 -0700
> Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI
> From: mic.gu...@gmail.com
> To: naemsp...@googlegroups.com

---

The New Busy think 9 to 5 is a cute idea. Combine multiple calendars with Hotmail. Get busy.

[Marc Berenson]

The services I work for routinely perform more than one 12 Lead EKG if the patient will be an ALS workup. This is especially required if the patient has any change in acute symptomatology for better or for worse, including as a result of therapy administered. It's also important to make sure an original copy of the EKG makes its way to the eyes of the ED Physician treating the patient. Prehospital treatment can in fact acutely change EKGs for the better, and making sure that someone has seen the initially abnormal EKG is imperative to ensure the patient receives appropriate definitive care.

 

I do like the idea of using BLS providers to acquire 12 Lead EKGs and transmit in areas that do not have access to prehospital advanced life support. This may do a wonder of good for the patients. However, my gut instinct is that services that do not have ALS providers are more likely not to be able to afford the very expensive cardiac monitors. In addition, these services are likely to be more rural, and the available communications technology may prohibit the transmission of 12 Leads in the field.

 

As for the ACI-TIPI score, I have to admit that this is the first I'm hearing of it and am very interested - can you provide a brief summary / make the paper available on the resource page?

 

Thanks. MB

--

Marc Berenson, MICP, NREMT-P

MICU Paramedic
Holy Name EMS
Hackensack University Medical Center
beren...@gmail.com

 

[Mic Gunderson]

Marc,

I'm working on getting the paper and some of the developers of it to
jump in here.

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

> As for the ACI-TIPI score, I have to admit that this is the first I'm
> hearing of it and am very interested - can you provide a brief summary /
> make the paper available on the resource page?
>
> Thanks. MB
> --
> Marc Berenson, MICP, NREMT-P
> MICU Paramedic
> Holy Name EMS
> Hackensack University Medical Center

> berenm2...@gmail.com

> > naemsp-dialo...@googlegroups.com<naemsp-dialog%2Bunsubscribe@goog legroups.com>

> > For more options, visit this group at
> >http://groups.google.com/group/naemsp-dialog?hl=en

> > Visit NAEMSP athttp://www.naemsp.org.

>
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[Margaret Keavney]

Our incidence of STEMIs identified with 12 leads in the field is much higher than your example.  About 20% of our ALS calls are cardiac/chest pain.  I don't have the exact numbers, be we see more like 120 a year, with an annual ALS volume of less than 100,000.  I can get the actual numbers if it would help this group.

Margaret A. Keavney

732-610-7100

www.njemslaw.com
Twitter: @keavneylaw
Ambulance Law Update: http://njemslaw.com/posts/

[Mic Gunderson]

The question raised by Dr. Isenberg about the cost effectiveness of
the investment in a prehospital 12 lead system raises other issues.

He recognized the value of a prehospital 12 lead for confirmed STEMI
cases. Is there a clinical and/or financial and/or operational return
on that 12 lead technology investment for the assessment and decision-
making process in other types of acute coronary syndrome cases - not
just STEMI? For example, is there a return on investment in making
better decisions on which cases are safer to take to the closest ED
rather than the PCI center? What costs are saved by making that
decision correctly? To what degree did that 12 lead help?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

[Cone, David]

I would agree that about 20% of most ALS calls are for chest pain – but very, very few of these turn out to be STEMI.  Even those that have STEMI-looking 12-lead ECGs often sometimes are not STEMI.  I was the fourth person to lyse (remember thrombolysis for MI?) a guy who came to our ED outside Philly repeatedly with chest pain and a horrendous looking ECG – but that was his baseline ECG – he finally began carrying a photocopy with him, to avoid getting lysed again.  (This was in the early 90’s, before we could retrieve old ECGs electronically.)

 

My point is that the percentage of chest pain patient transported by EMS who turn out to be true STEMI is quite low.  12-lead ECG can help sort that out (though there will be a small number of false positives, like the guy above), and can help allay the fears of small community hospitals that they will be losing large numbers of patients to regional STEMI/PCI centers.

 

Dave
--
David C. Cone, MD
EMS Section Chief

Yale Emergency Medicine

Editor-in-Chief

Academic Emergency Medicine

www.aemj.org

 

From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Margaret Keavney
Sent: Friday, May 07, 2010 10:25 AM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

 

Our incidence of STEMIs identified with 12 leads in the field is much higher than your example.  About 20% of our ALS calls are cardiac/chest pain.  I don't have the exact numbers, be we see more like 120 a year, with an annual ALS volume of less than 100,000.  I can get the actual numbers if it would help this group.

[Laurie Romig, MD, FACEP]

We ask our medics to leave 12 leads in place during transport for all cases in which we suspect potential myocardial ischemia (already known STEMI or not) and to do frequent repeat 12 leads for the purpose of tracking changes. We are also encouraging 12 lead acquisition as an early task when we have ROSC from SCA. We don’t yet have designated SCA centers or therapeutic hypothermia, although some of our hospitals are headed in that direction.

 

Laurie A. Romig, MD, FACEP

Medical Director

Pinellas County EMS

[tbouthillet]

I can eventually see prehospital 12-lead ECGs being used to help risk statify NSTEMI patients in the field (perhaps in conjunction with POC biomarkers). I have seen many situations where the prehospital 12-lead ECG showed the only evidence that a patient's chest discomfort was caused by coronary ischemia, since the 12-lead ECG had normalized by arrival in the ED.

 

Similarly, getting a baseline ECG prior to MONA for patients with LBBB or paced rhythm is extremely helpful for establishing whether or not the ST-T waves are changing, which suggests the dynamic supply vs. demand characteristics of ACS.

 

I also believe that 12-lead ECGs are an invaluable for the differential diagnosis of tachycardias (I'm not so much talking about using QRS morphology to differentiate between VT and SVT with aberrancy as I've seen that particular "skill" do more harm than good). However, it's not always obvious that a tachycardia is "wide" when viewed only in the limb leads, and "ruling-in" VT is fine in my book.

 

Patients who present with syncope should be screened for prolonged QT-interval, Brugada's syndrome, and hypertrophic cardiomyopathy, especially if they don't want to be transported to the emergency department. Prehospital 12-lead ECGs can help detect drug overdoses (especially TCAs) and electrolyte derangements (especially hyperkalemia).

As for whether or not we should be capturing a single 12-lead ECG or serial 12-lead ECGs, I loved Tim Phalen's comment on the MedicCast where he compared it to taking a single photograph of Old Faithful. Maybe it's a geyser -- maybe it's a hole in the ground!

 

An acute thrombotic lesion in an epicardial coronary artery is not a static event, and significant changes in QRS/ST/T-wave morphology can be observed within minutes. If you take a baseline 12-lead ECG on scene and then another when the patient is loaded in the back of the ambulance, that is frequently enough time to observe the change, which could influence the transport destination.

 

We're only scratching the surface of where we could (and should) go with prehospital 12-lead ECGs. It's an awesome tool, but to unlock the full potential requires time and education.

 

Tom

 

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

[David Carter]

In my opinion, biometric testing is still in its infancy and portability.  We now have high specificity troponin I test that are opening new doors.  My question is what is the next test that will apply to out of hospital care.  Keep in mind EMS arrives very early in the event.  The myoglobin may not have elevated when we arrive....  let alone the troponin....
 
David Carter RN MBA

Site Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza 

---

Date: Fri, 7 May 2010 13:38:02 -0400

Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

From: tbout...@gmail.com
To: naemsp...@googlegroups.com

---

The New Busy is not the old busy. Search, chat and e-mail from your inbox. Get started.

[Craig McMillan]

Tom's comment caught my attention.

I am interested to hear if the group thinks that using POC biomarkers (such as iStat), used in conjunction with prehospital 12 leads would significant improve the sensitivity and specificity of  STEMI (or NSTEMI) alerts?

Is anybody already doing this?

Craig McMillan

Clifton Park Ambulance

Albany NY

[Mic Gunderson]

(Posted on behalf of Dudley Wait)

I will echo Marc's comments. We leave the 12-lead on once we have run
one...our monitors watch the ST segment and on more than one occasion
over the last 4 years it has spit out another 12-lead once the ST
segments began to elevate.

We also train our EMT first responders to utilize the 12-lead
equipment
on their apparatus even if there are no EMT-P providers on the truck.
If they see Acute MI Suspected on the print-out, they pre-alert the
responding medics...who at times have then pre-alerted the hospital
even
before the ambulance arrives on scene. The couple of calls where this
have happened have had shorter scene times and really quick D2B times.

Dudley
Schertz EMS
Schertz TX

[tbouthillet]

That's true, David, but since a large percentage of patients are still waiting a couple of hours prior to contacting 9-1-1, there's an excellent chance that the myoglobin will be elevated. For prehospital use, I look at biomarkers like posterior chest leads. They have the potential to allow us to cast a wider net.

I don't see much value in obtaining leads V7-V8 when you've already identified an acute inferior STEMI with reciprocal changes. However, I do see value in obtaining them when the only significant finding on the initial 12-lead ECG is ST-depression in leads V1-V3.

Similarly, I don't think we should require positive cardiac biomarkers for patients who present with an obvious STEMI on the initial 12-lead ECG. On the other hand, an acutely ill patient with a nondiagnostic ECG, ST-depression, T-wave inversion, or baseline abnormalities that obscure the diagnosis of AMI, point-of-care biomarkers could help with the triage decision. 

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

On Fri, May 7, 2010 at 5:27 PM, David Carter <dave_...@msn.com> wrote:

In my opinion, biometric testing is still in its infancy and portability.  We now have high specificity troponin I test that are opening new doors.  My question is what is the next test that will apply to out of hospital care.  Keep in mind EMS arrives very early in the event.  The myoglobin may not have elevated when we arrive....  let alone the troponin....

 
David Carter RN MBA
Site Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza 

---

[tbouthillet]

As I mentioned to David, I don't think biomarkers should be required for home run STEMI patients. Including patients with ST-depression and positive biomarkers seems like the next logical step, but a decision like that would have to include all of the stakeholders in ACS care, since "early invasive strategy" for select NSTEMI patients does not always include an urgent trip to the cath lab (although it seems to be leaning in that direction).

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

On Sat, May 8, 2010 at 11:35 AM, Craig McMillan <crai...@planetnz.com> wrote:

Tom's comment caught my attention.

I am interested to hear if the group thinks that using POC biomarkers (such as iStat), used in conjunction with prehospital 12 leads would significant improve the sensitivity and specificity of  STEMI (or NSTEMI) alerts?

Is anybody already doing this?

