On Tuesday, our region voted to adopt a spinal board policy similar to the Yale-New Haven Sponsor Hospital document that came out a few months back as a first step toward eliminating the use of the long backboard for anything but extrication and movement. Today, the state EMS medical advisory committee (CEMSMAC) is expected to begin reviewing a guideline based on the National EMS Physician’s October draft that recommended eliminating long boards for spinal immobilization. Earlier, the state committee voted to develop guidelines based on that position paper.

At the meeting on Tuesday we debated a stronger document, but ultimately decided it would cause too many problems to be out of whack with what CEMSMAC might develop, so we decided to go in unison with New Haven, and then adopt the more comprehensive state document when it is ready. Hopefully, the state document will be ready for implementation soon.

Our limited policy will start on April 22. We again debated an implementation time ranging from waiting for the textbooks to be rewritten to opening up the window of the committee room and shouting. “Free at Last! Free at Last! Unboard My People Now!” Or perhaps, immediately adjourning the meeting, joining arms and skipping down Blue Hills Avenue, arm in arm, singing “Ding Dong! The board is dead! The wicked board is dead!” In the end we went with a two week notice to give the EDs and first responders time to be advised in order to prevent conflict, shouting, rioting and chaos.

Stay tuned.

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Text of North Central position:

“Effective April 22, 2013, long backboards will no longer be utilized for spinal immobilization of ambulatory patients. Patients who are ambulatory at the scene, but who require cervical immobilization based on our regional spinal immobilization guidelines, will be placed in the position of comfort, limiting movement of the neck during the process. This change in procedure is the first step toward eventually using long boards only when needed to facilitate extrication, and not during transport.”

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Several years ago I told a group of paramedics that while not relaying on the computer interpretation in the case of STEMI, they should consider it as a fellow paramedic offering his opinion. I told them that the studies showed a 60% sensitivity and a 90% specificity in identifying STEMI. In other words, the computer would only identify 60% of the STEMIs, but if it identified a STEMI, it was going to be right about 90% of the time. I based this on several older studies I had read.

I can tell you as a paramedic when I suspect a patient may be having a STEMI and the computer agrees and the tracing meets criteria, I feel much better about calling a STEMI alert. I confess once when I had a patient with an ECG suggesting a small elevation in I and AVL. I did 9 ECGs en route to the hospital, and finally on the 5th one, the computer came around and agreed with my suspicion that the patient was possibly having a STEMI, giving me the maniless to call in the alert (I know I was being a wimp). Though the computer reversed course again on the 6th and 9th ECG, the patient was in fact having a lateral STEMI. He coded in the ED, was revived and successfully had his 100% occlusion in his circumflex artery stented.

Conversely when the computer calls it a STEMI, but I disagree with the reading, I recheck my lead placement and do another. Some make me doubt my reading ability, others make me want to put a dunce cap on the monitor and put in the corner of the ambulance facing the wall. You weren’t paying attention in paramedic school obviously, bad monitor!

A new study in the April-June 2013 Prehospital Emergency Care, Prehospital Electrocardiographic Computer Identification of ST-segment Elevation Myocardial Infarction, reports a 58% sensitivity and a 100% specificity for computer interpretation.

They reviewed the transmitted 12-leads of a 100 consecutive STEMIs and found 58 of them had the interpretation “Acute MI Suspected” on the 12-lead. Then to determine specificity, they analyzed 100 random 12-leads from non STEMI patients and found none of them incorrectly said “Acute MI Suspected.”

I must ask: Does this high specificity match anyone’s experience? Or even come close?

How often do you do a 12-lead and it says ***Acute MI Suspected*** or “Consider Acute MI” depending on the monitor you use, and you can look at the 12-lead and say No. Not even close.

In my hospital I receive an email each time a 12-lead is transmitted. I enjoy reading the strip. Our medical director and I play a STEMI game where we immediately email each other with our vote STEMI or no STEMI assuming the patient always to be symptomatic. I can tell you the number of 12-leads transmitted that say “Consider Acute MI” is way more than the number that actually are STEMIs.

Consider these:

The computer seems particularly inaccurate in wide complex and tachycardic strips.

I have had to go back to the medics and say the studies are wrong. Don’t put as much stock in the computer interpretation as I suggested you should. It is not close to 90% accurate.

