To ECG or not to ECG (opinion thread)

[Tigger]

Really? Again the 12 lead rules nothing out. If you suspect cardiac involvement Paramedic needs to keep patient.

If most every patient is getting a 12 because that is expectation of the system, isn't it not fair to the medic to have to take everyone in that has no signs or symptoms of cardiac issues? If you're doing a 12-lead because you suspect something cardiac the yes, the patient should be ALS, but if you're doing the 12-lead just for the sake of doing to cross it off a list I would think that grays the water a bit.

 

[jjesusfreak01]

Lets break this up, as there are two issues:

1. Should an EKG be done for this patient?

Easy YES

2. Can this patient be handed down to BLS?

Depends. Most of the posters here are answering based on the protocols and policies of the systems in which they work; this doesn't really serve an educational purpose. The OP established that he did not require his EMT to do do anything outside of their scope, so that isn't an issue. If the OPs system has a rule about handing care down to EMTs, that should be followed.

What I will say is this. The paramedic should have the discretion to do whatever diagnostic tests they deem necessary without being forced to run the call themselves when they believe it to be a BLS level call. If the paramedic does not anticipate the patient will need further ALS interventions following assessment, then there isn't a reason why the call cannot be run by an EMT-B. The EMT can monitor the patient's vital signs for deterioration. The reasoning is that if forbid something went terribly wrong with the patient in the back of the truck the basic should be able to handle the situation for the 20 seconds it takes the medic to pull over and hop in the back.

As an aside, Wake County EMS puts an extra 5 minutes into their scene time limit for STEMI calls to allow an onsite EKG to be done, as destination triage is something that needs to be done before we leave the scene, ie, we are expected to complete a 12-lead onscene. Additionally, they are discussing the possibility of allowing EMTs to attend on calls where limited amounts of certain (generally safe) ALS medications have been given to the patients, indicating the medical director believes this to be a safe practice.

 

[DrankTheKoolaid]

re

People seem to think the 12 lead is the issue in this discussion. It really isnt. The fact that an ALS procedure was performed ( IV start ) and then was handed to a BLS provider is the issue. I would like to see anyone in Americas protocols stating specifically it is OK with your LEMSA / Medical Director that a BLS provider can assume care from their ALS partner after an ALS intervention was performed. Standard care run of the mill calls not including MCI etc etc.

 

[the_negro_puppy]

Really? Again the 12 lead rules nothing out. If you suspect cardiac involvement Paramedic needs to keep patient.

Wrong. A 12 lead ECG can rule out a arrhythmia or significant ischaemia causing ECG changes at the very point of time it is performed. This is pretty important.

 

[Tigger]

People seem to think the 12 lead is the issue in this discussion. It really isnt. The fact that an ALS procedure was performed ( IV start ) and then was handed to a BLS provider is the issue. I would like to see anyone in Americas protocols stating specifically it is OK with your LEMSA / Medical Director that a BLS provider can assume care from their ALS partner after an ALS intervention was performed. Standard care run of the mill calls not including MCI etc etc.

Err say what? The OP has already addressed this, and his area has a protocol that allows for this. I don't see the hangup here, and I highly doubt the protocol was designed just "so basics can take transfers" exclusively. No one is required to wonder whether or not the protocol applies to them, it's written for everyone for a reason.

And not that it matters, but many, many basics in Colorado can and do take patients that have an IV in that the medic started. Or the basic started the IV himself, and hung the fluid, and pushed the drugs (in a few specific scenarios). Not everywhere is like California.

 

[medic417]

Wrong. A 12 lead ECG can rule out a arrhythmia or significant ischaemia causing ECG changes at the very point of time it is performed. This is pretty important.

No it can rule in but it can not rule out. Lab is required to rule out.

 

[DrParasite]

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

in a nutshell, no. if you do a 12 lead, find nothing abnormal, than you can deem the patient BLS.

once you start the IV, it's automatically ALS.

however, if the patient is going to continue to receive cardiac monitoring during the trip, they should probably be ALS.