Craig McMillan

Clifton Park Ambulance

Albany NY

[Mic Gunderson]

(Posted on behalf of Ryan Lewis)

First, thanks to NAEMSP for offering this forum. I was excited to see
the topic of reducing the reperfusion interval, and reviewed the
featured article. I am also pleased to have been reminded of the
differences in this challenge when operating in rural versus the
mainly urban/suburban communities in which I practice.

Certainly 12-led electrocardiography plays a role in reducing the time-
to-readiness interval for the cath lab, and may help to reduce ED
times where patients do not bypass the ED. Still, it is only one
weapon in the medical director's armament for attacking barriers to
optimal reperfusion times. As technologies evolve, the feasibility of
more-widespread transmission will increase; however, in systems both
with and without this capability, I believe EMS systems have an
obligation to actively participate in at least three other types of
process optimization.

First, assuring that there is a process and common approach to
managing the first few minutes of a chest pain call can drastically
reduce the time to initial EKG acquisition, allowing crews to focus on
rapid transport and facilitating early hospital notification. The
value of 12-led transmission in speeding lab readiness is lost when we
don't acquire a diagnostic EKG until we are 5 minutes form the
hospital. Crews in our System acquiring a 12-lead before a 4-lead EKG
acquired it on average four minutes earlier than crews applying the 4-
lead first. Concerns for protection of patient modesty rank among the
most frequent reasons cited by our crews for delays in acquiring early
12-leads in both public and residential call locations. Consideration
could be given to equipping first responders to apply the precordial
leads, reducing time to application and serving as a visual reminder
to arriving ambulance-based crews to acquire the 12-lead early.
Scripted initial actions, coupled with retrospective and in-field
quality observations, may be the keys to establishing and monitoring
processes to ensure prehospital time reduction for STEMI patients. We
cannot control the distance people choose to live from our stations.
We generally cannot control where receiving hospitals are constructed,
or the density of traffic on our travel routes. Once we have optimized
unit deployment, the on-scene interval with the STEMI patient is the
only element of the prehospital timeline directly within our control,
we should have a responsibility to manage it.

Less common in my experience, but nonetheless important, is EMS
management of destination planning and interaction. The responsibility
of the EMS system to the community need not end at the hospital doors.
We may not be able to dictate the course of clinical care once our
patient is transferred, but EMS medical directors across the US have
begun to require application of hospitals to the EMS system in order
for PCI facilities to become and remain eligible to receive these
valuable human commodities. Some of these EMS agencies require the
hospital to share 100% feedback on patients transported for
interventional care or made STEMIs by the ED staff, allowing agencies
to understand their over and under triage rates. Ceilings for
acceptable door-to-balloon intervals are identified, performance is
reported, and patients may be selectively routed to other hospitals if
approved facilities fail to meet performance targets for volume,
efficiency, or outcomes over specified periods. With qualified
facilities identified, EMS may ask to participate in facility
committees charged with overseeing the in-hospital process. In our
community, we have partnered with receiving hospitals to streamline ED
care by helping to script ED actions. For instance, where diagnostic
quality EKGs are obtained in the prehospital environment, and lab
staff are present, the prehospital EKG is labeled to hospital/
accreditation and the patient remains on the EMS cardiac monitor and
stretcher. Interventionalists agreed that there was little value to be
gained in an ED chest radiograph when the lab offered better views
with one step on the pedal, eliminating the only other call to
transfer acute STEMI patients to the ED bed. After a quick patient
review by an ED attending, and rapid registration, the patient is
being rolled to the cath lab on the EMS stretcher, often in less than
5 minutes from hospital arrival. EMS personnel attend the monitor and
tie up only one hospital staff member from EDs that are already
stretched for patient-to-staff ratios by escorting the patient to the
lab. Where street volume allows, crews may remain to witness the
intervention should they so choose. While this has the benefit of
allowing the crews to immediately see patient outcomes, it also gives
us a diverse set of eyes to view the process and help to continuously
find new opportunities to improve it. In any case, EMS and its medical
direction are participating in process optimization inside the
hospitals' doors.

Finally, EMS agencies may play a role in reducing the time to
reperfusion by making minimization of the reperfusion interval a goal
in equipment specification. We can seek technologies that do not
require us to be so attentive as to continue to press the button to
acquire 12-lead EKGs but that instead schedule them or continuously
monitor ST segments. We can ask our vendors to allow easy patient data
entry in a format that, when transmitted, meets national patient
labeling standards for instant integration into the hospital record
and eliminates the need for an ED 12-lead to accomplish this goal. We
can insist that our vendors utilize non-proprietary data formats and/
or agree to to interface to existing or future transmission,
documentation, and other data infrastructure. The process of equipment
specification and selection should not be ignored.

While these examples may not be practical in every community, my
intended point is that the reach of EMS in reducing time to
reperfusion may be significantly broader than equipping ourselves to
acquire and communicate the 12-lead. Are there other opportunities for
EMS to reduce this interval that I have not touched on that our expert
panel or others could expound upon? Can destination management be
accomplished in most communities at the local level, or do we need
states to make such decisions legislatively within the purview of EMS
systems and communities?

Thanks for your time,

RSL

Ryan S. Lewis
Chief Clinical Officer
Wake County EMS System
Raleigh, NC

[David Carter]

Ryan,
The real question is how do we shift culture on a nation wide bases?
There is not just one front we must approach. First, we (EMS) must be
competent and consistent. Easier said than done. We have greatly
improved over the last 10 years on STEMI's. Something we should have
been experts in years ago. Fortuneatly there is now a critical mass of
physicians in prominent positions that started out in EMS. They have
become advocates for EMS and understand the weakness and strengths.
Second is research that supports why these patients benefit from PCI
over thrombolitics: done. Then we need research that demonstrates EMS
can discern STEMI: done, within acceptable limits in may communities or
they can transmit (not my favorite option).
Lastly we need to partner with the hospital's, medical community and
professional societies (ACC, AHA, ACEP ect): Now occurring across the
US.
Working with our medical directors, state medical directors, funding
sources are also extremely important. Most of the state medical
directors I have spoken with are in favor of regionalization on a number
of fronts: STEMI, CPAP, Hypothermia, STROKE, Trauma ect.

We are in the midst of turning a huge ship. The good news is that it is
turning.

David Carter RN, MBA

Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza

-----Original Message-----
From: naemsp...@googlegroups.com
[mailto:naemsp...@googlegroups.com] On Behalf Of Mic Gunderson
Sent: Monday, May 10, 2010 7:12 AM
To: NAEMSP Dialog
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[tbouthillet]

Ryan - 

I agree! The patient's-side-to-ECG interval is a very important benchmark to track! You are correct in that many paramedics are perfectly content to see the 3-lead ECG until the patient is in the back of the ambulance. By then, 15 minutes has gone by, and we know now that there's a significant increase in mortality for every 15 minutes of delay. Not to mention that we've given our oxygen and nitroglycerin 15 minutes to "clean up" the ischemic signs on the ECG.

I also think it's important to make sure that our EMTs and paramedics are prepping the patient appropriately. Patients should be completely undressed from the waist-up, the leads should be placed with care (the limb lead electrodes on the limbs and the precordial leads placed properly -- the majority of the time they are not placed properly, even in textbooks), and the ECG leads should be stranded out individually, not wrapped around oxygen and IV tubing. The patient should not be "twiddling" the leads and the patient should be in a comfortable position; not propping themselves up by the arm, and not shivering.

It's possible to obtain a prehospital 12-lead ECG with outstanding data quality, but it's like anything else. If it's not being watched, the results will be extremely variable. We get into the "technician" versus "clinician" discussion all the time on various listservs and forums, but the reality is that even if we're technicians, in many cases we're not very good ones when it comes to taking pride in doing the job with a high degree of precision.

I think all of your other comments are right on the money. Step 1 is to make sure that EMS is represented on the multi-disciplinary STEMI committee. That was a real door-opener for us, and it was also one of the primary goals of the SC Chapter of AHA Mission: Lifeline. Literally within a couple of months, I witnessed barriers start to melt away for EMS systems all over the state, and now we're doing beautifully.

We should expect 100% follow-up and data sharing with all of our STEMI patients (or suspected STEMI patients), including angiograms and cath reports if the patient was emergently cathed. These make the best "case studies" for continuing education. Some of my favorite ECGs are "false positives" from NC's RACE program. They're great learning opportunities to explain things like strain patterns from left ventricular hypertrophy.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

[Neubecker, Diana]

To decrease E2B time and improve M&M, it is important to emphasize chest
discomfort is just one indication for a 12-L ECG. Anginal equivalents
and risk factors need to be considered, esp. in women, the elderly, and
pts with DM or HF.

Of all pts diagnosed as having MI, one-third (33%) did NOT have chest
pain on presentation to the hospital. MI pts without chest pain had a
23.3% in-hospital mortality rate compared with 9.3% among patients with
chest pain. National Registry of Myocardial Infarction: 434,877
patients with confirmed MI. (JAMA. 2000;283:3223-3229.)


Diana Neubecker RN BSN EMT-P
NWC EMSS In-Field Coordinator

******************* PLEASE NOTE *******************
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[Mic Gunderson]

How does your EMS system handle the patient who either walked into a
non-PCI hospital or arrived under-triaged by ambulance and was found
shortly thereafter to have a STEMI and the ED is now requesting an
ambulance to transfer the patient to a PCI hospital? Does your EMS
system respond with lights and sirens to the ED? Why or why not?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

[saturnsc...@aol.com]

Mic,

Thanks for the Opportunity to follow this group and to all for the
educational responses.

To best answer your question, here is the link to the protocol for our
County that deals directly with the Inter-Facility Transfer of a STEMI
Patient.

http://www.sbcounty.gov/icema/protocols/New%20Manual/p08%20p8040.pdf

In terms of the why and why not, I will leave that for my Medical
Director to respond as I know he follows this discussion as well.

Christopher Linke
Paramedic
San Bernardino County AMR

-----Original Message-----
From: Mic Gunderson <mic.gu...@gmail.com>
To: NAEMSP Dialog <naemsp...@googlegroups.com>
Sent: Mon, May 10, 2010 8:29 pm
Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow
Interval for AMI

[Mic Gunderson]

(Posted on behalf of Launa Nielson)

Does our EMS system respond to the ED lights and sirens? Absolutely
not.
It would make a difference of approx 10 seconds and is far, far too
dangerous. Going lights and sirens increases your chances of having a
crash
many times over (sorry, can't remember the figure--see Nadine Levick
MD's
site www.objectivesafety.net). Besides which, when we do arrive at
our
rural ED they are frequently not ready for us anyway--still waiting
for
paperwork, labs, x-rays etc... We rarely go lights and sirens to
anything
anymore.