An informal tally using the same criteria as the 2012 study for sensitivity shows the Life Pack 15 is about 60%. It properly identifies 60% of STEMIs, but misses 40%.

But then when I analyze specificity, I admittedly use a different criteria, which will yield a markedly different, but more telling conclusion. I ask, what percentage of the time when the computer reads “Meets ST Elevation Criteria” and “Consider Acute Infarct,” is it actually a STEMI? And the answer in this small sample (50 cases) is 32%. Not 100%.

Note: The published study cited above used the Life Pack 12, my figures are for the LifePack 15, which uses a different software.

The computer seems to consistently misread tachycardic rhythms and wide complex rhythms.

These, in my mind, are the proper questions we should be asking if we are going to incorporate the machine reading into our decisions:

What percent of the time is it a STEMI and the machine missed it? Seems to run about 60%

When the machine does call it a STEMI, what percentage of the time is it right? That answer is clearly not 100%, or even close.

Obviously, this should be confirmed in formal studies, which can be easily done at any PCI facility.

Does this mean I would be in favor of removing the interpretation from the machines? No, I think they can be valuable. I am just saying we shouldn’t be misleading others and ourselves by claiming the machines are better than they are.

When making policy that incorporates the computer reading into the decision making, we need to understand its limitations.

We need to make certain that paramedics are not relaying on the computer alone to call, and that if the machine does read STEMI, the medic makes agrees with the interpretation.

And we need to continue to work to improve basic paramedic interpretation, as well as proper placement and technique of ECG aquisition.

This will help limit false activations for services that cannot transmit.

Note: In our state we use the following to help determine diversion to a PCI center:

c. ***ACUTE MI*** or equivalent prints on 12-lead ECG; paramedic agrees

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If I show this 12-lead to a group of paramedics, I would wager close to 100% would accurately identify it as an inferior MI and call in a STEMI alert if the 50 year old male patient in front of them was clutching his chest.

Now, if I have the same patient and the 12-lead shows this;

How many paramedics are going to say this is a STEMI?

It is not a STEMI, it is a Left Ventricular Hypertrophy.

In a recent  study published in the April 2013 issue of Prehospital Emergenncy Care, 63.3% of paramedics identified this ECG as a STEMI.

The study, PARAMEDIC ABILITY TO RECOGNIZE ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION ON PREHOSPITAL ELECTROCARDIOGRAMS, by Mencl, et al, goes against the findings of prior studies that have shown paramedics can identify STEMIs with a high degree of accuracy. The limitations of the other studies have been that they have used paramedics right after training classes and in many cases had them evaluate only a small number of relatively obvious ECGs. The 12-leads used in this study I believe offer a more realistic test of a paramedic’s interpretation abilities.

In this study they had 472 paramedics from 30 different EMS services in five counties with 15 different medical directors read 10 different ECGs and were asked to either identify the strip as a STEMI or not.

Here’s how they did:

The number indicates the percentage of paramedics who correctly identified the rythm as a STEMI or not a STEMI.

Inferior STEMI 96.0%, Anterior STEMI 78.0%, Lateral STEMI 51.1%

Normal 1 97.3%, Normal 2 100%

RBBB 79.2%, LBBB 39.0%, Ventricular pacing 52.8%, LVH 36.7% , SVT 65.3%

The study concludes: “Despite training and a high level of confidence, the paramedics in our study were only able to identify an inferior STEMI and two normal ECGs. Given the paramedics’ low sensitivity and specificity, we cannot rely solely on their ECG interpretation to activate the cardiac catheterization laboratory. Future research should involve the evaluation of training programs that include assessment, initial training, testing, feedback, and repeat training.”

I took the 10 ECGs from this study and gave them as a test to a large group of paramedics ranging from twenty-year veterans to new paramedics and found similar results.  These results square with my observations of paramedics bringing possible STEMI patients into our hospital.

Here’s what I take from it:

Paramedics can identify inferior STEMIs with a high degree of reliability.  Lateral and Anterior STEMIs can be more difficult.  Left bundle branch and LVH can particularly cause confusion in some paramedics.

My experience with field STEMI alerts is that paramedics tend to by shy about calling for STEMI alerts, and thus have fewer false activations than this study, if extrapolated,  would suggest.  In other words, if a paramedic is sure it is a STEMI, such as an inferior, the paramedic will call in a STEMI alert.  But while the paramedic might guess a 12-lead is a STEMI such as the LVH ECG above, the paramedic might be less likely to call in a STEMI alert with it. 

