Paramedic insight into wireless ECG transmission

[ohword3]

Hey guys,

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

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

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

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

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[Dwindlin]

Hey guys,

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

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

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

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

Not sure how insightful any of this will be, but we do use it here rather frequently.

1. Yeah, I think it is incredibly useful. Has most definitely shortened our door-to-balloon times.
2. I don't think so, we interpret the ECG ourselves, then the transmission is received by the ED doc, who makes the call on the cath lab. To my understanding the cardiologist won't see the ECG until the cath team is activated.
3. I would say make sure you have a good data provider. We recently changed our service provider and it's amazing how much faster the transmission is now.
4. Not really much to add here. As I already said, I think its a great tool.

 

[docB]

We don't have it. We have run into problems with overcalls from the field so cardiology won't move until we (the EPs) call them and tell them it's real. This slows down the times on the real ones. We also have problems with patients who have concerning EKGs but no other symptoms consistent with AMI. We'll continue the code STEMI for those but then the cardiologists call them off. They get irritated about it and that makes them more reluctant to move quickly when the code is initiated.

So in our case moving to realtime telemetry would fix some, but not all, of our problems.

 

[Deranged Medic]

Hey guys,

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

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

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

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

1. I do feel it is useful. I believe the most beneficial thing about being able to transmit an EKG is for the ED doc to actually see what I am talking about. Some of the ED docs I know state they feel a little more comfortable calling a cardiac alert when they can see it on an EKG vs taking my word for it.

2. I feel comfortable interpreting an AMI on an EKG in the field. I do not have to transmit the EKG, but if I feel like it warrants a cardiac alert, the ED doc usually wants to take a look at it. I transmit the EKG, then I call the doc and give him my interpretation. Like another poster stated, I do not think it goes to the cardiologist unless the ED doc sends it up for a consult or calls a cardiac alert.

3. We currently use a modem hooked into our lifepak 15. I do not really know anything else about it, but with iPads and 3G starting to gain some acceptance in the field, it seems like there is probably a better technology out there.

4. I do not know how proactive other regions are with cardiac alert patients, but our area is pretty good with sending us direct to the cath lab when we call a cardiac alert. Since I am still pretty new at the medic thing, I have not done this, but several of my coworkers have had this opportunity. Apparently this started to happen more once we started transmitting our EKGs. The cool thing-some of the EDs will post the EKG in the EMS room and state the 911 call to balloon time-I have seen a few times well under 1 hour!

 

[joeDO2]

Had the lifepak 15's with the modem attached for transmission. Before that we self-interpreted and activated over the phone. We retained the ability to activate based on our interpretation if data transmission was slow/not possible. There was not much delay since the system was setup so that after sending the ecg to the target hospital (takes about 1min) it automatically forwarded the ecg to the ED physician and interventional cardiologists PDA/smartphone.

 

[AlmostJesus]

Hey guys,

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

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

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

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

Might want to get a hold of the director of Mission Lifeline South Dakota through the AHA, they added 12 lead transmission capable monitors to every ambulance in the state. It would be nice to know if they are actually seeing an increase in cath lab activations. Check out the website and the director's name is there.

 

[tremulousNeedle]

Hey guys,

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

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

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

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

1) Field ECGs from the county paramedic service are very important in our major metropolitan area. They allow early activation of the cath lab in our county.
2) A trained cardiology is not necessary to read the ECG, but every EMS system needs to figure out what works for them. In our EMS system, paramedics do a prelim interpretation, but the cath lab is only activated by an emergency medicine physician viewing the electronically transmitted ECG.
3) My only concern is transmission failure. If a paramedic can text me a picture of an ECG (because my phone always has a signal), then a portable ECG machine should be able to get me a field ECG with high fidelity, which is not the case.

 

[Deranged Medic]

I guess the whole 12 lead transmitting thing isn't as awesome as I thought it was.

