12 Leads And Rerouting Ambulances

[x635 4,066]

Very nicely done and interesting article about a system upstate. Hopefully, this rerouting to a cardiac center idea will make it's way down here someday.

Turning a corner in heart care

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New system routes emergency patients to sites specializing in life-saving procedures

By HENRY DAVIS  

News Medical Reporter

7/8/2005  

 

 

The ambulance that sped off with David Perkins after his heart attack did the unexpected when it passed the closest hospital, only a few minutes away.  

Normally, the crew would have taken him as quickly as possible from his Kenmore home to the nearest facility to get the standard treatment - an injection of a drug that can dissolve blockages in arteries that starve the heart of oxygen and nutrients.  

Instead, the ambulance drove miles farther to Erie County Medical Center, one of a handful of hospitals in Buffalo that perform emergency procedures to unclog blood vessels around the clock.  

That decision marked an important turning point here in the changing treatment of patients with cardiac problems.  

Studies show that such procedures as balloon angioplasty or the insertion of stents in clogged arteries are often more effective than clot-busting drugs for the most serious type of heart attack. But the interventions must be done within a few hours of the heart attack to be worthwhile.  

Now, communities like Buffalo are preparing to transfer heart attack patients to the most appropriate hospital, similar to the way accident victims are rushed to specialized trauma centers.  

That's no easy thing.  

Transferring a heart attack patient can be risky business, requiring short transport times and careful consideration as to whether the clot-busting drug may be the best treatment.  

Paramedics must have the technology and training to identify types of heart problems in the field and transmit that data electronically to a cardiac center. Ambulance services and paramedic units also need agreements with cardiac centers to ensure that everyone is working as a team with a unified set of procedures.  

The centers, in turn, must be prepared to receive the data and alert a medical team on call 24/7 to provide the angioplasty within 90 minutes of the patient walking through the hospital doors.  

In Perkins' case, all the pieces fit together seamlessly for the first time in this region when he felt a terrible tightness in his chest on an icy midmorning last January while using a snowblower outside his house.  

Paramedics from the Town of Tonawanda attached a 12-lead electrocardiograph machine to his chest to measure the electrical impulses, or waves, traveling through the heart. The test picked up a wave pattern often linked to the most dangerous type of heart attack.  

The electrocardiogram strongly indicated an artery in his heart was blocked.  

Physicians at Kenmore Mercy Hospital, where Perkins would have gone, redirected the ambulance to Erie County Medical Center after reviewing the graph of spiky waves that had been faxed wirelessly by paramedics.  

A medical "milestone'  

"It was a milestone in cardiac care in this area. It shows the power of 12-lead EKGs when the system is set up right," said Scott Wander, director of the Office of Prehospital Care at the medical center.  

"We now have the technology and information to get patients to the most appropriate hospital," he said. "The key is that you have to jump on these patients to get them to those hospitals within the time window."  

The main cause of blockages is heart disease, the buildup of cholesterol and fat in the arteries. Coronary heart disease is the single largest killer in the United States, causing one of every five deaths, and the Buffalo area has one of the highest rates of heart disease in the nation.  

An estimated 1.2 million Americans each year suffer heart attacks, with around 500,000 resulting in death. Most are treated with clot-busting drugs called thrombolytics because only around 25 percent of hospitals provide angioplasty, which requires facilities for heart surgery in case of complications.  

Restoring blood flow to the heart within a few hours is vital to limit damage to the heart, giving rise to the maxim in cardiac care that "time is muscle."  

In angioplasty, which many patients undergo to prevent heart attacks, a tiny tube called a catheter is threaded through arteries to the blockage. In Perkins' case, the cardiologist propped open the blood vessel with a little metal mesh tube called a stent, and he was released the next day.  

"I was feeling pain in my chest at 10:30 a.m., and by noon I was on a table at the hospital getting an angiogram," said Perkins.  

