Who said computers don’t know how to interpret 12-lead ECGs?
Who said computers don’t know how to interpret 12-lead ECGs?
Why do a 12-lead on first patient contact?
If your patient is having a STEMI, you can recognize it sooner and then immediately notify the ED to get the cath lab activated. This will save heart muscle that will lead to a better quality of life for your patient.
Why else should you do a 12-lead on first medical contact?
Here’s a clue:
Check out these three 12-leads and note their times:
The first ECG was done at 13:09. The 2nd was 13:17. The 3rd at 13:18.
While studies have shown that between 15-20% of STEMIs don’t emerge until the 2nd or 3rd ECG, there are also cases like the above where the STEMI disappears after the first ECG.
The patient above had an occluded right coronary artery. As his chest pain eased, his ST segment came down to the point it was gone by hospital arrival. Based on the prehospital ECG, the cath lab had already beeen activated and the patient was brought to the lab, where the chest pain and ST elevation returned, and then resolved when the clot ( a 99% occlusion) was cleared.
Life Pack monitors are equipped to track the ST segment. Here on the trend summary, you can see evidence of the ST segment coming back to normal.
Note: the second and 3rd ECG were automatically printed out by the Life Pack 12 due to the changing ST baseline in lead III, a feature of the LifePack monitors, which monitors the ST segment every thirty seconds and alerts you (by printing out a new 12-lead) when it records significant change.
Failure to do a 12-lead on first medical contact, particularly when the patient is having chest pain can lead to a missed or significantly delayed STEMI identification.
Do a 12-lead on first medical contact of all patients you suspect of Acute Coronary Syndrome. Do another 12-lead when you begin transport and a final on hospital arrival.
A recent study in Prehospital Emergency Care, A Prospective Evaluation of the Utility of the Prehospital 12-lead Electrocardiogram to Change Patient Management in the Emergency Department showed that nearly 20% of the prehospital ECGs in the study had significant abnormalities from the first ED ECG and that these abnormalities influenced the resulting care by the ED MD.
We can all agree that these are goals of a perfect EMS system.
1. A paramedic on every priority one emergency call
2. A run form completed before leaving the hospital
3. A living wage for every paramedic
Ever since I have been in EMS — 24 years now — I have heard the discussions about ambulance availability, the need to leave a fully completed documented run form before leaving the hospital, and the need to improve paramedic pay.
I recently overheard an exchange between three people, one a paramedic, one a supervisor for an ambulance service and one a hospital administrator.
Here was the rub:
The hospital wanted the paramedic to not leave for the next call before they had finished writing the run form from the first call and they wanted the paramedic on the priority one emergency call.
The ambulance supervisor wanted the run form fully completed (for billing and data reporting) and the paramedic to clear the hospital quickly to do the priority one call.
The paramedic pointed out that is was often impossible to fully complete the run form, print it out and leave it for the hospital and get to the dispatched call in a meaningful time.
The paramedic said he skipped many of the boxes on the run form so he would get the form done quickly and be able to clear. He said he sometimes cleared to take the call without leaving the run form because the patient was alert and had no issue but a cut finger. The paramedic also said many times he did fully complete the run form, but the patient was still on his stretcher when the next call came in so even though his run form was done, he couldn’t clear to take the call.
The hospital administrator told the ambulance service to put more cars on the road so the paramedic could have the time to write the run form while the added paramedic did the call.
The ambulance supervisor wanted the hospital to hire more nurses so the triage lines weren’t so long and so that when the nurse heard the paramedic’s verbal report, they wouldn’t forget it immediately because they were taking care of so many patients. And he wanted the hospital to give his company more transfers so it could make enough money to put more cars on the road.
The paramedic said while you are spending more money on hiring more nurses and putting more ambulances on the road, how about kicking a few extra dollars my way because I’m not keeping up with the cost of living despite working 60 hours a week.
The bartender interrupted the conversation then, by asking if they would all like another round, which they did. On the TV over the bar there were news stories about crumbling schools, jobs moving out of state, and other bad news.
Here’s what happened. The paramedic did the best he could to leave the run forms and get to the calls so the patients didn’t suffer. Sometimes he completed the run forms, sometimes he didn’t. No nurses were hired. No cars were added. The triage lines stayed long. Calls were still dispatched before the crews had the patient off their stretcher. The paramedic did not get his raise. The three continued to drink beer together.