Despite this well done study, I continue to support field activation of the cath lab through paramedic interpretation alone, but I do believe we need to increase our 12-lead training efforts.

I believe that with frequent training and regular competency checking, paramedics can indeed identify STEMIs with a high degree of reliability.  But if you don’t do the training and keep it up, the results will not be as high.

In a future post – What about computer interpretation?

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In a recent post((These Go to Eleven), I made fun of some of my patients’ uses of pain scales. While I am big advocate for pain management, I am occasionally stumped by the pain scale declarations of 10. This last week in reading the report Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research, I read a section on pain scales that I thought was interesting.

Pain scales were widely introduced into the health care system in 2001 due to the efforts of the Joint Commission of Health Care Organizations which made pain the “5th Vital Sign” and a requirement for hospital accreditation. Health care personnel were now required to document a pain scale in a patient’s record right next to the more traditional vital signs of pulse, blood pressure, respiratory rate and temperature. It wasn’t long after that EMS began to require pain scales as well. In our region every patient requires a documented pain scale whether or not they are complaining of pain.

Here is what I read in the Relieving Pain book:

The full impact of the fifth vital sign approach is not entirely clear, however, as studies have indicated effects ranging from beneficial and limited outcomes to negative consequences. While adherence to the standard has improved satisfaction with pain management, adverse drug reactions have increased (Vila et al., 2005). In selected trauma care centers, overmedication with opioids and sedatives—attributed by the researchers to compliance with the new standard—reportedly contributed to higher mortality rates, usually resulting from too great a reduction in blood pressure or compression of the airway (Lucas et al., 2007). In a veterans’ outpatient clinic, monitoring pain as a fifth vital sign failed to improve pain management as the assessment was not followed up with recommended treatment, even for patients reporting substantial pain (Mularski et al., 2006). Similarly, in a study of eight veterans’ facilities in the Los Angeles area, documentation of pain—necessary for pain care planning—was frequently absent from the medical records of patients with moderate and severe pain (Zubkoff et al., 2010). Taken together, these studies suggest the need to exercise careful clinical judgment based on a comprehensive patient assessment instead of merely monitoring pain (meeting, in a sense, the letter of the law and not the spirit), using opioids to the exclusion of other treatment approaches, or routinely using these powerful medications when their use is not clinically indicated.

What I take from this is we need to exercise “careful clinical judgment” when evaluating pain. Every patient should get a pain scale, but we should not relay entirely on that scale to guide our treatment. I am not suggesting we revert back to the “I can judge your pain” mentality, when studies have clearly shown people are incapable of accurately judging another’s pain. What I mean by clinical judgment, is that paramedics need to decide, based on a number of factors, what is the most appropriate method of treating someone’s pain. Automatically giving a narcotic analgesic to any patient who says his pain is a 10 is no more right than automatically refusing to give narcotic analgesics because a patient doesn’t look like he is in pain.

It comes down to the old cookbook analogy. Paramedics should never blindly follow a protocol. Instead paramedics should assess, evaluate, consider, and then act in the best interests of the patient. And, of course, document why you reach the clinical course you do.

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I have written much about pain management and find it one of the most gratifying aspects of being a care-giver. I feel a little bad that in my last post I made fun of some of my patient’s pain scales – something I will address further in my next post, but I wanted today to reclaim the high road and talk about a book –Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research – I highly recommend to all.

The book is largely about chronic pain, but it does mention acute pain and the need to treat it promptly. Unfortunately there is no mention of the EMS role in the book, but there are still many lessons for us in it.

I am going to quote and comment on the opening paragraph of the book, which I think is beautifully written and drives home much of what I have come to learn and feel about the importance of pain management.

“Protection from and relief of pain and suffering are a fundamental feature of the human contract we make as parents, partners, children, family, friends, and community members, as well as a cardinal underpinning of the art and science of healing.”

The very first role of ancient healers was to treat pain. In the mix of our learning of various diseases and the skills to combat them, we often neglect the very patient in front of us. William Osler, the father of modern medicine said, “Care more for the individual patient than for the special features of the disease.”

