Recently I have taken part in a very interesting discussion on the NAEMSP dialog page. This discussion is based on the paper Early Cardiac Cath Lab Activation by Paramedics for Patients with STEMI on Prehospital 12 Lead ECGs. Tom B from The Prehospital 12-Lead blog, and contributing author to Paramedicine 101 is one of the active participants in the discussion.
Some of the problems discussed:
- Poor quality ECG captures
- Deficiency in knowing when to capture a 12-lead ECG (43% of paramedics in one study did not perform a 12-lead on an active STEMI)
- Deficiency with STEMI recognition (False positives are still far to frequent)
- Poor STEMI alert and transport guidelines
One of the solutions which has a lot of supporting evidence is the transmission of 12-lead ECGs from the field to the receiving PCI facility.
THE POSITIVE PREDICTIVE VALUE OF PARAMEDIC VERSUS EMERGENCY PHYSICIAN INTERPRETATION OF THE PREHOSPITAL 12-LEAD ELECTROCARDIOGRAM
Background. Obtaining a prehospital 12-lead ECG may improve triage and expedite care of patients with acute myocardial infarction (AMI). Whether the ECG should undergo physician review prior to activation of a percutaneous intervention (PCI) team is unclear. Objective. To document the positive predictive value (PPV) of the prehospital 12- lead ECG when interpreted by paramedics versus emergency physicians. Methods. This was a prospective, observational study. In November 2003, our local health care and emergency medical services (EMS) systems implemented a prehospital “cardiac alert” program in which patients suspected of having ST-elevation myocardial infarction (STEMI) based on the prehospital 12-lead ECG were diverted away from receiving facilities without emergent PCI capability and the PCI team was mobilized. For the first year, a cardiac alert was activated by paramedics (Phase I). After the first year, the ECG was transmitted to the ED, with the emergency physician (EP) responsible for activation (Phase II). The PPV for cardiac alerts in Phases I and II were compared by using three different “gold standards”: cardiologist interpretation of the prehospital 12-lead ECG, disposition to emergent PCI, and coronary lesions on angiography or arrest prior to emergent PCI. Results. A total of 110 patients were enrolled (54 in Phase I, 56 in Phase II). Cardiologist confirmation of a STEMI on the prehospital 12-leadEKGwas 42/54 (78%) in Phase I and 54/56 (96%) in Phase II. Disposition to emergent PCI occurred in 38/54 (70%) Phase I patients and 51/56 (91%) Phase II patients. Lesions at catheterization or arrest prior to emergent PCI were observed in 41/54 (69%) of Phase I patients and 50/56 (89%) of Phase II patients. All of these comparisons achieved statistical significance (p less than 0.01) Conclusions. Transmission to the ED for EP interpretation improves the PPV of the prehospital 12-lead ECG for triage and therapeutic decision-making.-PREHOSPITAL EMERGENCY CARE 2007;11:399–402
Okay so a solution I would like to provide, and please provide comments here and/or on the dialog page linked to above.
My solution is to provide an adjunct course. Much like ACLS, CPR, PALS or BTLS, this course could be taught in conjunction with the paramedic curriculum but will expire and renewals would be required. The current paramedic curriculum does not include enough instruction on prehospital 12-lead ECG interpretation. My proposed course would include a whole lot more information as well as STE-Mimic recognition. Why not? In my experience, I have noticed that the biggest deficiencies that paramedics present are airway, medication administration, and cardiac rhythm interpretation--especially 12-lead ECG interpretation.
So what do you think?
Provide your thoughts or your solutions to narrowing the EMS to repurfusion times.
14 comments:
I agree.
I think that 12 leads need to be a mandatory skill for paramedics. I expect that there will be a distinction between skilled paramedics and unskilled paramedics.
Unskilled will be the ones who cannot intubate, cannot interpret 12 leads, and do not use critical judgment.
The EMT-Intermediate. But the medics who do not, or cannot, develop and maintain skills will need to be demoted to this level to protect patients.
We have too many unskilled medics. We need to admit this and change it.
I agree that there needs to be more education regarding 12 Lead ECGs for paramedics. The biggest problem I see at this point is who would teach the information and what information they would present. I am not involved in paramedic initial education, but how much STEMI recognition or 12 Lead interpretation is on the National Registry Exam?
Skill maintenance is another issue entirely. Is another required course the best solution?...I don't know. Where should we place our emphasis on continuing education? I think ECG interpretation is important because obviously evidence shows how beneficial triaging patients to a PCI capable hospital is.
I agree we need to do something regarding paramedics who do not or cannot maintain their skills. This problem has multiple issues itself, but I think it needs to start with a medical director that recognizes the problem. I heard a rumor of a Medical Director that wouldn't allow a Fire Department to staff more "Assessment Engines" because he felt they would not maintain their low frequency-high risk skills...how true this is I don't know.
Geoff,
I agree we need to do something regarding paramedics who do not or cannot maintain their skills. This problem has multiple issues itself, but I think it needs to start with a medical director that recognizes the problem.
Absolutely.
Medical directors decide that medics are safe to treat patients, but the medical directors do not appear to have any accountability for the actions of incompetent medics - medics who would not be able to harm patients without the permission of the medical director - even if they did nothing to determine the competence of those medics.