After multiple attempts a couple nights ago, our LifePak modem wouldn't transmit a 12 lead, and it turns out my pt had a 100% blocked LAD. Since it was the night shift, the hospital wouldn't call a cardiac alert unless they had the 12 lead in hand, and it took the poor pt arresting in the medic to get the ball moving.

I guess they are awesome when they work, but it sure sucks when it won't.

 

[Dwindlin]

I guess the whole 12 lead transmitting thing isn't as awesome as I thought it was.

After multiple attempts a couple nights ago, our LifePak modem wouldn't transmit a 12 lead, and it turns out my pt had a 100% blocked LAD. Since it was the night shift, the hospital wouldn't call a cardiac alert unless they had the 12 lead in hand, and it took the poor pt arresting in the medic to get the ball moving.

I guess they are awesome when they work, but it sure sucks when it won't.

Goes back to making sure you have a great service provider.

 

[OCDEMS]

When transmission first came around I was one of a few paramedics against it from a professional stand point. I personally had a very high level of comfort with 12-Lead ECG interpretation and thought that myself and my colleagues were more than capable of achieving a 90%+ confidence rate in identifying STEMIs. Furthermore, I had trained in a large urban system with several large academic interventional cardiology centers. All of them used paramedic identification alone to bypass the ED (or call a STEMI) and move to the cath lab. The cost of a missed call wasn't as high, since there were always fellows who were nearly always in the hospital willing to come take a look.

Then I moved to a less urban setting and got a different perspective. The problem is that much of the "brand name" ECG classes on the market do an absolutely poor job of stressing MI mimickers to paramedics. They also give the impression that STEMIs are just running around everywhere, when we know that a large percentage of chest pains are not cardiac in nature and that only about 30% of patients experiencing true ACS are STEMIs. I saw one paper that showed that only about 2% of ED patients presenting with chest pain are eventually given a diagnosis of STEMI. I believe I read only 4-5% of EMS chest pains are STEMIs.

Paramedics are preached "1 mm of elevation in two or more contiguous leads." Sure, but there are plenty of things that cause nonspecific elevation. Some paramedic programs get 2-3 days of 12-Lead ECG training by a guest lecturer and then poof, on the street. This is the problem with some paramedic programs: lots of information, some of it good, and very little exposure with a skilled mentor. I realized I was lucky to have an entire semester of cardiology, was made to interpret several hundred practice 12-Leads, and then was further given the opportunity to spend time with practicing ED physicians and see the type of stuff that came through the door, i.e. I got exposure to what was a "real" STEMI vs. suspicious findings. It also gave me a threshold for "calling" a STEMI in the field since I had exposure to seeing what generally went to an interventionist and which patients waited for enzymes.

We need longer paramedic programs with more exposure to educated, skilled mentors. 12-Lead ECGs should be taught by skilled instructors, preferably practicing EM physicians or cardiologist.

The reality is that in most EMS systems the paramedic still has control. We certainly don't transmit every 12-Lead, so the physician isn't going to see one unless we think it's a STEMI anyway. It's a useful check and I now understand it from an economic perspective. Plus, if you're unsure then just transmit. Better safe than sorry. At our local ED an interventionist has to be called in from home during the night, so I can only imagine the crazy cost to the hospital every time he gets up to find a non-billable patient. I can also imagine that this only has to happen a few times before the several thousand dollars of transmission equipment pays for itself.

 

[joeDO2]

At our local ED an interventionist has to be called in from home during the night, so I can only imagine the crazy cost to the hospital every time he gets up to find a non-billable patient. I can also imagine that this only has to happen a few times before the several thousand dollars of transmission equipment pays for itself.