Launa Nielson
Wasatch County EMS
Heber City, UT

[Mic Gunderson]

(Posted on behalf of Adam Thompson)

Hello all, I am glad to join in this discussion. Late apparently.

Some research I was just reading prior to checking out this
discussion:

-----------------
PREHOSPITAL 12-LEAD ECG: EFFICACY OR EFFECTIVENESS? Robert Swor, DO,
Stacey Hegerberg, RN, Ann McHugh-McNally, Mark Goldstein, RN, EMT-P,
Christine C. McEachin, RN, EMT-P

ABSTRACT
Introduction. Previous literature has documented that prehospital 12-
lead electrocardiography (ECG) decreases the time to reperfusion in
patients with an acute ST-segment elevation myocardial infarction
(STEMI).

Objective. To compare time to ECG, time to angioplasty suite
(laboratory), and time to reperfusion in emergency medical services
(EMS) STEMI patients, who received care through three different
processes.

Methods. The setting was a large suburban community teaching hospital
with emergency department (ED)- initiated single- page acute
myocardial infarction (AMI) team activation for STEMI patients. The
population was STEMI patients transported by EMS fromJanuary 2003 to
October 2005. Not all EMS agencies had prehospital 12-lead ECG
capability. Paramedics interpret and verbally report clinical
assessment and ECG findings via radio. The AMI team is activated at
the discretion of the emergency physician 1) before patient arrival to
the ED based on EMS assessment, 2) after ED evaluation with EMS ECG,
or 3) after ED evaluation and ED ECG. Time intervals were calculated
from ED arrival. To assess the impact of interventions on performance
targets, we also report the proportion of patients who arrived in
laboratory within 60 minutes and reperfusion within 90 minutes of
arrival. Parametric and nonparametric statistics are used for
analysis.

Results. During the study period, there were 164 STEMI patients
transported by EMS; mean age was 66.1 years, and 56% were male. Of
these, 93 (56.7%) had an EMS ECG and 31 (33%) had AMI team activation
before ED arrival. Mean time to laboratory for all patients was
49.8±34.4 minutes and time to reperfusion was 93.2 +/- 34.5 min.
Patients with prearrival activation were transported to laboratory
sooner (mean, 24.3 vs. 53. 4 minutes; p < 0.001) and received
reperfusion sooner than all other patients (mean, 70.4 vs. 96.3
minutes; p= 0.007). More prearrival activation patients met
performance targets to laboratory (96.7% vs. 73.7%; p = 0.009) and
reperfusion (85.2% vs. 51.0%; p = 0.003). There was no difference in
time to laboratory or to reperfusion for patients who received EMS ECG
but no prearrival activation compared with those who received EMS
transport alone.

Conclusions. A minority of patients with EMS ECGs had prearrival AMI
team activation. EMS ECGs combined with systems that activate hospital
resources, but not EMS ECGs alone, decrease time to laboratory and
reperfusion.

PREHOSPITAL EMERGENCY CARE 2006;10:374-377
-----------------

Looking at the research only roughly 57% of STEMI patients even had a
prehospital ECG performed. This begs for more education on when to
perform a 12-lead ECG. Gut instinct is not a clinical indication.

33% Cath lab activation. These are STEMIs we are talking about here,
not UA/NSTEMI patients that were recognized by biomarkers. I'm not
sure as to when the STEMI was recognized, because the full study does
not provide that data. There is no way of knowing if these patients
showed ST-elevation during their time with EMS, but over 43% of them
didn't even receive a prehospital 12-lead ECG, and that can be
improved upon.

This data is over 4 years old now, just thought I would jump into the
conversation.

As Tom has advocated, I believe a better education in 12-lead
acquisition, and interpretation is desperately needed for paramedics.
STE-Mimic recognition is lacking by most, and apparently knowing when
to even perform the procedure is lacking.

Any thoughts?

Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College

[Marc Berenson]

I think Adam brings up an important point: The technology is only useful when it is correctly applied. I have observed a mindset that 12 Lead EKGs should only be performed in the prehospital setting when there is a suspicion that there will be a positive result. Most 12 Lead EKGs performed in the ED setting are not acutely ischemic but rather mandatory as part of a thorough evaluation / rule out process. If, as this one abstract suggests, we are missing over 40% of EMS transported STEMIs (though I'd really like to know if all those EMS transports were ALS vs BLS), Adam is right that we need to start at the beginning and talk about when these should be performed and manage the expectations of prehospital providers so that the default assumption is that the vast majority of these will be negative.

Just a little bit of anecdote: I have seen pale, cold, diaphoretic, severely distressed 10/10 chest pain patients an ACS admission but no STEMI. I have also seen pleasant, barely distressed, 2/10 patients having STEMIs. Gut instinct, while a valuable tool in many cases, can run you very afoul in detecting AMI. 

One last thing - The most important piece of that abstract is the following: "EMS ECGs combined with systems that activate hospital resources, but not EMS ECGs alone, decrease time to laboratory and reperfusion." If we want this to work, we have got to get the buy-in from our in-hospital partners.

--

Marc Berenson, MICP, NREMT-P

MICU Paramedic

Holy Name EMS

Hackensack University Medical Center
beren...@gmail.com

[tbouthillet]

One of the things I found out through my work with AHA Mission: Lifeline is that some EMS systems simply do not do interfacility transports. Other EMS systems will not leave their jurisdiction for any reason. That means that a patient with an acute STEMI who presents to a non-PCI hospital (or is triaged to a non-PCI hospital) and undergoes failed thrombolysis could languish in a hospital bed and ultimately receive no reperfusion, especially during periods of bad weather when aeromedical transport is not an option. 

It seems to me that EMS systems that "don't generally do interfacility transports" should make an exception for time sensitive life threatening medical emergencies (e.g., acute STEMI, subarachnoid hemorrhage, and so on). The argument that "they're in a controlled environment" holds absolutely no water in these situations. So I feel that these types of calls should be handled with all the urgency of a 9-1-1 call, and transferring units should not be waiting around for x-rays and paperwork (the x-ray isn't necessary and the paperwork can be faxed).

This issue of whether or not the unit responds "lights and sirens" is not as relevant, as long as the unit is dispatched and responds immediately. I think this is a good example of the types of issues that need to be addressed when building regionalized systems of care, and AHA Mission: Lifeline can be huge asset. First, because they can't help shed light on the issue. Second, because of their strategic alliances with groups like the ACC, ACEP, ENA, etc.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

[tbouthillet]

Why not spell out the complaints that warrant a 12-lead ECG?

Those should include:

Chest pain or discomfort (nose to navel, front and back)

* includes arm, neck, back, or jaw pain without chest pain as well as epigastric pain

Shortness of breath (especially new exertional dyspnea)

Syncope or near-syncope

Palpitations

Unexplained nausea and/or vomiting

Feeling of impending doom

Diaphoresis unexplained by ambient temperature

General weakness

Suspected diabetic ketoacidosis

I would simply caution that the specificity of EMS-initiated STEMI Alert is much lower when the chief complaint is something other than chest discomfort, so it's up to each STEMI system to determine what constellation of signs and symptoms warrants a STEMI Alert or non-PCI hospital bypass.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

[Nick Nudell]

These are all valid concerns. Marc I appreciate your comment about only doing an EKG when its assumed it will be positive for STEMI.

 

Diana mentioned yesterday that 30% (some papers show it as high as 60%) of AMI's occur without symptoms that are recognized by the patient or the provider as anginal equivalents. That is 30-60% of people who live long enough to call 911 or arrive at the hospital (that is only 70% of the total).

 

This results in only a fraction - 21% conservatively - of patients who could have ST changes suggestive of an AMI are having EKGs acquired in a timely manner.

 

If we perform an ACS risk assessment for every patient, as common as the ABCs, would that help reduce the false negative rate? If we put an end to the "requirement" that a patient must have angina to warrant an EKG, would that help? How many EMS protocols are still written  to include a "chest pain" protocol? What if the patient is among the large minority that doesn't have "chest pain"?

 

I regularly talk to cardiac patients that do not and have never had chest pain or even anginal equivalents. They can have ST elevations at rest or significant ST changes on a treadmill yet have no symptoms at all. Many have aches and pains that are common among ACS patients (many of whom also have peripheral vascular disease), that in c-spine clearance we would call "distracting injuries", yet in this instance we rely on the severity of chest pain to do a workup.

 

Cheers,

Nick

 

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[David Carter]

On the same topic, there is an EMD card for dispatch that helps with assessing the urgency of the transfer.  If our dispatch heard STEMI, we were dispatched "priority"  lights and sirens verses "without delay".  We treated it like a scene call and the ED we worked with were very cooperative in getting the patent out the door and keeping our scene time to a minimal.  In my new facility we typically fly STEMI's out.  Bay Flite remains "HOT" and I am happy to say that their average "scene time" is 10 min or less.  We are ready for them when they arrive.

 
David Carter RN, MBA
Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza
 

---

Date: Tue, 11 May 2010 14:04:02 -0400
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI
From: tbout...@gmail.com
To: naemsp...@googlegroups.com

---

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[ADAM THOMPSON, EMT-P]

Now that is an idea Tom. Chest pain has proven itself a poor lone
indicator of MI. This is quite an interesting discussion, with
seemingly knowledgeable individuals. What is the goal here? If we
are discussing this to make progress, how are we going to do it? Tom
has listed some great indications for acquiring a 12-lead ECG, where
do we take this information? In the end, deficiencies can be
discussed and debated all day long, but I believe solutions should be
proposed. I think a curriculum change needs to be made. Whether it
be through the actual initial paramedic practicum or advanced classes
like ACLS, there needs to be more. There are probably hundreds of
discussions just like this one, begging for a solution.

Here are some of the problems we have listed:

- Poor knowledge on when it is appropriate to obtain a 12-lead ECG

- Poor STEMI recognition

- Poor destination determination (ie. PCI facility)

- Poor inter-facility transport protocols for active STEMI patients

- Poor 12-lead acquisitions (ie. clothing, artifact, etc.)

Solution time, where do we start and how do we get there?

ps. Tom, how did you become affiliated with the AHA, this is something
I have been interested in for a while. Shoot me an email if
possible.

Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College

Paramedicine101.blogspot.com
Paramed...@gmail.com

[Laurie Romig]

We try to take the subject of potential atypical presentations of ACS very seriously here in Pinellas County, and it's paid off well in very low missed STEMI rates. Quoted below is part of our 12 Lead ECG Procedure so that you can see our approach. It's relatively easy for us to do this because we are an all-ALS system and we do tend to do 12 leads at the drop of a hat, but with nearly 800 paramedics and about the same number of EMT's, I count this as a low cost risk management and skills competency approach.

