ECG In the Field

[MadMack]

In the area where I'm training we see a ton of cardiac calls. My question is this: how long do you wait before slapping the ECG leads on your patient?

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[jbar]

I do a three lead right away if it is a medical call or I'm suspicious that it's cardiac. If the patient is in a heart block or having a STEMI it will change how the rest of the call goes. If they are stable I would say do the 12 on scene, if sick do it in the truck. (If you already know they are sick, and think it's a cardiac call, you should be going emergent to somewhere that has a catch lab. The only thing the 12 gets you is if you should activate the cath lab ahead of time.)

All of this depends on things like how much help you have, and how good they are. I worked in an ALS system where it was a medic and EMT on each rig. But the EMTs were trained to do ECGs (3 and 12), start IVs, and most had taken ACLS. So it was easy for the medic do a quick 12 while still in the house because he didn't have to do everything himself. Often while the medic was getting a quick history the EMT put the patient on the 3 lead, set up the IV, started it. Fire would be putting on 02 and finding the patients meds. If there was down time the EMT can also put the 12 lead stickers on but not do the 12 until the patient is in the rig if people are suddenly ready to go.

So, no easy answer and people have different styles. But I would say you want a quick 3, start your inital treatment (IV, 02, ASA etc) and then do a 12 when you have time and it will help you in your decision making process (which hospital to go to)

 

[TerraMedicX]

I pretty much agree with jbar. My system cared a little more about us getting 12-leads early, and our buses rattled like none other so I generally was already putting suspected MI patients on the 12-lead as soon as the 3-lead was on. Again, helpful to have a bunch of hands that you can rely on for thinks like IVs and gathering meds!

N.

I do a three lead right away if it is a medical call or I'm suspicious that it's cardiac. If the patient is in a heart block or having a STEMI it will change how the rest of the call goes. If they are stable I would say do the 12 on scene, if sick do it in the truck. (If you already know they are sick, and think it's a cardiac call, you should be going emergent to somewhere that has a catch lab. The only thing the 12 gets you is if you should activate the cath lab ahead of time.)

All of this depends on things like how much help you have, and how good they are. I worked in an ALS system where it was a medic and EMT on each rig. But the EMTs were trained to do ECGs (3 and 12), start IVs, and most had taken ACLS. So it was easy for the medic do a quick 12 while still in the house because he didn't have to do everything himself. Often while the medic was getting a quick history the EMT put the patient on the 3 lead, set up the IV, started it. Fire would be putting on 02 and finding the patients meds. If there was down time the EMT can also put the 12 lead stickers on but not do the 12 until the patient is in the rig if people are suddenly ready to go.

So, no easy answer and people have different styles. But I would say you want a quick 3, start your inital treatment (IV, 02, ASA etc) and then do a 12 when you have time and it will help you in your decision making process (which hospital to go to)

 

[deleted92121]

Just passed my registry so I am now NREMT-P...wooo

Anywho, ABC first plus high flow 02 with immediate 12 on-scene. As long as BP > 100 and no contras go ahead with NTG and ASA.

Just how I do it.

dxu

 

[MedicFL]

If you really feel this is cardiac you are doing your pt no good by delaying transport by wasting time on scene doing 12 leads. You should be enroute to the cardiac center and get the 12 lead in the truck....Time is muscle, now if they are stable and you are just doing it as a r/o then I have no problem with a 12 lead in a house. You can do the 12 lead in the truck before you start heading to the hospital, or you can grab it at a traffic light if you are not running hot..

 

[MedicFL]

Just passed my registry so I am now NREMT-P...wooo

Anywho, ABC first plus high flow 02 with immediate 12 on-scene. As long as BP > 100 and no contras go ahead with NTG and ASA.

Just how I do it.

dxu

You why are you leaving out morphine. Remember MONA? It seems so amny medics are afraid of MS04 for chest pain patients. I am not saying every chest pain is an MI and needs MS04 but many do.

 

[jbar]

But morphine doesn't improve mortality. Neither does Nitro. ASA and beta blockers do. So MS might make the patient feel better, which is always nice. But it isn't a priority especially if you are worried about their pressure.

 

[leviathan]

But morphine doesn't improve mortality. Neither does Nitro. ASA and beta blockers do. So MS might make the patient feel better, which is always nice. But it isn't a priority especially if you are worried about their pressure.

Well, it hasn't been *shown* to improve mortality, which doesn't necessarily mean it isn't helpful, although you may direct your priorities to more clinically proven pharmaceuticals first.