That's why its best to have transmission to their smartphone. They can take a look and decide whether to come in or wait for further evaluation by the ED.
Although I do agree with you that we need further educational opportunities at the paramedic level, transmitting the ecg will get a more accurate interpretation the vast majority of the time. After the 4 weeks of ecg in medic school, a semester of electrocardiography in college, 5 years prehospital experience, and 2 years of medical school, there are still things that I occasionally miss that a cards fellow would see right away. Its simply not realistic to try to equalize the interpretation skills. Any medic evaluation will be a broad screening at best.

 

[docB]

This discussion has gone in some interesting directions.

A few points:

The stakes on STEMI have gone way up in this age of massive pressure on door to balloon times. In my area crews are so afraid of missing a STEMI that they way overcall. I am forced to overcall as well. The professional liability (both med mal and hospital political) for me to miss a STEMI vs. call something that turns out not to be a STEMI is too great. So if it conceivably could be a STEMI and it's got a good story I call it. I have seen a lot of questionable cases called (not just by me) and taken to the lab because of this weird tyranny we now practice under regarding "missing" a STEMI by not making the time.

My point is that this issue is not just about wether or not a medic can recognize a STEMI. There's a lot more confounding baggage that has been heaped on this issue than that alone.

The other thing I see coming up is the practice of bypassing the ER. Medics love this. But this practice has some issues. First it is only even possible in facilities with a 24 hour staffed cath lab and cards on site. I would guess that describes <15% of hospitals in the country and I'm probably too high on that. Second I think the Emergency Physician has something to contribute to these cases. I see so many instances where patients need additional diagnostics or stabilization before they go to the lab. I also see the chaos when patients become unstable once already in the lab. As mentioned in a previous post only a subset of patients with chest pain are ACS and only a subset of those are STEMIs. Well only a subset of STEMIs are appropriately sent to the lab bypassing the ED.

 

[Oenak]

The province I currently work in has a Vital Heart Response (VHR) program in place.

We have thrombolytics in every ALS ambulance along with enoxaparin and clopidogrel. Our process upon recognition of an acute STEMI is to transmit the ECG while actively treating the chest pain, administer thrombolytics at the discretion of one of the emergency physicians involved in the VHR program (or just administer antithrombin medications if thrombolytics are not indicated), and then transport the patient either directly to the cath lab or to the ED chosen by the consulted emergency physician.

To answer your questions:

1) For our purposes transmission of the ECG has a direct impact on patient care as they can receive thrombolytics in the field. Our LP15s rarely have transmission issues. If there is no service in a particular area it is easy enough to travel down the road and try again.

I work casual for another service that uses the new Zoll monitors. Transmission is done by tethering an iPhone to the monitor. I have yet to transmit by this method so I cannot comment on its effectiveness.

2) We are responsible for identifying a STEMI in the field and then transmitting it to the emergency physician for interpretation. If it is a non-STEMI, we do not transmit the ECG and simply transport the patient to the nearest ED.

3) The system we have now is pretty seamless. Press transmit on the LP15, select the recipient, and the ECG is promptly received on the emergency physician's phone.

4) No comments right now!

 

[Paseo Del Norte]

n=1 anecdote: I've been pulling shifts for a rural service and we transport to a rural hospital without a cath lab; however, a chest pain certified facility is a bit over an hour away and that facility is owned by the same company that owns the smaller facility, making transfers a bit easier in some sense. When we perform a XII lead, the results are sent to both facilities and if the ER doc at the rural facility decides to call a "code heart," the transfer to the cath lab capable facility appears to be quite smooth as the receiving physician already has the initial XII lead and some basic patient information when the ER physician makes the call.

 

[isquared]

We use it. (Montgomery County Maryland). Our door to balloon times are pretty low. We do run into tech issues at times, and we aren't always able to transmit.

At any rate, most of the ED docs trust our ability to interpret ECGs, and if we say we have a STEMI, and tell them specifically what we see, they activate the cath lab. (I have even taken pictures with my iPhone and sent the 12 lead to the doc in a text message.)

If you want concrete data, check with Suburban and Shad Grove hospitals. They have been keeping data on EMS door to balloon times.