"It is certain that many infarcting patients that dial 911 will not present with chest pain. Obviously, not every out-of-hospital patient should receive a 12 lead ECG and judgment must be exercised. However, EMS can maintain a high index of suspicion, obtaining a 12- lead ECG when an Acute Coronary Syndrome (ACS) is considered a realistic possibility. Such suspicion may help to identify these patients earlier. The following Anginal Equivalents are to be used during the assessment of patients over the age of 30.
a.    Dyspnea
b.    Chest pain
c.    Palpitations
d.    Syncope or near syncope
e.    CVA/TIA
f.    General Weakness
g.   DKA/Diabetes
h.   CHF/PE
i.    Diaphoresis not explained by environment
j.    Heart rate over >150 or < less than 50
k.    Epigastric pain or indigestion
l.    Thoracic back pain without trauma
m.    Overdose (OD) especially with tricyclic antidepressants, cocaine and other known substances that may cause cardiac irregularity.
n.    Cardiac transplant patients

Patients with severe and/or multiple risk factors should be evaluated with a high index of suspicion for acute coronary syndrome. Such would include:
a.    Individuals under the age of 30 that have pre-existing cardiovascular disease
b.    Smoking
c.    Hypertension
d.    Family history
e.    Obesity and sedentary lifestyle
f.     Hyperlipidemia"

Laurie

Laurie A. Romig, MD, FACEP
Medical Director

Pinellas County (FL) EMS

[Nick Nudell]

Dr. Romig that is comendable and great to see!

 

Not as a critique of that protocol but for the purposes of this discussion, I would suggest consideration of a patient's TIMI risk score and recent history may be very appropriate as an indicator of transport destination (not just EKG acquisition). That can be simplified (perhaps) by adaption for use in a manner similar to a trauma triage system.

 

There are two TIMI scoring methods, depending on the presentation (STEMI or NSTEMI/UA) [too complicated to discuss in this thread but I have a lot of info on TIMI scoring]. Patient's scoring 3 or more have between 5-41ish% risk of having a second event within 1 (for STEMI) or 6 (for NSTEMI) months. That could probably be broken down a little more but to keep it similar to triage categories, there could be something like this for patients with the kinds of symptoms you describe in your protocol (not requiring any EKG findings):
TIMI   Triage Color      Destination

1-2       Green             any ED is ok

3-4       Yellow            chest pain center

4+       Red                 open cath lab with surgical backup only

 

Other details like patients who recently stopped taking plavix in <1 year from a stent placement, <60 days from stent placement, recent positive stress test without intervention, etc should perhaps be upgraded to the next level.

 

It would not be too difficult to develop a decision tree that could be used here.

 

What do you think?

 

Cheers,

Nick

 

 

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[ADAM THOMPSON, EMT-P]

Nick,

I think that is a good idea.

Check out the following study:
The TIMI risk score for unstable angina/non-ST elevation MI: A method
for prognostication and therapeutic decision making.

Abstract:
CONTEXT: Patients with unstable angina/non-ST-segment elevation
myocardial infarction (MI) (UA/NSTEMI) present with a wide spectrum of
risk for death and cardiac ischemic events. OBJECTIVE: To develop a
simple risk score that has broad applicability, is easily calculated
at patient presentation, does not require a computer, and identifies
patients with different responses to treatments for UA/NSTEMI. DESIGN,
SETTING, AND PATIENTS: Two phase 3, international, randomized, double-
blind trials (the Thrombolysis in Myocardial Infarction [TIMI] 11B
trial [August 1996-March 1998] and the Efficacy and Safety of
Subcutaneous Enoxaparin in Unstable Angina and Non-Q-Wave MI trial
[ESSENCE; October 1994-May 1996]). A total of 1957 patients with UA/
NSTEMI were assigned to receive unfractionated heparin (test cohort)
and 1953 to receive enoxaparin in TIMI 11B; 1564 and 1607 were
assigned respectively in ESSENCE. The 3 validation cohorts were the
unfractionated heparin group from ESSENCE and both enoxaparin groups.
MAIN OUTCOME MEASURES: The TIMI risk score was derived in the test
cohort by selection of independent prognostic variables using
multivariate logistic regression, assignment of value of 1 when a
factor was present and 0 when it was absent, and summing the number of
factors present to categorize patients into risk strata. Relative
differences in response to therapeutic interventions were determined
by comparing the slopes of the rates of events with increasing score
in treatment groups and by testing for an interaction between risk
score and treatment. Outcomes were TIMI risk score for developing at
least 1 component of the primary end point (all-cause mortality, new
or recurrent MI, or severe recurrent ischemia requiring urgent
revascularization) through 14 days after randomization. RESULTS: The 7
TIMI risk score predictor variables were age 65 years or older, at
least 3 risk factors for coronary artery disease, prior coronary
stenosis of 50% or more, ST-segment deviation on electrocardiogram at
presentation, at least 2 anginal events in prior 24 hours, use of
aspirin in prior 7 days, and elevated serum cardiac markers. Event
rates increased significantly as the TIMI risk score increased in the
test cohort in TIMI 11B: 4.7% for a score of 0/1; 8.3% for 2; 13. 2%
for 3; 19.9% for 4; 26.2% for 5; and 40.9% for 6/7 (P<.001 by chi(2)
for trend). The pattern of increasing event rates with increasing TIMI
risk score was confirmed in all 3 validation groups (P<.001). The
slope of the increase in event rates with increasing numbers of risk
factors was significantly lower in the enoxaparin groups in both TIMI
11B (P =.01) and ESSENCE (P =.03) and there was a significant
interaction between TIMI risk score and treatment (P =. 02).
CONCLUSIONS: In patients with UA/NSTEMI, the TIMI risk score is a
simple prognostication scheme that categorizes a patient's risk of
death and ischemic events and provides a basis for therapeutic
decision making. JAMA. 2000;284:835-842

Sorry, the link to the full study was broken. Other studies show that
the TIMI risk score is outdated for the hospital, but without cardiac
biomarkers, as in the prehospital environment, I see it's worth. Good
point to bring up! I would like to hear from any of those agencies
that use prehospital fibrinolytics, and how they feel about the ease
of the score to use.

Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College

Paramedicine101.blogspot.com
Paramed...@gmail.com

[Laurie Romig]

Hi Nick:

That particular procedure doesn't cover transport destination decisions; regardless, I've not considered basing any destination decisions based on TIMI scores. As a matter of fact, I'd have to do some digging to see if it would be effective and/or practical for us, so I'm not even going to try to give you what would be an uninformed opinion at the moment. Interesting thought though! It could very well help us with some of our gray area, false positive patients. Thanks for the idea!

Laurie

Laurie A. Romig, MD, FACEP
Medical Director
Pinellas County (FL) EMS

[Mic Gunderson]

Nick Nudell provided a PDF of the paper on the TIMI scoring (Antman et
al:The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI - A
Method for Prognostication and Therapeutic Decision Making. JAMA.
2000;284:835-842). It is now available for download on the resource
page (http://groups.google.com/group/naemsp-dialog/web/topic-3---ems-
role-in-reducing-symtom-to-reflow-interval-in-ami).

Thanks Nick!

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

[Mic Gunderson]

(Posted on behalf of Geoff Dayne)

I'm kind of late replying to this one, but in Los Angeles County, we
were told that a non-STEMI center can call 911 for an emergent
transfer to a STEMI Receiving Center. My agency's response area does
not have an ED in it, so I cannot say for 100% certainty the response
mode. I would guess it would be with lights & sirens because it is a
911 call and that is how most agencies respond to 911 medical calls.

Geoff Dayne
Paramedic / Firefighter
Santa Fe Springs Fire Rescue
Los Angeles County, CA

[DW...@schertz.com]

Dr. Romig,

 

Thanks for the protocol language, but there is a line in this protocol I have heard many, many times in a number of protocols, discussions and other email lists...yet I do not know why. 

 

"Obviously, not every out-of-hospital patient should receive a 12 lead ECG..." 

 

My question is "Why Not?"  I often joke that our protocol in the Schertz system for getting a 12-lead is "the ability to call or have 911 called for you".  This came from several years ago when we first acquired the ability to do 12-leads and being a small-to-medium sized agency, the frequency of conducting 12-leads was not common enough to retain the initial 12-lead interpretation training or the opportunity to get better.  So, we started encouraging our medics to acquire 12-leads on just about anyone they could so that they could see more of them.  We evaluated their interpretation ability and our crews were able to increase their 12-lead interpretation skills and actually used this tool to find a few things that we probably wouldn't have found otherwise. 

 

Then when we began differentiating for STEMI's we had some early success in finding STEMI's in atypical patients which further increased their eagerness to do 12-leads as regularly as possible. 

 

I have always assumed that the reluctance to do them with greater frequency was probably tied to hospital or physician office practice and potentially tied to funding issues in these environments...but since EMS reimbursement for 12-lead ECG's is spotty if at all, are there other reasons why this philosophy may be present in EMS Systems? 

 

Just curious.

 

Dudley Wait

Schertz EMS

---

From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Laurie Romig
Sent: Tuesday, May 11, 2010 7:18 PM
To: naemsp...@googlegroups.com

Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

[Paul Rostykus]

I think that there are two separate and related issues here:

1)      Obtaining a pre-hospital 12 lead ECG, which should have a low threshold (as for BP or CBG) such as the list below (a – n) from Dr. Romig (most of whom do not have ACS or at least do not need to go to the cath lab emergently)

2)      Using the information from the field 12 lead ECG for EMS to bypass some hospitals, which will be very system dependent

 

In our system, we have chosen to have fairly limited clinical criteria (cardiac chest discomfort or Vfib/Vtach converted to a spontaneous rhythm) and ECG ST elevation criteria that are highly correlated with STEMI for direct EMS cath lab activation.  All other patients, some of whom may truly have ACS, are evaluated at the hospital of their choice by a physician and then, if appropriate, may be transferred to a cardiologist.  Most of the non-STEMI ACS patients in our area are not taken emergently to the cath lab.  The cath team and cardiologists are happy that only about 5% of our EMS STEMI Activation patients do not go emergently to the cath lab.  By expanding our clinical criteria, we would very likely have more cath team/cardiologists standdowns, and thus less support for our STEMI program.  Additionally, if more patients without STEMI (or ACS) were diverted away from their usual hospital of care and taken to the cath lab hospital, we would very likely lose local hospital and physician support for our program.

 

Thanks.