I heard a rumor of a Medical Director that wouldn't allow a Fire Department to staff more "Assessment Engines" because he felt they would not maintain their low frequency-high risk skills...how true this is I don't know.
I don't know if this is what you are referring to, but this is from August.
Fla. EMS director pulls certification of 25 paramedics
That wasn't what I was referring to, but I did read it. It happened in California. One of the biggest problems we will encounter is the public "outcry" due to the perception of "losing" paramedics.
We have to admit a problem, stop lying to ourselves about the problem and correct it.
RM,
That link you posted is from the county south of mine. Dr. Tober took away the credentials of the fire medics that did not pass their recredentialing test. He caught a lot of slack for that and continues to, but I think it was the right thing to do--if I have the facts right. Some have rumored that he doesn't think firefighters should be paramedics.
Back to the topic.
Geoff, I think a course is a good option because the option to make it expire forces the continuing education. Even if the refreshers were online courses, it would be better than what we have now.
The problem with leaving it up to the medical director. How does the medical director know about the efficiency of his paramedic's ECG interpretation if no one goes to him, and he does not review their calls. In my system, the medical director is only notified if their is a serious deficiency. The QI/QA personnel handle all other issues.
My medic class was structured in that manner, with heavy emphasis on 12L interpretation and recognition of STEMI-mimics. We also had to take the Tim Phalen class online which was a huge help. All EMT-P's and EMT-P students in NC can register for Tim's class for free!
Geoff,
We do need to stop worrying more about the number of medics, than the quality of medics.
You mentioned National Registry. I see them as part of the problem. They spend so much time on avoiding discrimination, that they miss the point. Testing is supposed to discriminate between those who understand and those who do not understand. Multiple choice questions and rehearsed scenarios do not evaluate understanding.
NR is cut rate EMS. We need to admit that good EMS is not cheap.
Adam,
The problem with leaving it up to the medical director. How does the medical director know about the efficiency of his paramedic's ECG interpretation if no one goes to him, and he does not review their calls. In my system, the medical director is only notified if their is a serious deficiency. The QI/QA personnel handle all other issues.
The medical director should not allow this to happen.
Most EMS organizations do not pay medical directors adequately for real oversight.
Does EMS even want real oversight?
Does EMS even want real oversight?
In general... No. However, there are those of us whom beg fore it.
I think that having a 12 lead "cert" that would have to be renewed every couple of years would be a step in the right direction.
As far as oversight for EMS. We need it. I think we all know of medics out there that just don't measure up. In my EMS system and in the others under which I have worked there are no easy ways to try to either help them or get them out of paramedicine. In addition to QI/QA maybe some peer evaluation is needed.
Christopher, sounds like you recommend Tim Phalen's on-line course? I took his 4 hour STEMI class when we started, plus a few books, but was looking for more structured information. I have done the AHA STEMI course, but it wasn't what I was hoping for.
...and yes, more oversight.
The problem with this proposal, as with all of the "merit badge" courses is that it is a band aid approach to fixing what ails EMS.
First, there are too many paramedic, too many paramedic programs, and the existing curriculum is way too short.
I know medics who have taken PALS, ABLS, NALS, PEPP, PHTLS, ITLS, AMLS, and other courses. They rave about what they learn, but I have to wonder why they didn't learn the material in their paramedic program. The answer of course is that the programs don't cover the material Which is good for the NAEMT because they get money from running the courses. I don't think it's good for attempts to upgrade the image of the trade, which wants to be a profession.
12 Lead ECG interpretation should be part of the cardiology section of every paramedic program.
I also have to wonder if some medical directors and ED directors don't want medics reading 12 Leads because that would put pressure on EDs and cardiology services to get patients into the cath labs more quickly.
I also have to wonder if some medical directors and ED directors don't want medics reading 12 Leads because that would put pressure on EDs and cardiology services to get patients into the cath labs more quickly.
Very interesting theory.
12-lead ECG is taught in paramedic courses, but to what extent? STEMI & BBB recognition is not the only use for 12-leads.
Okay here is my two cents. I do understand why some fire medics get a bum rap. They promoted for the pay increase and don't have the passion to be a Paramedic. But what about all these young kids now getting out of p-school at 20 or 21 years of age. They don't have the experience or maturity to be taking care of critical patients. At least fire medics have to work 1 to 3 years as an EMT before promoting. Now I will go way out on a limb. Why not require all paramedics to be nurses? We have ICU, ER, Critical care nurses etc etc. Why not a nurse paramedic? It would require more of a committment cut down on the people going to a 1 year paramedic course and then setting them free to take care of patients. It would keep them in school longer and hopefully gain some maturity. It would defintiley weed out the people that just decide out of the blue to be a paramedic. The nurse paramedic course could be structured more to 12-lead interpretation, intubation skills etc etc. Fire Departments couldn't afford to send people to school so you would have to come on as a nurse paramedic if you wanted to be a fire fighter. My paramedic course required only 10 tubes. Looking back that was crazy. I know this is not popular but there are definitely way too many inexperienced paramedics out there. And you can't teach experience.
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