Today, the 55-year-old bus driver and instructor for the Niagara Frontier Transportation Authority is back at work and enjoying the best year of golf in his life.  

"I didn't suffer any damage to my heart," he said.  

In the last year or so, Mercy Hospital, Buffalo General Hospital, Millard Fillmore Hospital, Veterans Affairs Medical Center and ECMC have established programs to provide angioplasty on an emergency basis. And, New York State may by year's end officially designate certain hospitals as referral cardiac centers, similar to the way it designates particular hospitals as the ideal places for stroke or trauma care.  

When minutes matter  

But much work is still needed to minimize time delays in the transfer of patients from community hospitals and the field. A matter of a few minutes can reduce damage to the heart or save a life.  

To accomplish this, paramedics need 12-lead EKGs, a more sophisticated heart monitor than previous models. The 12-lead EKG provides better information about the status of the heart, something like the difference between a three-dimensional and flat picture. Personnel on the scene also need to be able to send that information quickly to hospitals.  

Twelve-lead devices are not new. But the Town of Tonawanda Paramedic Unit earlier this year installed up-to-date, faster machines that incorporate software to identify heart disturbances, and combined them with wireless communication capabilities, becoming the first unit in the region to put together the pieces of the prehospital cardiac care puzzle.  

"The value of using this technology can't be questioned," said Dr. Joseph R. Takats III, medical director of Tonawanda's paramedic unit. "The studies show you're decreasing deaths and improving outcomes if you can get patients to the hospital for the interventions in a timely manner."  

Town of Tonawanda paramedics see about 500 patients a month in their territory. They have performed about 40 12-lead EKGs a month since initiating the program, referring roughly two patients a month to one of the cardiac centers. The equipment has helped shave 12 to 15 minutes from transport times.  

Currently, the paramedics must send the EKGs to their closest hospital to confirm the diagnosis and to discuss whether to transfer a patient to a cardiac center. But that will likely change as the state establishes protocols for transferring patients directly from the field, said Takats.  

"You can see where prehospital care is headed. In the future, paramedics will be able to make that decision with the patient," said Takats, who also serves as chairman of the panel of physicians that advises the Western Region Emergency Medical System, which represents paramedics.  

Other emergency medical services see the need to adopt the technology, prompted by the shifting standard of care, an anticipated push by the state to expand the use of 12-lead EKGs and the expected designation of cardiac referral centers.  

Expensive package  

But cost remains an obstacle.  

In the Town of Tonawanda, the James V. Ryan Foundation purchased six of the devices and their accessories for about $20,000 each.  

Rural/Metro Medical Services plans to buy 10 of the 12-lead EKGs by the end of the year and install them in "fly cars" that ferry advanced life-support equipment in support of ambulances.  

"It's an expensive project. We couldn't and wouldn't put one in every ambulance right now," said Steve Beauchamp, spokesman for the large ambulance company that serves Buffalo, Cheektowaga and Hamburg.  

 

[roeems87 0]

Very cool. I guess the problem with this may be that (now I'm not a paramedic, this is just by word of mouth and observation by an EMT) many doctors and nurses don't pay any attention to the 12-lead the medic does in the bus and completely ignore their interpretation of what's going on. That means relying on telemetry in the time it takes you to begin a rapid transport to the nearest hospital, this will require a rapid sequence of events on a fairly regular basis, but it would be great if it could work. And I do believe it has the potential to in our area...

This is another one of those specializations that hospitals are becoming more solidified in. The other classic example is hospitals becoming "designated stroke centers." White Plains I believe is the only one in the area at the moment currently applying for it. That protocol would be to show that you bypass all hospitals except the stroke center if you can place the known time of the onset of the stroke symptoms within 2-3 hours and you can transport within that time frame.

I think it's all great. There is no reason why the only real designation we make for transports is trauma. Granted, when someone has special needs, you consider the most appropriate hospital, but having "centers" like we have leveled "trauma centers" for many other problems that can be "diagnosed" on scene is a giant step up in field patient care. In the same way we evaluate MOIs for trauma, perhaps NOIs can become the same type of standard.