 

[deleted92121]

Obviously every situation is different. My example was based on being in a residence in which extrication would take ~5mins anyway. Everything goes in on a call (EKG, Bag, Bottle, Drug Box, and sometimes suction). If I walk in to the house and my patient is pale, cool, and dripping like he just ran a 5k, that sends up major red flags that this has increased potential to be an AMI and we need to skoot. But lets say I am in a one floor single family residence with easy str access and Pt is 60 y/o overweight male that is soaking wet and pale. I would immediately move Pt to str, have EMT place Pt on 02 and obtain VS for me while I talk with Pt and get SAMPLE and OPQRST and place 12 lead at same time. Everything checks out and there are no contras, administer ASA and NTG. If you utilize your partner correctly things can be done much quicker than by yourself in the back of the truck. Enroute I would start line and consider MS04.

What I am getting at is that certain diagnostics and interventions are proven to increase the likelihood of recovery, etc when done within a certain time. I could easily load my Pt up and do everything in the truck and get to my cardiac center possibly 3-5 mins quicker. And yes time is muscle. But providing ASA and meds that increase perfusion is proven to aid in survival rates if done early enough. I'm willing to risk getting to the cardiac center 3-5 mins later if my Pts condition has remained stable or improved due to our interventions.

Let's face it though. We all have our different ideas and ways of doing things. Some our dictated by our protocols and med command. Some are just due to our preference. In the end though, its all about the Pt.

 

[QuikClot]

If you really feel this is cardiac you are doing your pt no good by delaying transport by wasting time on scene doing 12 leads. You should be enroute to the cardiac center and get the 12 lead in the truck....Time is muscle, now if they are stable and you are just doing it as a r/o then I have no problem with a 12 lead in a house. You can do the 12 lead in the truck before you start heading to the hospital, or you can grab it at a traffic light if you are not running hot..

In some systems what you suggest is probably best, but not in mine. We transmit our 12 leads directly from the field and can bypass the ED entirely; gurney --> cath lab with no work-up in between.

County record is 26 minutes between the 911 call and the cath lab.

 

[MedicFL]

But morphine doesn't improve mortality. Neither does Nitro. ASA and beta blockers do. So MS might make the patient feel better, which is always nice. But it isn't a priority especially if you are worried about their pressure.

I agree but there are very few EMS systems that carry and allow betablockers for chest pain in the field.. But kudos to you if your system does.

 

[MedicFL]

Obviously every situation is different. My example was based on being in a residence in which extrication would take ~5mins anyway. Everything goes in on a call (EKG, Bag, Bottle, Drug Box, and sometimes suction). If I walk in to the house and my patient is pale, cool, and dripping like he just ran a 5k, that sends up major red flags that this has increased potential to be an AMI and we need to skoot. But lets say I am in a one floor single family residence with easy str access and Pt is 60 y/o overweight male that is soaking wet and pale. I would immediately move Pt to str, have EMT place Pt on 02 and obtain VS for me while I talk with Pt and get SAMPLE and OPQRST and place 12 lead at same time. Everything checks out and there are no contras, administer ASA and NTG. If you utilize your partner correctly things can be done much quicker than by yourself in the back of the truck. Enroute I would start line and consider MS04.

What I am getting at is that certain diagnostics and interventions are proven to increase the likelihood of recovery, etc when done within a certain time. I could easily load my Pt up and do everything in the truck and get to my cardiac center possibly 3-5 mins quicker. And yes time is muscle. But providing ASA and meds that increase perfusion is proven to aid in survival rates if done early enough. I'm willing to risk getting to the cardiac center 3-5 mins later if my Pts condition has remained stable or improved due to our interventions.

Let's face it though. We all have our different ideas and ways of doing things. Some our dictated by our protocols and med command. Some are just due to our preference. In the end though, its all about the Pt.

There is really nothing that you are going to give that pt in the field that has been proven to improve outcomes except ASA. I do agree with you but to stand around on scene and try and do everything in the house is just plain a waste of time. We have ALS engines here so every call has at least 3-4 medics on it and many times its just easier to throw then in your truck and leave instead of wait for everyone to decide what is best..

 

[jbar]

I agree but there are very few EMS systems that carry and allow betablockers for chest pain in the field.. But kudos to you if your system does.

Yeah, I know. But figure I'd do some education, and I was trying to be complete rather than just saying "ASA is the only thing that improves mortality."

Bottom line is 12 leads shouldn't be done in the house if it's going to slow you down significantly. And you should figure out how to change your scene management if running a 12 lead is going to add more than about a minute to your scene time.

 

[MedicFL]

Yeah, I know. But figure I'd do some education, and I was trying to be complete rather than just saying "ASA is the only thing that improves mortality."

