To ECG or not to ECG (opinion thread)

[TheGodfather]

I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)

***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***

I work a medic/basic truck.

1) Called to a local assisted living center for a 91yo F - "sick person".
ATF pt lying supine in bed, AOx3. staff states she has been not feeling well since the start of the morning (it was now 1300ish) and they would like her to be checked out. Staff also stated patient has been depressed due to a recent loss of mobility.

CC: "not feeling well" -no chest pain, dib, etc.
skin: NWD
Aatent
B: 16 clear bilaterally, non-labored; spo2 96 RA
C: pulse 94, strong radial.
D: PERRL, intact neuro.
E: afebrile

(these are a rough estimate):
BP: 146/84
PR:90-100 Regular
RR:16NL
SPO2: 96 RA
BGL: ~110

S: "feels sick"
A: IV contrast
M: too long to list
P: DM, Pacemaker, 2 stents (unknown date), "cardiac", stroke, hyperlipidemia.
L: breakfast x4(ish)hrs PTA (didn't eat much then/recently due to depression)
E: woke up feeling ill

-----------------------------------------

2) In a nutshell: IV TKO, blood draw for hospital, BGL, 4-lead, 12-lead (to rule out silent cardiac event--- because she is OLD, FEMALE, and DIABETIC) - 12-lead was normal, nothing worth mentioning.

I deemed this patient BLS, handed off to my EMT-B partner, and drove in without incident/change in status.

----------------------------------------
3) My boss told me I was incompetent as a paramedic, and also stated that if I had any intuition of patient being in an acute coronary state, why would I ever let the patient be taken BLS. He stated also that "we just don't do that" (referring to doing quick rule-out 12-leads), and if I were to do that, I should take the patient in everytime....

Last time I checked, BLS caregivers are more than capable of handling calls like that. The practice of performing 12-lead ECGs on the elderly with broad "non-emergent" complaints (IMO) should be done ALWAYS.

After I described the patient state and what I found on my assessment he said, "you should not have performed the 12-lead, and you should have just let the patient be taken in BLS" ----- ok, now, let's say hypothetically this patient has a silent MI... we just delayed ACLS care 20-30 minutes because we didn't perform a 30 second 12-lead...... In his words, it would be ok to lessen my goal of optimum patient care, to meet standards of "what their standards are" --- this is not okay with me....


Opinions? Am I taking this too critical? Let's hear it!

 

[Shishkabob]

91yo F - "sick person".

That's all I need to perform a 12-lead.






If someone trips and falls and hits their head, but doesn't complain of anything else and is otherwise ok, does your boss require ALS on that as well? I mean, my God, what if you try to rule out a head injury by asking questions?! Does he demand a doctor go in the truck if you're transporting from a clinic, too? If you do no ALS interventions, what's the need for an ALS provider after assessment?



He's either new in his position, incompetent himself, scared of litigation, doesn't trust your agencies EMTs, or real old.

 

[DrankTheKoolaid]

re

I recently got in trouble for performing [what I feel is] good standard patient care on a patient I had recently. I'll give the scenario(1), my interventions(2), and what my agency's argument against me was (3)

***note: don't get too hung up on the nitty gritty of the patient care/status/etc, that's not the point; I'm going to be really brief***

I work a medic/basic truck.

1) Called to a local assisted living center for a 91yo F - "sick person".
ATF pt lying supine in bed, AOx3. staff states she has been not feeling well since the start of the morning (it was now 1300ish) and they would like her to be checked out. Staff also stated patient has been depressed due to a recent loss of mobility.

CC: "not feeling well" -no chest pain, dib, etc.
skin: NWD
Aatent
B: 16 clear bilaterally, non-labored; spo2 96 RA
C: pulse 94, strong radial.
D: PERRL, intact neuro.
E: afebrile

(these are a rough estimate):
BP: 146/84
PR:90-100 Regular
RR:16NL
SPO2: 96 RA
BGL: ~110

S: "feels sick"
A: IV contrast
M: too long to list
P: DM, Pacemaker, 2 stents (unknown date), "cardiac", stroke, hyperlipidemia.
L: breakfast x4(ish)hrs PTA (didn't eat much then/recently due to depression)
E: woke up feeling ill

-----------------------------------------

2) In a nutshell: IV TKO, blood draw for hospital, BGL, 4-lead, 12-lead (to rule out silent cardiac event--- because she is OLD, FEMALE, and DIABETIC) - 12-lead was normal, nothing worth mentioning.

I deemed this patient BLS, handed off to my EMT-B partner, and drove in without incident/change in status.