“Pain is part of the human condition; at some point, for short or long periods of time, we all experience pain and suffer its consequences.”

I have been giving my pain management talks for a long time and, at times, have been nearly hooted out of the room by old guard medics who followed the “I have to hurt looking at you for me to give you pain meds” philosophy and others who see a drug-seeker behind every person in pain. Over time many of these paramedics have come back to me and apologized, and said they had no idea of what pain was until they tore their shoulder or had a kidney stone themselves, and now they treat patients much more liberally and compassionately, understanding what it is like to be in real pain.

“While pain can serve as a warning to protect us from further harm, it also can contribute to severe and even relentless suffering, surpassing its underlying cause to become a disease in its own domains and dimensions.”

Untreated acute pain can rewire a patient’s body making them more susceptible to pain in the future. For people who think pain is a simple message from the injured part to the brain that goes away when the injury heals should think about amputees who still feel pain in their missing limbs to understand the complexity of our neurons and physiology. We need to think of pain as a disease that attacks the body right from the outset and pain management as a time sensitive intervention that in cases of acute pain, can affect the outcome of patient’s lives. As Dr. R McKenzie writes “The pre-hospital practitioner has the first and perhaps only opportunity to break the pain cascade.”

“We all may share common accountings of pain, but in reality, our experiences with pain are deeply personal, filtered through the lens of our unique biology, the society and community in which we were born and live, the personalities and styles of coping we have developed, and the manner in which our life journey has been enjoined with health and disease.”

Who are we to sit in judgment of others, not having walked in their shoes? Should the judgment of Drug Seeker! and Faker! be gaveled down in the court of the back of the ambulance? I am uncomfortable with that. I would rather err on the side of the patient and let the rest be sorted out in the hospital. How many times can we be wrong about a drug seeker to justify withholding drugs from someone truly in pain? And we must remember often people seek drugs because of their pain. They aren’t all just bored and looking to get a quick high.

“The personal experience of pain is often difficult to describe, and the words we choose to describe pain rarely capture its personal impact, whether it is sudden and limited or persists over time.”

Pain scales I realize are imperfect and better techniques of assessing pain need to be developed. But more about pain scales and their pros and cons in the next post.

“Severe or chronic pain can overtake our lives, having an impact on us as individuals as well as on our family, friends, and community.”

People as young children didn’t dream of growing up to become dependent on pain medicince. The suicide rate for people with chronic pain is much higher than the national norm. 100 million Americans suffer from chronic pain. Many of us will suffer chronic pain at some point in our lives. Let’s hope our care-givers are compassionate with us.

“Through the ages, pain and suffering have been the substrates for great works of fiction, but the reality of the experience, especially when persistent, has little redeeming or romantic quality.”

For most of history people believed that the mind and the body were separate — that people could just soldier on without damage. But we have learned now that mind and body are interlinked by physiology. Pain can destroy both body and mind.

“The personal story of pain can be transformative or can blunt the human values of joy, happiness, and even human connectedness.”

No one should have to sit before another and have to beg to be treated as a fellow human. In EMS we are caregivers. We are the door to compassion – to human connectedness. Open 24/7.

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Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research is a publication of the National Institute of Medicine that came out in 2011 and is available for free PDF download at this site:

Relieving Pain in America

Here is the description of the report:

Chronic pain costs the nation up to $635 billion each year in medical treatment and lost productivity. The 2010 Patient Protection and Affordable Care Act required the Department of Health and Human Services (HHS) to enlist the IOM in examining pain as a public health problem. In this report, the IOM offers a blueprint for action in transforming prevention, care, education, and research, with the goal of providing relief for people with pain in America. To reach the vast multitude of people with various types of pain, the nation must adopt a population-level prevention and management strategy. The IOM recommends that HHS develop a comprehensive plan with specific goals, actions, and timeframes. Better data are needed to help shape efforts, especially on the groups of people currently underdiagnosed and undertreated, and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. Because pain varies from patient to patient, healthcare providers should increasingly aim at tailoring pain care to each person’s experience, and self-management of pain should be promoted. In addition, because there are major gaps in knowledge about pain across health care and society alike, the IOM recommends that federal agencies and other stakeholders redesign education programs to bridge these gaps. Pain is a major driver for visits to physicians, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. Given the burden of pain in human lives, dollars, and social consequences, relieving pain should be a national priority.

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