Bottom line is 12 leads shouldn't be done in the house if it's going to slow you down significantly. And you should figure out how to change your scene management if running a 12 lead is going to add more than about a minute to your scene time.

No I agree with you yet again, a 12 lead is something simple that can be done in a min or two max. But then you run into given NTG and ASA in the house but before you do that you should have a line now your 10 mins into the call when you could have been at the ER already. My system has avg onscene times in the 20-30 min range which is way too long. The problem is also in my system there is private ambulance that transports part of the area so hand off must take place that also adds more time to the scene. Many times its just faster and easier to throw them in the truck and go. When you get 5 medics in a room from two different agencies sometimes things do go as smoothly as they should. Some parts of the county there will be a city engine a county box and a private ambulance.

 

[jbar]

There is no one right way to do things. That being said I would be uncomfortable moving a patient to the rig who I thought of as unstable without a line in place. If you really think this patient is having an MI, there is a pretty good chance they may have an arrhythmia. An if they code as you are carrying them down the steps or on the way to the hospital and you don't have a line, you are a little more behind the eight ball.

Deciding how long to stay and play is something that is somewhat personal preference and comes with experience. Yes time is muscle, but what matters is the time to balloon, not time to ED. So if you can do cath lab activations from the field, you already have things moving for you before you even get to the hospital. Furthermore, they aren't going to the cath lab without a line or usually two. So whether that happens on scene or in the ED the patient is going to be waiting for the line before going back, and I'd personally have the patent line before getting in the rig.

There are definately times when the patients is sitting on the curb, or fire is being a pain, or whatever when it makes more sense to just go. But again, if you have the proper help you should be able to get ASA, line and 12 lead before the ED. Also I'd put the line as a higher priority than the 12 lead. IF you know that they are sick they need a line regardless of if they are having an MI. And if you see elevations on the 3 lead that is enough to get you going on treatment.

I'm not arguing with anything MedicFL is saying, just using it as a jumping off point.

 

[leviathan]

There is no one right way to do things. That being said I would be uncomfortable moving a patient to the rig who I thought of as unstable without a line in place. If you really think this patient is having an MI, there is a pretty good chance they may have an arrhythmia. An if they code as you are carrying them down the steps or on the way to the hospital and you don't have a line, you are a little more behind the eight ball.

Deciding how long to stay and play is something that is somewhat personal preference and comes with experience. Yes time is muscle, but what matters is the time to balloon, not time to ED. So if you can do cath lab activations from the field, you already have things moving for you before you even get to the hospital. Furthermore, they aren't going to the cath lab without a line or usually two. So whether that happens on scene or in the ED the patient is going to be waiting for the line before going back, and I'd personally have the patent line before getting in the rig.

There are definately times when the patients is sitting on the curb, or fire is being a pain, or whatever when it makes more sense to just go. But again, if you have the proper help you should be able to get ASA, line and 12 lead before the ED. Also I'd put the line as a higher priority than the 12 lead. IF you know that they are sick they need a line regardless of if they are having an MI. And if you see elevations on the 3 lead that is enough to get you going on treatment.

I'm not arguing with anything MedicFL is saying, just using it as a jumping off point.

Good discussion guys! It's nice to see that we're all pretty much on the same page when talking about the priorities for a patient having an ACS. Here we will generally 'scoop and run' like a trauma patient and try to initiate IVs en route. The only thing on scene we will do is initiate oxygen therapy, grab a set of vitals, attach the 12 lead, and activate the cath lab if ischemic changes are noted. Certainly if there is additional extrication or scene time out of our control, there is an unstable arrythmia, or the patient looks like they are about to go belly up, an IV would be started on scene.

 

[MedicFL]

IF a person is really unstable I will go ahead and pop a line in on scene as well.. There really is not a right and wrong answer each case is different and thus will require a different approach.

 

[deleted92121]

IF a person is really unstable I will go ahead and pop a line in on scene as well.. There really is not a right and wrong answer each case is different and thus will require a different approach.

Agreed. I guess you make your choices based on your resources.

Good discussion though!

dxu

 

[MedicJ]

There is no reason a 12 lead, IV and initial cardiac meds should take more than 1-2 minutes. If you have a problem with people standing around trying to decide what to do, then your service needs to have a more established scene control. There should be one person making the medical decisions and the others should just be there to help. If you do it any other way, it only adds confusion and wastes time.

 

[MacBook]

In the area where I'm training we see a ton of cardiac calls. My question is this: how long do you wait before slapping the ECG leads on your patient?

I usually have enough hands to get someone to slep on my gear and get me a basic set of vitals while I round up meds and a Hx. If I think the call might be at all cardiac related and it's not a swipe and run, then within the first few mins I arrive on scene. Gives me an idea of what I'm working with.