 

Paul S. Rostykus, MD, MPH

Jackson County (OR) EMS Supervising Physician

 

From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Laurie Romig
Sent: Tuesday, May 11, 2010 5:18 PM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

 

We try to take the subject of potential atypical presentations of ACS very seriously here in Pinellas County, and it's paid off well in very low missed STEMI rates. Quoted below is part of our 12 Lead ECG Procedure so that you can see our approach. It's relatively easy for us to do this because we are an all-ALS system and we do tend to do 12 leads at the drop of a hat, but with nearly 800 paramedics and about the same number of EMT's, I count this as a low cost risk management and skills competency approach.

No virus found in this incoming message.
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[Marc Berenson]

**Devil's Advocate Warning** :)

 

In general, I'm a pretty vocal proponent for increasing scope of knowledge for prehospital providers. I think pushing the boundaries is what keeps us moving forward and driving both excellent prehospital and, in some cases, in-hospital care. However, I do think we have to ask ourselves at what point are we expecting too much from the average field ALS provider?

 

The core of this job is performed in an non-sterile, uncontrolled and sometimes unstable environment. While most Paramedics I know pride themselves on their ability to bring a sense of calm to that storm, there comes a point where the burden to perform too many tasks may in fact reduce the effectiveness of those tasks already being performed.

 

Dr. Romig said she has over 800 paramedics to supervise in her system; is it realistic that a system with that many providers will be able to perform this correctly and in timely fashion? Also, in an all ALS system, are providers being exposed to these cases with enough frequency to handle this level of sophisticated triage? **Of course none of this is an attack on individual system's performance in any way.**

 

The science is not yet there to support early intervention for NSTEMI 100% of the time - hence why it is not a standard of care. We should acknowledge that STEMI centers (or whatever equivalent name you have for them in your systems) are designed to rapidly facilitate emergency cardiac catheterizations for patients who need them. Therefore, as EMS systems, we should send patients who require emergency reperfusion to those facilities. This is paramount to excellent cardiac clinical care.

 

However, simply bypassing patients because there is a chance that at some point they may require some type of PCI feels like we are over-reaching. Many community hospitals will fight these diversions as they seem them as potential revenue lost... not the most altruistic of reasons but whether we like it or not (and most days I don't like it), healthcare is a business. Also, if the patient doesn't need that intervention, we now have removed them from their community and decreased their likelihood for continued and successful follow up care. If the patient requires further care, an appropriate level interfacility transfer can accomplish that goal.

 

Again, I'm mostly playing devil's advocate here. But I think it's easy to get caught up in very good and somewhat Utopian ideals and lose sight of the (sometimes unfortunate) realities that get in our way.

 

MB

--

Marc Berenson, MICP, NREMT-P
MICU Paramedic
Holy Name EMS
Hackensack University Medical Center
beren...@gmail.com

[Doc Wesley]

I have been lurking on this topic from the beginning and would like to
chime in with some thoughts.

False Positive Issue
There is a difference between Inappropriate Activation and False
Positive Cath. A Inappropriate Activation is where the medic
incorrectly makes a STEMI interpretation when in fact there is no
diagnostic ST elevation. The most common cause of this is failure to
recognize a LBBB. It also depends on the criteria you use for ST
elevation. Most programs require >1mm in inferior leads and >2mm in
precordial leads. Some programs require >1mm in precordial leads and
this results in increased False Positive Caths since repolarization
and J point elevation (particularly in the younger patient) can
present with 1mm elevation in the precordial leads. Few programs
activate the cath lab based on suspected new LBBB and posterior MI
findings. In my system the Inappropriate activation is less than 3%
with bundle branch block leading the cause.

False Positive Cath is a patient with STEMI criteria who is found
to have no culprit artery and the JAMA article by Larson confirms that
this rate is 8-14%.

The bottom line is EMS can do nothing about the False Positive
Caths. We only have control over our interpretation and perhaps this
is where the risk assessment scores may help lower the False Positive
Caths however I doubt it. They will simply be seen in the ED, get a
cardiology consult and then get a cath (perhaps the next day)

Cost of 12-lead acquisition
The AHA study that condemned the lack of 12-lead availability did
not take into consideration that 12-lead ECG is for the vast majority
of the nation only provided by Paramedic services. Paramedic services
are concentrated in the urban and suburban areas where access to PCI
centers is highest. Therefore, the greatest potential impact of pre-
hospital 12-leads is going to be in the BLS areas where the issue of
diversion of air medical use should be considered.

Now to the cost. I'm amazed at the number of BLS services who have
developed a 12-Lead program are buying used LP12s at the cost of
10-15K. This is overkill since the vast majority of the devices
capabilities are not within the scope of the BLS provider. I have
researched the options and found a PC Laptop based 12-Lead device that
connects to the USB port and if the laptop has an aircard in it can
then send the ECG to the receiving hospital or simply transmit over
the radio the ECG interpretation. Learn more about this at
http://www.dremed.com/catalog/product_info.php/products_id/1662
It cost about 3K

Strategies to Reduce Time
I apply the same standards of the ED to pre-hospital 12-lead
acquisition. 12-Lead within 10 minutes of patient contact. Cath Lab
Activation within 10 minutes of ECG acquisition.

Another strategy that we are studying is drawing blood on NSTEMI
patients so that when they arrive at the ED their cardiac markers can
be sent directly to the lab and started. We hypothesize that this will
result in 30-40 minute reduction in time to lab results which for the
NSTEMI patient who is still having pain and has elevated markers may
provide them a wider window of good results from early PCI.

Sorry for the long post. Look forward to your comments

Keith Wesley, MD
Medical Director
HealthEast Ambulance
St. Paul, MN

[tbouthillet]

Excellent comments, Dr. Wesley.

My service uses 1 mm of ST-elevation (2 mm in leads V2 or V3). Typically the "male pattern" of ST-elevation (or J-point elevation) is limited to the right precordial leads. I think it would be a mistake to require 2 mm of ST-elevation in leads V5 and V6.

I suspect one of the reasons paramedics fail to recognize LBBB is that most paramedics don't understand the difference between a primary and a secondary ST-T wave abnormality. That's unfortunate because it's present in most of the STE-mimics (LBBB, paced rhythm, and LVH in particular). The concept of "appropriate T-wave discordance" and recognition that the degree of secondary ST-T wave abnormality tends to be proportional to the size of the QRS complex was a major "ah-ha!" moment for me. It's the gift that keeps on giving, but it's certainly not being taught in the run-of-the-mill 6-8 hour "STEMI Recogition" courses being taught around the country. 

I also think we need to re-think the "new LBBB" criteria (and I hope it changes with the 2010 update). As the focus shifts from "rise and fall of cardiac biomarkers" to "thrombotic lesion in an epicardial coronary artery confirmed by angiography" we will continue to see that new LBBB secondary to acute STEMI will meet Sgarbossa's criteria (or the modified form that takes into account the depth of the S-wave for discordant ST-elevation). As I mentioned before, almost half of LBBB patients in the Larson study had no culprit artery.

As for NSTEMI patients and TIMI risk scores, I think a more "fast and dirty" risk score could be developed for field use (think Cincinnati Stroke Scale) for select NSTEMI patients. For example, positive troponins and ST-depression or dynamic T-wave inversion. However, it's worth pointing out that the same conditions that cause STE-mimics also cause STD-mimics. However, if the patient is not going to be emergenty cathed at the receiving facility, it's a waste of time and money, IMHO. It could also undermine support for the STEMI system if referral hospitals (and cardiologists at referral hospitals) perceive it as a significant loss of revenue, rightly or wrongly.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

@tbouthillet / @EMS12Lead

On Wed, May 12, 2010 at 10:01 AM, Doc Wesley <drwe...@charter.net> wrote:

False Positive Issue
   There is a difference between Inappropriate Activation and False
Positive Cath. A Inappropriate Activation is where the medic
incorrectly makes a STEMI interpretation when in fact there is no
diagnostic ST elevation. The most common cause of this is failure to
recognize a LBBB. It also depends on the criteria you use for ST
elevation. Most programs require >1mm in inferior leads and >2mm in
precordial leads. Some programs require >1mm in precordial leads and
this results in increased False Positive Caths since repolarization
and J point elevation (particularly in the younger patient) can
present with 1mm elevation in the precordial leads. Few programs
activate the cath lab based on suspected new LBBB and posterior MI
findings. In my system the Inappropriate activation is less than 3%
with bundle branch block leading the cause.

  False Positive Cath is a patient with STEMI criteria who is found
to have no culprit artery and the JAMA article by Larson confirms that
this rate is 8-14%.

 The bottom line is EMS can do nothing about the False Positive
Caths. We only have control over our interpretation and perhaps this
is where the risk assessment scores may help lower the False Positive
Caths however I doubt it. They will simply be seen in the ED, get a
cardiology consult and then get a cath (perhaps the next day)

[Laurie Romig, MD, FACEP]

I see your point Dudley, but when you do 180,000 plus responses a year and are as liberal as we already are with doing 12 leads (and have been for many years), practicality has to be considered. I think that your idea is great for services that are relatively new to doing 12 leads, where the percentage of patients with “obvious indications” (as previously defined by local protocol or as perceived by the medics) is low, and/or where call volume is low enough to absorb the extra time required (as relatively minimal as it may be). We don’t discourage our folks from doing 12 leads and we probably have higher expectations for when 12 leads should be done than many EMS systems do. In addition, we require all medics to have completed an 8 hour 12 lead course either prior to or within about 6 months of entry into our system, offer 12 lead courses monthly, and include 12 lead interpretation in our CME programs. Of course, this doesn’t mean that all of our folks are equally competent, but I think we have a decent balance between education, protocol, liberal practice, and keeping the system functioning.

 

Everybody else’s mileage is highly likely to vary!

 

Laurie

Laurie A. Romig, MD, FACEP

Medical Director

Pinellas County EMS

[Nick Nudell]

Hi Dr. Wesley,

Regarding false positives... LBBB can be diagnostic for an acute ACS event. In your measure of false positive reductions are you also measuring false negatives? If so, how are they discovered?

 

About false positive cath's... what is a culprit artery? This is very difficult to define without a core lab with over readers using consistent criteria. Some are cardiologists are more aggressive and some are more conservative in lesion identification and stent placement versus medical therapy and even then, some lesions can't be stented. You didn't mention what the criteria is?

 

I enjoyed your comments on the laptop 12 lead. I have one (Nasiff brand http://www.nasiff.com/suite.html) myself ;-) and have done lots of non-clinical EKGs with it although they aren't as simple as a purpose built box they can be done. EMT's have no trouble connecting a pulse ox and auto-BP to a patient, I see no reason they couldn't also apply a 12 lead for someone else to interpret.