 

[DrankTheKoolaid]

re

Err say what? The OP has already addressed this, and his area has a protocol that allows for this. I don't see the hangup here, and I highly doubt the protocol was designed just "so basics can take transfers" exclusively. No one is required to wonder whether or not the protocol applies to them, it's written for everyone for a reason.

And not that it matters, but many, many basics in Colorado can and do take patients that have an IV in that the medic started. Or the basic started the IV himself, and hung the fluid, and pushed the drugs (in a few specific scenarios). Not everywhere is like California.

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

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

 

[TheGodfather]

It was a LT/Medic in charge of QA
I addressed the issue with my MCP yesterday; Results:

1) any indication that patient may possibly be ALS should just be taken ALS. In the case of that specific patient, he stated that just doing a 12-lead to be proficient (if no real clinical s/s or risk factors present), I may perform an ECG and transmit prior to BLS transport.

2) for BLS patients (whom of which will most likely still require lab work) he stated as a form of courtesy to the ER, I may initiate an IV and lock/titrate to KVO rate. (state protocol allows this) --- He was unsure about the billing aspect of doing this.

not specifically in writing, but it was verbalized face-to-face... i'm having trouble determining why this is so upsetting to you?

 

[DrankTheKoolaid]

re

1. Its poor form, what exactly does this show to up and coming paramedics. Thats its alright to be a glorfied IV starter and then turf your patient on a lower provider?

2. from a risk management standpoint, explain in a court while granny died because she was turfed onto BLS provider while there was a paramedic driving who had already deemed her worrisome enough to initiate a IV start.

Its thing like this that keep EMS at such a low standard, we have so far to go especially with crap like this happeneing.

That is why it is upsetting.

 

[TheGodfather]

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

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

 

[Tigger]

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

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

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

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

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

 

[Fish]

Really? Again the 12 lead rules nothing out. If you suspect cardiac involvement Paramedic needs to keep patient.

Nothing huh? I would beg tje differ.

 

[usalsfyre]

If this came across my desk in a QA role, I'd nail you to the wall on it. Here's why.

1) First and foremost you failed to document your assessment findings in this patient. YOU assessed the patient first, ruled out etiology based on you knowledge base and performed an intervention that is out of a basic providers skill set. He shouldn't be documenting your assessment findings for you, and can't document his 12 lead interpretation. You've put him and yourself in a crappy position documentation wise.

2)You said it yourself, it's a borderline patient. This isn't letting a newer provider of the same level ride progressively harder calls, it's letting a lower level of care ride a patient that your concerned enough to do a full assessment on. Considering the majority of paramedics I've seen (spanning multiple agencies and states) have relatively poor assessment skills, I'm skeptical of your ability to "clear" a patient with an ambiguous problem.

3)Finally, the whole thing smacks of laziness. I can't determine intent, but your going to have a darn hard time convincing me there was anything educational about this for the Basic (and I'm going to ask what you taught him). You've got to accompany the patient to the ED anyway, just write the freaking chart. The way it's presented feels like "there's some cool stuff I can do, but once that's over, this call is beneath me". Weak dude.

I highly doubt your OMD intended for the "basics riding saline locks" to be used this way and what he intended is the final word.

There are calls that are entirely appropriate for BLS providers to take, but if there's any question, part if being a paramedic is taking those borderline calls. It protects both partners and is part of being the leader on the truck. Anything else asking for trouble and a poor reflection in you as a provider.

 

[TheGodfather]

by ways of verbalizing the parts of this call, it's hard to really depict what really was going on..

the EKG was done by me because any old person complaining of anything gets an EKG (usually); does that mean I have to ride in all old people? IMO, no.

the reason why i said it was "borderline" was based on hx alone... no symptoms, no complaints, just tried to cover my butt...

and for a 3rd time...med control has directly told me that it is appropriate (and preferred) to have IV locks in place on any patient who will most likely require access/blood work once they hit the ED (even if BLS rides it in)

i am far from lazy... if anything, most providers would shut their partners in the back without even doing any assessment (just by basing the looks and complaint of the patient alone)... i have no problem writing charts, but i do have a problem taking away good BLS patient contacts from my equally enthused partner because i like to provide cautious, standardized patient care using all of the tools at my disposal....

