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Prehospital EKGs

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docB

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We were talking about prehospital EKG telemetry in this thread:

http://forums.studentdoctor.net/threads/paramedic-insight-into-wireless-ecg-transmission.978671/

Couple of interesting articles in this month’s Prehospital Emergency Care regarding field EKGs.


The first article found that prehospital STEMI activation resulted in a decrease of 14 minutes in door to balloon times but this didn’t lead to any improvements in outcomes and it did lead to a lot of false calls.


http://informahealthcare.com/doi/abs/10.3109/10903127.2013.836263


The next article found that the practice of doing prehospital EKGs can positively impact patient care in up to 19% of cases. In those cases the EMS EKG showed abnormalities not seen in the initial ED EKG.


http://informahealthcare.com/doi/abs/10.3109/10903127.2013.825350


So apparently we should do the EKGs but it’s not clear if we should call the STEMIs.
 

Dwindlin

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I can't see the full article. Does it discuss what made up the majority of false activations? I think there is a role for pre-hospital cath lab activation, it's just a matter of deciding what level of false activation we are willing to accept, and where the education needs to be shored up.
 

OCDEMS

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I can't see the full article. Does it discuss what made up the majority of false activations? I think there is a role for pre-hospital cath lab activation, it's just a matter of deciding what level of false activation we are willing to accept, and where the education needs to be shored up.

I can tell you where the false activation comes from and, hint, it has a lot to do with one of the other words in your post: education. I worked as a paramedic prior to medical school and here are my observations about paramedic education:

1) It's not consistent. Paramedic education on 12-Lead ECG analysis was only recently made mandatory with the implementation of the National Scope of Practice Model and, before this, the method that paramedics were trained in 12-Lead analysis was variable. Some paramedic programs taught it effectively, others as an after thought. It simply wasn't necessary in the old DOT curriculum.

2) Paramedics have a false perception that STEMIs are everywhere. A lot of this comes from the fact that there still, in my opinion, is not good education focused toward prehospital providers. An EM doc might see them pretty regularly, but that's because an ED typically serves a centralized population of patients, not a smaller geographic location like a medic unit. Please correct me if I'm wrong, but isn't it something like 2% of all chest pain complaints to an ED end up being STEMIs (roughly 30% of all ACS classified chest pains)? Paramedics are not taught this, nor are they then given the necessary education and training to extrapolate this to their locale. STEMIs are just not that common, particularly in rural/suburban areas where we're talking 1000-2000 calls per year.

3) I worked with a few paramedics who were quick to call STEMI. 1 mm of nonspecific ST elevation was "ST elevation" and so they sounded the alarms, consulted, etc. The problem is that many of the CE education programs that have proliferated on the market simplify STEMI to "1 mm in 2 or more contiguous leads." They don't get into the details and prevalence of ST elevation mimics and nonspecific elevation, or, if they do, they're taught as afterthoughts on a PowerPoint. It took several hospital QA reports to convince one paramedic that his STEMI every other week was a bit over the top. He just couldn't understand why none of his STEMIs were going to the cath lab.

4) Depending on how advance the system is, a paramedic can intervene very early in the presentation of ACS. If grandma gets chest pain and calls 911 within seconds, it's very realistic that a paramedic might show up within 10 minutes of the initial presentation of symptoms. This leads to another phenomenon that I think is pretty common for paramedics to encounter: patients of evolving presentations OR patients where early administration of oxygen and nitrates decreases presentation of ST elevation, only for it to show up en route when it can be subtle and more difficult to call. There is a tremendous now or never expectation for paramedics. Their education really emphasizes getting it right and, because it's common for them to get piled on later by hospital staff, they are sometimes terrified of missing a call. This leads to the "better safe than sorry" approach.

I don't blame paramedics. They are certainly capable of highly accurate 12-Lead interpretation when properly trained and given adequate exposure. I blame the ridiculous education standards that have existed for far too long. A few things can solve this problem: A) 12-Lead ECG transmission. B) Better education. One of the best thing a group of EM docs can do is get out in their community and teach future and practicing paramedics.
 
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austintr

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Just a little bit of input from a paramedic interested in pre-hospital ECG's: I was fortunate enough to have a very knowledgeable and passionate teacher when it came to cardiology and such in paramedic school. However, you just can't learn everything (or even enough) about the heart and disease patterns and mimics and underlying physiology, etc. in a couple of months (at best). I have worked with dozens of paramedics that don't even know about anginal equivalents, let alone why they're doing the ECG or what it means. Before I get on to some sort of soap box here, I will say that >90% of my (in my opinion) decent knowledge base has come from my own reading of blogs, textbooks, and studies after paramedic school. So there is absolutely a flaw in the system. There are tons of flaws in the system, and unfortunately, as with nearly every profession, the bad eggs cast a negative shadow over the extremely good ones.
 

joeDO2

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EMS education is a flawed system for many reasons discussed on other threads. It always will be IMHO. This is because you can't convince someone to go to school for years to get a job making $16/hr. That being said, there are some very knowledgeable medics out there. Everything rests with the individual medic to further their education. It helps to work for a company that values education as well. There are many resources out there...just have to look. I have said before, look to the physician conferences if you can afford them... they are much better quality and content than most things on the EMS side.
 
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