 

Does your QA process only include patients who complain of "chest pain"? How do you discover the patients that did not get a field 12 lead but got one at the ED or ended up having an ACS diagnosis? I think that is a current dilemna in many places.

 

By the way, I've seen a number of patients now with active vulnerable plaques (+ rupture) that present without enzyme changes. They also usually present with minimal EKG changes, typically slight Twave inversions or ST changes in various locations. I think most of these have been LAD or circumflex distributions as well.

 

Take care,

Nick

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[Mic Gunderson]

Dr. Wesley and Nick,

Are either of you (or anyone else...) aware of BLS systems using older
monitor defibrillators without 12 lead technology per se to get
'diagnostic' tracings for the purpose of STEMI identification using
MCL leads as surrogates for V leads? With these older machines, you
could get all 6 precordial leads (in MCL format) and well as I, II and
III if recording in the 'diagnostic' mode. I'm certain that many of
you were 'early adopters' and did this 'back in the day' before
prehospital 12 machines were on the market. Is that such a bad option
for BLS systems to keep costs down (or for some ALS systems with less
financial means)?

--- Mic

Mic Gunderson
Editor / Moderator, NAEMSP Dialog;
President, IPS

[Launa Nielson]

This is going to sound corny but living in a rural area in the Rockies, some of you probably have no idea just how informative and helpful this discussion has been for us! (I know, grammatically that stinks)  Dudley your idea would work great for our agency and I will try to implement it asap.  I could go on and on but thank you to all of you for sharing your thoughts and current policies.  Please continue with your great ideas .

Launa Nielson

Wasatch Co EMS

[tbouthillet]

I also think you have to be careful, because the reality is that paramedics are taught a very surface-level understanding of 12-lead ECGs. I've seen one occasion where a 16 year old female with a congenital heart defect received a prehospital 12-lead ECG for a panic attack and was given MONA (minus the morphine) because the 12-lead ECG showed a right ventricular strain pattern (which showed ST-depression in the precordial leads). You can see the ECG here. If we start thinking that any given patient might be a STEMI, regardless of their age, chief complaint, or reason for calling 9-1-1, we're actually taking away common sense and critical thinking, and perhaps making it even more confusing for our paramedics. There has to be a history of present illness that makes sense or we're going to see a huge number of false positives.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

@tbouthillet / @EMS12Lead

[Laurie Romig, MD, FACEP]

Hi Marc:

 

I definitely have to agree with your point that it is possible to go overboard with the triage to PCI facilities. We first officially started our PCI transport policy for STEMI patients in 2002 and have stuck pretty closely to classic 12 lead criteria for STEMI partly because of the concern from our non-PCI facilities about interrupting continuity of care for their patients and, frankly, loss of income. Their fear was that anyone who had chest pain would end up going to PCI because “they might need it”; that’s one reason that we require on-line medical control contact (ours is centralized, rather than hospital based) for STEMI Alert patients and other potential ACS patients for whom the crews believe that PCI transport may be indicated. Initially, we did get a significant number of “just to be safe” consults; we do still get them occasionally, but they tend to be centered around atypical presentations, STEMI mimics and “gut feelings”. Another reason for not wanting to overdo PCI triage is that many of our PCI facilities tend to be our higher volume ED’s and also have other limited resource capabilities. If we severely over-stress those facilities without sufficient cause, we may interrupt their abilities to provide some of those other services to other patients. Even in our system where 7 out of our 12 hospitals have PCI capability and all hospitals are within a 200 square mile area, that can become a significant system resource issue. I can only begin to imagine the implications for rural systems with much more limited resources.

 

And yes, the size of my EMS brood (can you tell that I’m a bit motherly about it?) presents a constant challenge, and one that has to factor into everything we do. Fortunately, I’m blessed with strong support for medical direction and have the data to show that we’re doing a really good job in this particular arena, so something’s working!

 

Laurie

Laurie A. Romig, MD, FACEP

Medical Director

Pinellas County EMS

 

From: naemsp...@googlegroups.com [mailto:naemsp...@googlegroups.com] On Behalf Of Marc Berenson
Sent: Wednesday, May 12, 2010 2:55 AM
To: naemsp...@googlegroups.com
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

 

**Devil's Advocate Warning** :)

[Mic Gunderson]

(Posted on behalf of Daniel Griffin)

This is a great discussion. I have been teaching 12 Lead EKGs for our
local
Paramedic program for about 12 years and enjoy reading the blog posts
from
many of the contributors on the list.

I wanted to add some information that many EMS providers may not be
aware of
in regards to curriculum changes suggested by other contributors on
the
list. Like many other states, we in Florida are working on the
implementation of the new EMS Education Standards. These Standards
will
replace the National Standard Paramedic Curriculum (NSC) written in
1998.
The 1998 NSC has very little information about 12 lead EKG use in the
field,
since it was not a common practice at the time on a nation level.

One of the most important, but often overlooked facts about the
standards is
the document is not a curriculum, but is a set of terminal objectives
that
will be used by each instructor to write their own local curriculum.
This
allows the instructors local control and the ability to add new
material
when evidence (research) determines it should be a standard of care
and
taught in EMS education programs. I saw the reference in an earlier
post
about the need to update and change the curriculum for 12 lead EKG
recognition and the new EMS education standards will allow instructors
to do
just that at a State or local level.

As this discussion moves towards a set of recommendations for
improvement of
STEMI care, I would suggest the a proposal for EMS education
objectives that
can be used by your local educators to improve EKG interpretation and
cardiac care. Although,I recognize this does not help the current
field
provider, we can make changes that will have long term effect for the
entry
level paramedic coming out of our local EMS programs.

Keep up the good work!

Danny

Daniel J. Griffin, CCEMTP, President
The Florida Association of EMS Educators
Gainesville, FL.

[Doc Wesley]

Nick raises several great points.

First, culprit artery was a term used by Larson in JAMA study and
essentially an operative lesion.

Second, we over-read every 12-lead performed at HeathEast Ambulance to
catch false-negatives

Third, if an ACS is discovered at a receiving hospital that my medics
failed to do a 12-lead we have a CQI Inquiry process that I can
guarantee you they will let me know.

Finally, the issue of the NSTEMI with dynamic ECG changes is not a
case most cardiologist want to take directly to the cath lab. These
patients often have small vessel disease and other associated medical
problems (particularly renal insufficiency) that if taken directly to
the cath lab have significantly more complications.

What I hear from the interventional cardiologist is that they have a
great sense that if the patient is taken to the Cath lab they are feel
incredible pressure to do the cath. I know that this is a poor
argument. They should "man up" and re-evaluate the patient and inform
them that they don't need a cath right now. But the argument has
fallen on deaf ears when the transferring hospital and doc have
already told the patient "we're sending you to the PCI center to get a
cath"

Keith Wesley, MD
Medical Director
HealthEast Ambulance
St. Paul, MN

--

[tbouthillet]

Dr. Wesley - 

We hear the exact same thing here.

I can sympathize in today's medico-legal climate! When you already have a STEMI Alert (confirmed by a board certified ED physician) spinning up the cath lab and putting a whole system into motion for a patient who is showing signs and symptoms of sudden cardiac ischemia, I think you really are sticking your neck out when you say, "Hold on.... I'm not sure it's a STEMI. Let's wait." 

The quality assurance folks are watching! Of course, that's why you said they need to "man up" but I'll bet it only takes one time being wrong (and being sent to peer review) to make you say, "The heck with it, if they call me in a patient's getting cathed!" 

So unless it's an obvious case where atrial flutter is mistaken for ST-elevation or the STEMI Alert was called based on a computerized interpretive statement confounded by horrible data quality, I understand why the patient ends up on the cath table. Incidentally, this is all a valid reason why it's not a bad idea for the interventional cardiologist to get the ECG on a handheld and be the one to make the STEMI Alert (or Code STEMI) decision! But from what I've seen, they often don't want that responsibility.

Tom

--

Tom Bouthillet

Lieutenant / Paramedic

Town of Hilton Head Island

Fire & Rescue Division

843-247-3453 (cell)

ems12lead.blogspot.com

@tbouthillet / @EMS12Lead

[ADAM THOMPSON, EMT-P]

I have a short but essential question.

What are cardiologists being taught in regards to STEMI recognition
that paramedics aren't? Obviously, cardiologists have more tools at
their disposal to confirm an ACS event, but if their 12-lead
interpretations are better, why can't we teach this to paramedics?

On a side note, I am soon presenting a STEMI vs. STE-Mimics class to
my EMS agency. If any of you have some good references or resources
please send them my way.

Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College

Paramedicine101.blogspot.com
Paramed...@gmail.com
@Paramedicine101

[Mic Gunderson]

(posted on behalf of Tom Bouthilliet)

It could be taught to paramedics, but we'll never have the same level
of
education and experience to go along with it. Cardiologists read
hundreds if
not thousands of 12-lead ECGs during residency and fellowship.

Having said that, there's no secret to it. The information is out
there and
it's learnable. On the other hand, Tomas Garcia MD (12-Lead ECG: The
Art of
Interpretation) is fond of saying that the #1 reason cardiologists
fail
their board examinations is ECG interpretation!

Think of the controversy with prehospital tracheal intubation. You
might
say, "If anesthesiologists have fewer unrecognized esophageal
intubations,
what are they learning that paramedics aren't? Why can't we teach it
to
paramedics?"

Well, a lot of it can be taught to paramedics. For example, how to
evaluate
a patient's airway anatomy for difficulty or ease of intubation. Why
is it
that most paramedics have never heard of a Cormack grade or Mallampati
score? Is it any wonder we struggle with the skill when our initial
education was poor and our opportunities to perform the skill are few
and
far between?

So I would be in favor of a radically modified initial education that
actually teaches 12-lead ECG interpretation as opposed to "STEMI
recognition" which is problematic for many reasons, not the least of
which
is the fact that acute STEMI is not the most common cause of ST-
elevation in
chest pain patients.

If we really want to do an excellent job with the STE-mimics, we need
to be
able to understand the difference between a primary and secondary ST-T
abnormality at a glance. Instead, I see paramedics squinting at ECGs
trying
to add up the depth of the S-wave in lead V2 with the height of the R-
wave
in lead V5 or V6 to see if the voltage criteria for LVH is met, with
no
understanding of typical strain pattern is supposed to look like.

In spite of that, I keep hearing how "studies show" that paramedics
can read
an ECG "as good if not better than a doctor". Well, in the vast
majority of
circumstances it simply isn't true, and a lot of those studies that
took
place outside of venues like Boston measured whether or not paramedics
could
"identify ST-elevation" on the prehospital 12-lead ECG.