----------------------------------------
3) My boss told me I was incompetent as a paramedic, and also stated that if I had any intuition of patient being in an acute coronary state, why would I ever let the patient be taken BLS. He stated also that "we just don't do that" (referring to doing quick rule-out 12-leads), and if I were to do that, I should take the patient in everytime....

Last time I checked, BLS caregivers are more than capable of handling calls like that. The practice of performing 12-lead ECGs on the elderly with broad "non-emergent" complaints (IMO) should be done ALWAYS.

After I described the patient state and what I found on my assessment he said, "you should not have performed the 12-lead, and you should have just let the patient be taken in BLS" ----- ok, now, let's say hypothetically this patient has a silent MI... we just delayed ACLS care 20-30 minutes because we didn't perform a 30 second 12-lead...... In his words, it would be ok to lessen my goal of optimum patient care, to meet standards of "what their standards are" --- this is not okay with me....


Opinions? Am I taking this too critical? Let's hear it!

First you were justified in doing the 12 Lead. Obviously this is not a full report though and based on what you did post no way in hell should this patient be BLS'ed.

1. You already started ALS interventions by performing the IV start
2. This patient is borderline tachycardic and i would venture to guess one of her many medications rate controller despite her having a implanted pacemaker
3. Loss of mobility" we talking just due to the current illness? If so that just seals the coffin
4. And the 1000 dollar question is!......... Polyuria, dysuria? LOL is UTI until proven otherwise. And like digoxin use UTI is the master imitator and can present as simply as dysuria to complete coma at the other end of the spectrum. And never be fooled by a geriatric patient that is afebrile

 

[TheGodfather]

1)IV maintainence of a saline solution is a BLS skill in my area.
2)rhythm was paced, electrical capture with each complex, no ectopy (im ball parking the rate - it was above 80, lower than 100...i do not remember completely)
3)loss of mobility was 2 months ago; from being old. ---forgot to mention she has history of osteoarthritis.

why would there be any issue BLSing the patient? i would have done the same interventions that my BLS partner was capable of and trained to do...

 

[firecoins]

12 lead is a must with illness and hx.

Once you did that, its an ALS job that should not be handed over to an EMT to take in. You did the 12 lead and started a line, giving it to an EMT is unacceptable.

Doesn't matter if you did the same exact BLS skills the EMT would do, its an ALS patient.

 

[TheGodfather]

12 lead is a must with illness and hx.

Once you did that, its an ALS job that should not be handed over to an EMT to take in. You did the 12 lead and started a line, giving it to an EMT is unacceptable.

Doesn't matter if you did the same exact BLS skills the EMT would do, its an ALS patient.

this is a direct copy from my state protocols:

Field application/acquisition of 12 lead ECG for transmission only* (Transmission may be defined as direct
paramedic interpretation and voice communication; automated computer algorithm interpretation, wireless
transmission and physician interpretation, or any combination of these strategies)

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

 

[Devilz311]

Not sure how the medical billing works in your state, but once you initiated ALS interventions (IV) it would be billed as an ALS transport. Had the line not been started, it probably could have been billed as BLS.

We run 2 Medics on our transport trucks, and sometimes answer BLS dispatches. If a BLS dispatched run for a "sick person" could benefit from fluids or Zofran or any other ALS measure, then it would have to be turned into an ALS chart, and billed accordingly.

 

[Devilz311]

12 lead is a must with illness and hx.

Once you did that, its an ALS job that should not be handed over to an EMT to take in. You did the 12 lead and started a line, giving it to an EMT is unacceptable.

Doesn't matter if you did the same exact BLS skills the EMT would do, its an ALS patient.

Again, this depends on the state. If we're dispatched as ALS along with a BLS unit, we will more than likely do a 12-lead if the call warrants it. If in the assessment we find no need for further ALS interventions, we can certainly release the Pt to BLS for transport.

Don't get me wrong, I'm all for finding reasons to treat the Pt instead of finding reasons to release the Pt, but if the Pt is just ill and needs a ride to the hospital, I'm not going to stick them with a $2k bill for a hand-holding ride to the ER.

 

[Remeber343]

Why in gods name would you ALS if you did a 12 lead??? You use it to rule out, obviously none showed on his 12 lead. And if his area trains emts in iv maintenance and they are able to competently control rate and flow, why not Bls it? If they are trained, and his region allows it, it can be Bls. Regardless of what your regions protocols are. That's how things happen in his neck of the woods. Not yours. Plus he's in the front seat if something were to happen, which, the likely hood is slim to none.

 

[DrankTheKoolaid]

re

1)IV maintainence of a saline solution is a BLS skill in my area.
2)rhythm was paced, electrical capture with each complex, no ectopy (im ball parking the rate - it was above 80, lower than 100...i do not remember completely)
3)loss of mobility was 2 months ago; from being old. ---forgot to mention she has history of osteoarthritis.

why would there be any issue BLSing the patient? i would have done the same interventions that my BLS partner was capable of and trained to do...