 

[usalsfyre]

the EKG was done by me because any old person complaining of anything gets an EKG (usually); does that mean I have to ride in all old people? IMO, no.

So your either not confident enough in your assessment skills to determine who it's actually appropriate to perform an EKG on or you were concerned there was an occult cardiac event and when the 12 lead came back with out a STEMI you thought "I'm good". Which is it? Because neither one is good. Your opinion doesn't mean a whole hell of a lot in this case, it's the opinion of your QA department and medical director that actually matters. And geriatrics have a lot of atypical presentations, so a negative EKG (in a paced patient at that) doesn't let you off the hook for advanced care.

the reason why i said it was "borderline" was based on hx alone... no symptoms, no complaints, just tried to cover my butt...

The patient had a vague, non-specific complaint with multiple comorbidities and as such you felt the need to "cover your butt", yet you turfed the call when a diagnostic test that's not sensitive for any number of serious conditions came back without one finding. See the problem here?

and for a 3rd time...med control has directly told me that it is appropriate (and preferred) to have IV locks in place on any patient who will most likely require access/blood work once they hit the ED (even if BLS rides it in)

My bad. I don't agree with it, but if the physician is comfortable with it, it's not my place to say.

i am far from lazy... if anything, most providers would shut their partners in the back without even doing any assessment (just by basing the looks and complaint of the patient alone)...

This is really about how it works in most places. It's very obviously BLS, or the medic needs to ride it. Number one because it's good patient care. Number two because if you don't get a good handle on things basics will be riding all sorts of things they shouldn't.

i have no problem writing charts, but i do have a problem taking away good BLS patient contacts from my equally enthused partner because i like to provide cautious, standardized patient care using all my tools at my disposal....

And what did your partner learn sitting in the back taking one more set of vitals that he hadn't already learned on scene? "Experience" is not all equal.

"Throwing everything against the wall and seeing what sticks" may be fine for House M.D., but it's crappy real world medicine. The 12 lead was appropriate here, but nowhere near all elderly patients need 12 leads, just like not all patients need FSBGLs or IVs.

I'm not going to be able to convince you of why this was an issue, I simply ask that you take a step back and examine the REAL reason you turfed this call. I've got a BLS partner who is far, far more enthused about running calls than I am a lot of times. There's no way in hell I'd turf a call to her under the conditions described.

 

[TheGodfather]

we can butt heads all day long about this... am i competent to determine who needs an ECG? yes.

is the patient sick because she has a virus, or is she sick because of an underlying cardiac arrhythmia? Based on the fact that i dont have x-ray-ct-sonagraphic-super-cardiac-detecting eyes, I checked out her rhythm..

could there have been a underlying change in cardiac status? sure there COULD have. she COULD also be suffering from a number of other conditions that are undetectable by the prehospital care provider.... bottom line, transport time was 10 minutes... patient was complaint free... there was no obvious signs of any life-threatening condition... so i opted to let him ride... shame on me i guess!

 

[usalsfyre]

we can butt heads all day long about this...

My point exactly.

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

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

 

[TheGodfather]

no, i have, and to be quite honest, i can see from both ends of the perspective on this one... it's just one of those "you gotta be there" things... when it gets to the nitty gritty, if u were on scene with me, and you told me to ride it in, i would listen (given the simple fact that your experience trumps mine 10 fold)... my perspective was there was minimal risk, so i chose to let it go.. wrong? maybe. did she die in our care? no.

 

[usalsfyre]

We are all armchair quarterbacking here, and it is hard to say one way or the other without laying eyes and hands on the patient. Some of it is preference and background on my part, when I was a (VERY) green basic I saw medics turf stuff they never should have with scary results.

We probably all make the wrong call (according to someone else) daily and get away with it. Agree to disagree?