 

[deleted92121]

I've got me and and an EMT-B. That is it.

Still make damn good time.

 

[MacBook]

I have to add, that most of the time I never hook up my patient to the monitor. I always make sure it's my partner (which tends to be a EMT-I/or basic)who does it. To busy doing other things and they are always quite competent in doing it without my help. I just double check once it's done.

 

[fiznat]

There is no reason a 12 lead, IV and initial cardiac meds should take more than 1-2 minutes.

haha okay. I'm going to go ahead and say there is *no way* you can get a 12 lead, IV, and meds all done within two minutes. I'm sorry, but there is too much to do as far as set-up, explaining to the patient, double checking meds, reading the 12, and general scene stuff that gets in the way to have all that done so quickly. I know time tends to compress when on scene with a critical patient but two minutes for all that is unreal.

I understand we have goals as far as getting things done quickly and being efficient on scene, but come on. This isn't a sprint race, and we need to be a little realistic.

 

[MedicJ]

haha okay. I'm going to go ahead and say there is *no way* you can get a 12 lead, IV, and meds all done within two minutes. I'm sorry, but there is too much to do as far as set-up, explaining to the patient, double checking meds, reading the 12, and general scene stuff that gets in the way to have all that done so quickly. I know time tends to compress when on scene with a critical patient but two minutes for all that is unreal.

I understand we have goals as far as getting things done quickly and being efficient on scene, but come on. This isn't a sprint race, and we need to be a little realistic.

Ok, maybe 3 minutes...tops. You were saying it takes time to set stuff up? My EMT usually does that. It saves a ton of time. As far as explaining things to the patient and double checking meds-I usually do that while I am doing the 12-lead. I would love to spend more time on scene but our dispatch usually pushes us to be en route to the hospital at 10 minutes. Do you work for a service that allows you to stay at the hospital until you have all of your paperwork finished,2? I have heard of those places. They sound nice. My place of employment doesn't like to spend enough money to provide us with enough paramedics. We usually get our next 911 dispatched to us before we get our patient into the hospital.

 

[leviathan]

Ok, maybe 3 minutes...tops. You were saying it takes time to set stuff up? My EMT usually does that. It saves a ton of time. As far as explaining things to the patient and double checking meds-I usually do that while I am doing the 12-lead. I would love to spend more time on scene but our dispatch usually pushes us to be en route to the hospital at 10 minutes. Do you work for a service that allows you to stay at the hospital until you have all of your paperwork finished,2? I have heard of those places. They sound nice. My place of employment doesn't like to spend enough money to provide us with enough paramedics. We usually get our next 911 dispatched to us before we get our patient into the hospital.

I agree, 2 minutes is do-able. The thing is, if you walk in and do your doorway diagnosis of the patient and realize they are sick, everyone gets things done quite quickly. Over here we usually have a BLS crew respond first, and if an ALS crew is on the way/is called by BLS, then you have 4 people working to get things done. BLS would be starting an IV, getting the initial vital signs and collecting the basic history while ALS hooks up the 12 lead and begins doing whatevery they need to do. It's a pretty cool thing to watch/be a part of when you have 4 competent paramedics working together and things get done LIGHTNING fast.

 

[jbar]

. It's a pretty cool thing to watch/be a part of when you have 4 competent paramedics working together and things get done LIGHTNING fast.

Unless all four decide that they are in charge. I've been on some not so fun scenes where there are two or three paramedics and medic student. I'd rather go sit in the truck and not deal with it all. Too many chefs and all that.

 

[MedicJ]

I agree, 2 minutes is do-able. The thing is, if you walk in and do your doorway diagnosis of the patient and realize they are sick, everyone gets things done quite quickly. Over here we usually have a BLS crew respond first, and if an ALS crew is on the way/is called by BLS, then you have 4 people working to get things done. BLS would be starting an IV, getting the initial vital signs and collecting the basic history while ALS hooks up the 12 lead and begins doing whatevery they need to do. It's a pretty cool thing to watch/be a part of when you have 4 competent paramedics working together and things get done LIGHTNING fast.

That sounds great! I wish our BLS crews could respond to emergency calls. Our Bls can only do hospital->hospital transfers.
Some of our fire stations have medics. I REALLY love showing up after they get there. They usually have everything done except for the 12-lead because they are still doing cardiac old-style, but they usually already have a couple sets of v/s, an IV, a med list with allergies.. I can usually leave with the pt as soon as I get there. Unfortunately, we only see a fire-medic about once a week or less. I work in a city with fire and ambulance separate.