IV maintainence may be BLS in your area and i would love to read your protocols as i bet that is meant for BLS providers to take transfers. I would also venture to say that your protocols say a patient must not be transfered to a lower level of care once an ALS intervention is performed (your IV start was ALS as your BLS provider can not do it) read: abandonment.

And if you do this on a regular basis i would just LOVE to see how it is billed.. Medicare fraud comes to mind if your company bills it as an ALS call when a BLS provider attended

 

[TheGodfather]

IV maintainence may be BLS in your area and i would love to read your protocols as i bet that is meant for BLS providers to take transfers.

section copied from BLS Skills section:

IV Maintenance (involves ONLY monitoring and maintenance of previously initiated IV lines as well as
calculation and adjustment of flow rates - fluids NOT containing any medications or blood products).

as far as the politics of it, abandonment, etc... you may be correct. i will look deeper on it... thank you for the input though! Positive or negative, it still gets my wheels turning! I like seeing things from all angles.

 

[Epi-do]

Where I am at, I would have been taking this patient in, not my BLS partner. Not so much for the 12-lead, but because of the IV. (Although, if I felt something warranted taking a look with a 12-lead, I'm not going to hand it over anyway, even if I don't do any additional ALS interventions on the way to the ER. There was a reason I felt the 12-lead was warranted to begin with.)

BLS providers are allowed to transport patients with IVs and a limited number of fluids/meds for inter-facility transports around here. If a medic starts an IV on scene, then the medic must transport the patient.

So, with the situation you presented, it doesn't really matter to me what my BLS partner is or isn't allowed to do. If I felt the need to basically do a full workup on this patient (IV, monitor, dex), I am sitting in the back. Even if everything checks out ok, there was a reason I felt the need to do everything.

 

[Medic Tim]

To quote Bob Page . If they have a pulse and a problem they get the monitor. I would have done a 12 lead

Is it a policy thing you got in trouble for? I have heard in some areas if you do anythingabove emt scope the pt it the medics. I also know of areas that the Medic can triage the pt to the emts , even after als interventions if the pt is stable and the emts can handle the call.

 

[DrankTheKoolaid]

To quote Bob Page . If they have a pulse and a problem they get the monitor. I would have done a 12 lead

Is it a policy thing you got in trouble for? I have heard in some areas if you do anythingabove emt scope the pt it the medics. I also know of areas that the Medic can triage the pt to the emts , even after als interventions if the pt is stable and the emts can handle the call.

in Canada or America. If in America can you post the area so I/We can read the protocols. As this is considered abandoment in any circle i have ever been in or discussed patient care. Be it local, state, federal ( USFS ) nowhere have i ever heard of or have read that a ALS provider can give the patient to a BLS provider after an ALS intervention has been performed.

Emslaw whats your take as a practicing lawyer on this. Especially if something went wrong and the BLS hadnt noticed it or patient wasnt still on the monitor.

 

[STXmedic]

in Canada or America. If in America can you post the area so I/We can read the protocols. As this is considered abandoment in any circle i have ever been in or discussed patient care. Be it local, state, federal ( USFS ) nowhere have i ever heard of or have read that a ALS provider can give the patient to a BLS provider after an ALS intervention has been performed.

At my part-time gig (south TX), it's not at all uncommon for the medic to run a 12-lead and then downgrade our pt to our intermediate partner (if we're working with an I; it's usually P/P). And our Intermediates are I85, not I99.

 

[DrankTheKoolaid]

re

12 lead aquisition is a rote skill and not ALS. IV start is ALS, hence my whole discussion in this thread

 

[STXmedic]

12 lead aquisition is a rote skill and not ALS. IV start is ALS, hence my whole discussion in this thread

Ahh, I misread in my skim . Never heard of downgrading to a basic after an invasive procedure has been performed or a medication has been given.

 

[EMSrush]

In a nutshell: IV TKO

In my region, this would have instantly converted the Pt to an ALS Pt.

 

[TheGodfather]

with the exception of the IV start (shame on me, i will clarify with medical control next time I meet with him) ---- the commotion all boiled down to the 12-lead.... so here is the final question:

As an advanced care provider, is it wrong to perform diagnostic ECGs, interpret, transmit, and deem patient BLS?

 

[EMSrush]

with the exception of the IV start (shame on me, i will clarify with medical control next time I meet with him) ---- the commotion all boiled down to the 12-lead.... so here is the final question:

As an advanced care provider, is it wrong to perform diagnostic ECGs, interpret, transmit, and deem patient BLS?

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