Obviously that's the wrong question.

So assuming that paramedics can be taught, we need to answer the
question,
"Who will teach the teachers?" because paramedic programs (generally
speaking) are not taught by physicians anymore, and we need to contend
with
the reality that the major stakeholders in EMS education don't want
this
much education and knowledge in the curriculum.

That means that the minority of EMS systems in the nation that really
want
to take it to the next level (and allow cath lab activation by
paramedics
from the field without ECG transmission) either have to do a lot of
after-market education or develop criteria that includes computerized
interpretive statements or strict protocols with matching clinical
criteria.

For example, if your protocol looks like this:

1.) The patient has signs and symptoms of ACS
2.) ECG shows excellent data quality
3.) QRS duration is < 120 ms
4.) No signs of LVH
5.) ST-elevation in 2 or more contiguous leads
6.) Reciprocal changes are present

You'll probably call a STEMI Alert with a fairly high specificity.
However,
your sensitivity will suffer.

For now, I think ECG transmission is the best way to go for the
majority of
EMS systems, provided that there's consistency in the quality of
interpretation and consistency of action on the other end of the
transmission.

I can imagine a day when 12-lead ECG interpretation will be a
fundamental
part of the paramedic education, but it will probably happen when
paramedic
education becomes a degree program.

Tom

--
Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
ems12lead.blogspot.com
@tbouthillet / @EMS12Lead

[Jerry Allison]

Great points by Tom Bouthillet.  We must keep in mind that while there are obvious ECG's (postivie s-t elev and neg s-t elev) there are many in between.  This is one reason why we often consult with cardiologists during our management of the patient with suspected MI.   We can provide the education to paramedics to understand and interpret the most difficult and challenging ECG's and to evaluate and manage the most complext airways.  How much time are we willing to put into the education program, or what are you willing to give up?     Jerry Allison, MD, MS, EMT-P (ret)

[ADAM THOMPSON, EMT-P]

Tom does make some excellent points.

Jerry,

I am not advocating the instruction of every possible ECG
presentation. We may not even have to change the paramedic
curriculum, which I do feel is lacking in many other areas as well. A
possible solution in my opinion would be an adjunct course. As
paramedics we cary CPR, BTLS, PHTLS, ACLS, PALS cards in many areas.
Some of these are required by our governing agencies, and some are
required by our places of employment. ACLS is currently aimed at
advanced care, mostly for patients in cardiac arrest. The best thing
about these classes is the fact that you need to refresh them every so
often. Would a similar course, directed only at 12-lead ECG
interpretation be feasible?

-

Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College
Paramedicine101.blogspot.com

Paramedicine...@gmail.com
@Paramedicine101

[David Carter]

In the dark ages (when I became a paramedic) there were no paramedics to teach paramedicine.  My instructors were nurses and physicians.  In the last 30 years (since the dark ages)  that has shifted to almost 100% taught by paramedics.  Not that that is bad.  To be a nursing instructor you must have a masters.  I am not saying all paramedic instructors need to have a masters.  I have found paramedic program quality inconsistent across the US.  This is an opportunity. 
We need to reengage folks with higher level of education and experience in teaching and the training of paramedics.
 
This is my favorite test:  Ask 10 of your paramedics how to perform a TTJV.  Many do well on the insertion and securing of the catather.  Where I have been disappointed is in how they ventilate the device.  Of course the correct answer is with a 50 PSI source of O2.  Sadly, I have had many state that using a #3 ET tube adapter attached to a ambu bag (50 cm water pressure) the way to ventilate...... we need to improve consistency of education across the US.
 
David Carter RN MBA
Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza 
 
> Date: Wed, 12 May 2010 13:20:30 -0700
> Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI
> From: aj.thomp...@gmail.com
> To: naemsp...@googlegroups.com

---

The New Busy is not the too busy. Combine all your e-mail accounts with Hotmail. Get busy.

[David Carter]

Funny, I have seen ED and Cardiologist disagree on ECG's.  We don't need or want 100% . I would be comfortable with 85% or higher accuracy in recognizing STEMI.  I see the NSTEMI as the next challenge.  We do not have a star trek device to wave over the patient (yet) to give us a diagnosis.  I also disagree with pushing transmission. To me that is saying Paramedics can not be taught.  They can and do quite well.  Let along the ability to transmit is spotty at best. 

 
David Carter RN MBA
Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza
 

> Date: Wed, 12 May 2010 12:22:47 -0700

> Subject: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI

> From: mic.gu...@gmail.com
> To: naemsp...@googlegroups.com

---

The New Busy think 9 to 5 is a cute idea. Combine multiple calendars with Hotmail. Get busy.

[Mic Gunderson]

(posted on behalf of David Carter)

We need to push the development of technology that will facilitate
quick efficient recognition of ACS that needs early intervention. Both
STEMI and NSTEMI that need immediate cath or intervention. We as a
group need to look past today and ask for tomorrow. 10 years ago there
was much debate about the value of troponin and the specificity...
just 10 years ago. Now its the gold standard.

What is the technology or assessment that will help guide us....... we
need to innovate. During my days in Dallas we were studying "near
infrared spectrophotometry" for assessing cellular oxygen levels.


We need a device that we place on the chest and it sees the heart
ejection fraction and performance and interpretation of the
performance. There is now an ultrasound device being tested that
accomplishes many of the above,

David Carter RN MBA

Sarasota Memorial Health Care System
North Port Medical Plaza

[tbouthillet]

David -

 

I don't think I'm "pushing transmission" as much as recognizing that it's the most realistic solution considering the current state of paramedic education in the vast majority of the country. I'm certainly not saying that paramedics can not be taught, because I think anyone with reasonable intelligence and the desire to learn can be taught. The question is, are they being taught and to what level? 

 

If we're all agreed that paramedic education needs to be enhanced, what are we going to do about our STEMI patients in the meantime? Developing consensus on the national level about what paramedics should be taught is not easy, so I still think this is going to have to be solved locally.

 

Paramedics (and even EMTs) should be able to detect homerun STEMI's (heart rate < 100, narrow QRS complexes, 4-5 mm ST-elevation, reciprocal changes) after a 6-hour STEMI recognition class. That's the low-hanging fruit, and I agree that EMS professionals can easily be taught to recognize these situations, especially with the aid of computerized interpretive algorithms.

 

However, this cannot substitute for expert interpretation, and I worry about the patients we leave behind. There will always be marginal cases with minimal ST-segment deviation or low voltage (the so-called "semi-STEMIs") that are ambiguous and fall through the cracks, or patients with baseline abnormalities like LBBB, or isolated posterior STEMI for whom the diagnosis may not be immediately obvious to a paramedic in the field (or even the ED physician at the hospital).

 

But our goal should be to "catch" as many of these patients as possible.

 

Sometimes ECG transmission allows for an "old" ECG to be pulled from the chart for comparison. That's huge, and it has nothing to do with what a paramedic can or cannot learn to do.

 

You stated that you would be comfortable with 85% accurate STEMI recognition by paramedics, but even that is prone to misunderstanding without elaborating on the sensitivity and specificity. Are we talking about 85% sensitivity and 65% specificity? 65% sensivitity and 85% specificity? 85% sensitivity and 95% specificity?

 

My general sense is that each EMS system is different (often radically different), and experience has shown that any of the 3 strategies (paramedic interpretation, computerized interpretation, ECG transmission) can work, but that paramedic interpretation requires the most time and effort. I'm in favor of any system that creates a safer environment for our cardiac patients.

 

Perhaps the optimal solution is that "appropriately trained" paramedics initiate a STEMI Alert when the patient meets certain criteria, and the ECG is transmitted (where transmission is available) for marginal cases. But again, what really matters is that the stakeholders in each system come to some kind of agreement as to how the system should function.

 

Tom

 

--
Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
ems12lead.blogspot.com
@tbouthillet / @EMS12Lead

 

On Wed, May 12, 2010 at 7:06 PM, David Carter <dave_...@msn.com> wrote:

Funny, I have seen ED and Cardiologist disagree on ECG's.  We don't need or want 100% . I would be comfortable with 85% or higher accuracy in recognizing STEMI.  I see the NSTEMI as the next challenge.  We do not have a star trek device to wave over the patient (yet) to give us a diagnosis.  I also disagree with pushing transmission. To me that is saying Paramedics can not be taught.  They can and do quite well.  Let along the ability to transmit is spotty at best. 

 
David Carter RN MBA
Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza
 

[tbouthillet]

Adam -

 

The problem is that these certifications will become as useless as ACLS certification. Can anyone say with a straight face that the current video-driven ACLS course is anything other than a complete waste of time? I'm an ACLS instructor but I dread being asked to teach ACLS class (although I'd like to teach the EP course). The AHA now offers the Learn: Rapid STEMI ID program, but that won't be the avenue through which we are liberated from ECG transmission. It's only approved for 4.62 contact hours by the ENA.

 

There is clearly a huge disconnect between what I perceive paramedics "ought to know" compared to what other folks think paramedics ought to know.

 

Tom

--
Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
ems12lead.blogspot.com
@tbouthillet / @EMS12Lead

 

On Wed, May 12, 2010 at 4:20 PM, ADAM THOMPSON, EMT-P <aj.thomp...@gmail.com> wrote:

Tom does make some excellent points.

Jerry,

I am not advocating the instruction of every possible ECG
presentation.  We may not even have to change the paramedic
curriculum, which I do feel is lacking in many other areas as well.  A
possible solution in my opinion would be an adjunct course.  As
paramedics we cary CPR, BTLS, PHTLS, ACLS, PALS cards in many areas.
Some of these are required by our governing agencies, and some are
required by our places of employment.  ACLS is currently aimed at
advanced care, mostly for patients in cardiac arrest.  The best thing
about these classes is the fact that you need to refresh them every so
often.  Would a similar course, directed only at 12-lead ECG
interpretation be feasible?

-
Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College
Paramedicine101.blogspot.com

Paramedicine...@gmail.com
@Paramedicine101

 

--

[Nick Nudell]

Hi Adam,

I think one primary but very important difference is that cardiologists have access and opportunity to compare their EKG findings with patient presentation and outcomes. Whether they follow the patient in the cath lab or in the clinic, they are able to correlate the EKG with anatomy, medication usage, and further care.

 

In EMS, we see patient's only briefly before handing them off. While some systems can provide abbreviated information about what happened to the patient after hand-off, it is far from universal and most likely does not tell the whole story.

 

This combined with the limitations of EMS education in the topic provides the primary differences, in my opinion. There are others, such as the undergraduate physics, chemistry, and biochem that most physicians are required to take. An understanding of these is very helpful in learning electrocardiography. 