A day after I posted about the benefits of reducing door-to-balloon times to improve mortality, Door-to-Balloon Time and Mortality the New England Medical Journal released a major new observational study that showed that despite a significant reduction in door to balloon time in recent years, there has not been a corresponding decline in 30 –day in-hospital mortality.
It is a provacative article and I look forward to the medical community discussion about the findings.
Here is my initial reaction:
In-hospital mortality is not the best measure of effectiveness of door-to-balloon time. Very few STEMI patients actually die in the hospital. 4.7% in this study. Most of the ones who die are very sick (patients in cardiogenic shock etc, some post ROSC) when they come in. Most STEMI patients, particularly those who come in shortly after presentation, do quite well and are out of the hospital within 2 or 3 days. Many leave with no loss of heart function at all! Perhaps a better measure of the effectiveness of door-to-balloon time would be heart function and post MI quality of life.
The authors suggest, and I agree, that we need to look less at door-to-balloon time and more at symptom onset-to-balloon time.
Here again is an article I mentioned in my previous post, Association of onset to balloon and door to balloon time with long term clinical outcome in patients with ST elevation acute myocardial infarction having primary percutaneous coronary intervention: observational study, which concluded:
“Short onset to balloon time was associated with better 3 year clinical outcome in patients with STEMI having primary percutaneous coronary intervention, whereas the benefit of short door to balloon time was limited to patients who presented early.”
The NEMJ article suggests that hospitals have gotten their in-house systems down so well that perhaps, they are saving everyone that can be saved and there is no more room for improvement.
An accompanying editorial to yesterday’s New England Medical Journal article, Time to treatment in patients with STEMI suggests that:
“It’s unlikely that reducing in-hospital delays by another few minutes will affect clinical outcomes, given the small portion of total ischemic time those minutes would represent and the success that’s been achieved in the system of in-hospital STEMI care. The primary opportunity for reducing total ischemic time and time to treatment, and for improving outcomes, now lies in the prehospital STEMI system of care.”
The time period for this study was 2005 to 2009, before most EMS systems started transmitting ECGs, using STEMI alerts, and field activations.
Jason, a reader, yesterday raised the following question about door to balloon times:
So I read something interesting a while back and unfortunately I’m not going to be able to site a source but it said this. A door to ballon time (d2b) of < 90 mins was immensely beneficial in decreasing m&m in STEMI pt's. We all know that now. It said a d2b < 75 mins added a little more benefit in reducing m&m. But I think at about d2b of about 60 mins we start to approach the limit. That is in decreasing d2b below 60 mins we realize no additional benefit.
Can anyone site the study?
There are many studies out there. Most of what I have read suggests the shorter the door-to-balloon time the better. Here is the study I use in some of my presentations.Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. It was published in the British Medical Journal in 2009.
Here was the conclusion:
“Any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes.”
Here is a graph from that article illustrating the impact of decreasing door-to-balloon times on mortality.
A new study, also in the British Medical Journal (May 2012), Association of onset to balloon and door to balloon time with long term clinical outcome in patients with ST elevation acute myocardial infarction having primary percutaneous coronary intervention: observational study, suggests that what really matters is presentation to balloon time. And that in those patients who present early, the shortest possible door-to-balloon time improves outcomes.
Here is their summary:
What is already known on this topic:
Results from previous studies are quite inconsistent regarding the relation of symptom onset to balloon time and clinical outcomes in patients with ST segment elevation myocardial infarction.
The time to evaluate endpoints varied widely between these different studies.
Little is known about the relation of onset to balloon time with long term clinical outcomes in actual clinical practice.
What this study adds:
A clear association has been shown between a short onset to balloon time of less than three hours and better long term (three year) clinical outcomes.
The benefit of short door to balloon time was limited to patients who presented early.
Further improvement in the outcome of patients with ST segment elevation myocardial infarction could be achieved by reducing the total ischaemic time with various efforts.
The bottom line for paramedics is do everything we can to contribute to the safe shortening of door-to-balloon times in STEMI patients. The best way we can do that is through early activation.