 

The fundamentals of these should also be a part of EKG training for EMS.

 

Cheers,
Nick

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[Nick Nudell]

David,

To ask for tomorrow... I might suggest a high specificity/sensitivity measure that can indicate when a plaque vulnerable to rupture that does not require a patient to first have symptoms. Now that is a challenge and is not likely to be a technology used in EMS unless the event happens in our presence!

 

As long as EMS is a "responder" we will have to wait for something to happen to respond to. Perhaps that response could be to an early warning system. Disclaimer: my employer is sponsoring a clinical trial of an investigational implanted early warning system based on objective measures of ischemia (no symptoms required). I am not authorized to speak on behalf of my employer - my opinions are my own.

 

JACC has accepted (in press) the first peer reviewed paper of the DETECT and CARDIOSAVER studies, abstract pasted below (actual pub date should be very soon). The authors concluded that patients with the early warning system had a median alert-to-door time of 19.5 minutes.

 

Cheers,

Nick

 

Initial Clinical Results Using Intracardiac Electrogram Monitoring to Detect and Alert Patients During Coronary Plaque Rupture and Ischemia

Tim A. Fischell, MD, David R. Fischell, PhD, Alvaro Avezum, MD, M. Sasha John, PhD, David Holmes, MD, Malcolm Foster III, MD, Richard Kovach, MD, Paulo Medeiros, MD, Leopoldo Piegas, MD, Helio Guimaraes, MD, and C. Michael Gibson, MS, MD

ABSTRACT

Objective:

We report the first clinical studies of intracardiac ST-segment monitoring in ambulatory humans to alert them to significant ST-segment shifts associated with thrombotic occlusion.

Background:

Despite improvements in door-to-balloon times, delays in symptom-to-door times of 2-3 hours remain. Early alerting of the presence of acute myocardial infarction (MI) could prompt patients to seek immediate medical evaluation.

Methods:

Intracardiac monitoring was performed in 37 patients at high risk for acute coronary syndromes. The implanted monitor continuously evaluated the patients’ STsegments sensed from a conventional pacemaker RV apical lead, and alerted patients to detected ischemic events.

Results:

During follow-up (median 1.52 years, range 126-974 days) 4 patients developed STsegment changes of > 3 standard deviations of their normal daily range, in the absence of an elevated heart-rate. This in combination with immediate hospital monitoring led to angiogram and/or IVUS which confirmed thrombotic coronary occlusion/ruptured plaque. The median alarm-to-door time was 19.5 minutes (6, 18, 21, and 60 minutes). Alerting for demand related ischemia, at elevated heart-rates, reflective of flow-limiting coronary obstructions, occurred in 4 patients. There were 2 false-positive ischemia alarms related to arrhythmias and 1 due to a programming error that did not prompt cardiac catheterization.

Conclusions

: Shifts exceeding 3 standard deviations from a patient's daily intracardiac STrange may be a sensitive/specific marker for thrombotic coronary occlusion. Patient alerting was associated with a median alert-to-door time of 19.5 minutes in patients at highrisk of recurrent coronary syndromes who typically present with 2-3 hour delays.

 

___________________
Nick Nudell
medi...@gmail.com
(714) 699-3549

[Mic Gunderson]

(posted on behalf of Dudley Wait)

Tom,

I have seen your outline for a 12-lead class for EMS. My thoughts are
that we do not necessarily need another merit badge course...but I
believe we need to develop a standard curriculum of 12-lead knowledge
that should be included in any course or any agency that wants to have
a
robust 12-lead program. This curriculum would then be signed off by
the
ACC or some other body of physicians. It sets a standard while working
towards buy-in from the physician group we need to build the
relationship with the most.

Dudley Wait
Schertz EMS

[David Carter]

In 2020 it will all be clear.  Until then, research like the one you are engaged is the way to get to 2020.  While the 12 lead and Troponin are the standard today, we may be looking a a very different set of indicators tomorrow.
also... I recognized that all paramedics are not created equal. 

 
David Carter RN MBA
Administrator

Sarasota Memorial Health Care Sstem
North Port MedicaL Plaza  

---

From: medi...@gmail.com
Date: Thu, 13 May 2010 14:49:06 -0700
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI
To: naemsp...@googlegroups.com

---

The New Busy think 9 to 5 is a cute idea. Combine multiple calendars with Hotmail. Get busy.

--

[David Carter]

I am sad to say I have to agree with you... I just don't want to accept it. 

 
David Carter RN MBA
Administrator
Sarasota Memorial Health Care System
North Port Medical Plaza
 

---

Date: Thu, 13 May 2010 09:18:04 -0400
Subject: Re: [NAEMSP Dialog] Re: EMS Role in Reducing the Symptom to Reflow Interval for AMI
From: tbout...@gmail.com
To: naemsp...@googlegroups.com

---

Hotmail has tools for the New Busy. Search, chat and e-mail from your inbox. Learn more.

[tbouthillet]

That makes sense to me, Dudley! 

As a side-note, I attempted to take the ABIM's ICE ECG examination a few years back but it's not open to non-physicians.

Tom

-- 
Tom Bouthillet
Lieutenant / Paramedic
Town of Hilton Head Island
Fire & Rescue Division
843-247-3453 (cell)
ems12lead.blogspot.com
@tbouthillet / @EMS12Lead

[weg...@aol.com]

All,

In my last paramedic job before retiring, I was working in a rural system where the nearest hospital with a cath lab was 40 miles away.  Over the roads we had, this put us an hour to cathlab at best and, depending on what part of the county we found our patient in, up to 2 hours.  This made it imperative that we become competent at 12-lead interpretation.  We spent lots of time looking at LBBBs both with and without evidence of MI and I think most of us were quite comfortable with the subtlties of LBBB situations.

Since we were a small service, we tended to have well experienced paramedics.   We also had an awesome work ethic, and we peer reviewed every call ourselves and had frequent conferences with each other and our medical director, who ran the clinic next door. Every STEMI was reviewed at the monthly M&M meeting which everybody including the medical director attended.

We also used the Spectral Cardiac STATus test, which is a combined Myoglobin/Troponin I/CK-MB test that returns a reading in a maximum of 15 minutes and generally much more rapidly.

This enabled us to make the call early on and either call for air transport or start rolling toward the hospital immediately and call an alert very early on.  Actually, we would call our medical director on his cell or page him stat, and he would make the call based upon our reading and the test results.  He handled all conversations with the cardiologists except very rarely when he was unreachable by cellphone.  

During this time we had NO missed MIs that I recall,  and so far as I know no false alarms.

Query:  Does anybody else use the Spectral exam?  Would it be useful in other rural services?

Gene Gandy

[ADAM THOMPSON, EMT-P]

Dudley,

The reasoning behind my "merit badge course" proposal is that those
types of certifications have an expiration date. While I do think the
curriculum needs a solid change, continuing education is just as
important. There are tons of online 12-lead ECG courses as well as
available workshops, but none are traditionally required by employment
agencies, and the people whom take these courses and attend the
workshops are probably not the people whom need the education we are
talking about. At least we are now discussing solutions. I think
that Tom is right in regards to using ECG transmission in the
meantime. The research behind it is impeccable in comparison to
paramedics efficiency in STEMI determination.

Adam Thompson, EMT-P
Lee County (FL) EMS;
EMS Educator, Edison State College

Paramedicine101.blogspot.com

Paramed...@gmail.com
@Paramedicine101

> For more options, visit this group athttp://groups.google.com/group/naemsp-dialog?hl=en
> Visit NAEMSP athttp://www.naemsp.org.

[ADAM THOMPSON, EMT-P]

Nick,

You make some excellent points. Particularly, the access that
cardiologists have to the continuation of care. This is something
that I think would exponentially help us as paramedics. I feel like
we aren't making any progress when a paramedic can call a false-
positive STEMI and never be made aware of their mistake. They might
not ever be told why their ECG is negative for STEMI, or they may
never even be told that their patient wasn't a true STEMI. What
paramedic, knowing he/she just messed up, isn't going to go back and
learn more to avoid that mistake again? On the other side of things,
having the reassurance of your STEMI call could help as well. Seeing
your D2B time, and seeing before & after images of the culprit artery
would reinforce good STEMI care. I know this lack of feedback occurs
because it is occurring in my very system right now. Our PCI facility
use to provide a myriad of information on our STEMI patients, but has
recently put the kibosh on all feedback due to some "privacy
infractions".

Tom,

Is the AHA M:L working on hospital to EMS relations in regards to
outcomes and data feedback, or are they just sticking to getting STEMI
systems up and running, and registered?

Adam Thompson, EMT-P
Lee County (FL) EMS;

EMS Educator, Edison State College
Paramedicine101.blogspot.com
Paramed...@gmail.com
@Paramedicine101

On May 13, 3:55 pm, Nick Nudell <medicn...@gmail.com> wrote:
> Hi Adam,
> I think one primary but very important difference is that cardiologists have
> access and opportunity to compare their EKG findings with patient
> presentation and outcomes. Whether they follow the patient in the cath lab
> or in the clinic, they are able to correlate the EKG with anatomy,
> medication usage, and further care.
>
> In EMS, we see patient's only briefly before handing them off. While some
> systems can provide abbreviated information about what happened to the
> patient after hand-off, it is far from universal and most likely does not
> tell the whole story.
>
> This combined with the limitations of EMS education in the topic provides
> the primary differences, in my opinion. There are others, such as the
> undergraduate physics, chemistry, and biochem that most physicians are
> required to take. An understanding of these is very helpful in learning
> electrocardiography.
>
> The fundamentals of these should also be a part of EKG training for EMS.
>
> Cheers,
> Nick
>
> ___________________
> Nick Nudell

> medicn...@gmail.com

> (714) 699-3549
>
> On Wed, May 12, 2010 at 10:51, ADAM THOMPSON, EMT-P <
>
>
>
>
>
> aj.thompson.1...@gmail.com> wrote:
> > I have a short but essential question.
>
> > What are cardiologists being taught in regards to STEMI recognition
> > that paramedics aren't?  Obviously, cardiologists have more tools at
> > their disposal to confirm an ACS event, but if their 12-lead
> > interpretations are better, why can't we teach this to paramedics?
>
> > On a side note, I am soon presenting a STEMI vs. STE-Mimics class to
> > my EMS agency.  If any of you have some good references or resources
> > please send them my way.
>
> > Adam Thompson, EMT-P
> > Lee County (FL) EMS;
> > EMS Educator, Edison State College

> > Paramedicine101.blogspot.com <http://paramedicine101.blogspot.com/>
> > Paramedicine...@gmail.com

> > @Paramedicine101
>
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