[ems-buff 81]

doesn't white plains hospital do something like that for strokes

[Guest alsfirefighter]

12 Lead EKG is woefully misused and misunderstood here in Westchester and surrounding regions. I haven't had any problems with utilizing my 12 lead in the field and I do it very often and not had a nurse and/or ER MD ask me for a copy of mine to see if any morphology changes have occurred from my treatments. Its just like everything else, if those who use it don't understand it and know it, those whom don't who we need to give it to also won't and automatically dismiss it.

Another case in point, the automatic chest compression machines. I swear by the autopulse for a multitude of reasons other then cost. It frees up hands to achieve more advanced care and in the ER allows the same without someone having to stand on a stool to deliver compressions if they are vertically challenged. Most important, consistant depth, rate and location of the compression. I came into a ER in our county and after 2 mins the nurse blurts out...can we get this off so someone can do real CPR....my answer "honey, if you don't what that is doing that's ok...but thats as real and as good as you can get." There was mix of giggles and looks and I'm sure you can tell which sides of the medical mix they each came from.

[WAS967 97]

I still remember that. Kind of surprising coming from someone who grew up in EMS with thumpers. Or maybe BECAUSE she grew up with thumpers, who knows.

As for 12-Leads, I've used em, and agree they are woefully underappreciated by ER staff. In fact, I'd do them more often if they bothered to use them more often. Otherwise unless there is a clear cut need, I simply have better things to do because it becomes a waste of time. A recent QA report of a call stated "I wonder what a 12 lead would have shown". My response: "Who cares? The ER sure doesn't." Oh well. With the above triaging of patients to designated heart centers however, 12-Leads will HAVE to become as commonplace in the treatment of r/o MI cases as ASA administration.

[x635 4,066]

At the ED I frequent the most, I find the MD's and most of the nurses very receptive to a 12 lead....that's when I actually do one. Unless it's going to change my course of treatment, i.e. going to a cardiac center, then I'm not going to delay my more crucial interventions to do a 12 lead.

You can also probaly get permission from Med control to divert to a Cardiac facility too, if you play your cards right. However, I want it in standing protocol!

[WAS967 97]

...I'm not going to delay my more crucial interventions to do a 12 lead.

I agree 100%. Surprising you actually get them to pay attention to your ECGs. Maybe I'll try again in the future, who knows, maybe others have broken the ice and gotten it across that we're more than glorified oxygen administrators.

[Guest NYTruckie]

...I'm not going to delay my more crucial interventions to do a 12 lead.

I agree 100%. Surprising you actually get them to pay attention to your ECGs. Maybe I'll try again in the future, who knows, maybe others have broken the ice and gotten it across that we're more than glorified oxygen administrators.

I have had MD's ask if I did a 12 lead, if they could see it and get a copy. As for the time where I work there is time either waiting for the ambulance or in transit. I also believe that "all cardiac" chest pain are to have a 12 lead done (If available) in the Westchester Co. Protocols.

[Guest mediconpatrol]

I am a firm believer in the use of 12 lead EKG's. I feel that they do help me with my diagnosis and give me a helpful picture of what may be going on with my patient at the time that I am with them. But, without the capabilities of transmitting at this time, it is there to help me and give the doctor and example of what I was seeing. I would never treat a patient based on another persons assessment, nor would I expect the ED to do the same. Unsure if the criteria has changed, but it used to be fibrinolytic therapy criteria required 3 EKG's including a right sided before consideration and treatment. It could be 10 minutes or more from the time I obtained my 12 lead and arrival to hospital. So much could have changed in that time and since we monitor in lead 2, we may not have seen it. I am not at all insulted when the ED does and EKG on arrival, I feel it is continuity of care.

Hudson Valley Hospital is also applied and seeking Stroke Center Credentialing.

As for the "CPR machine". I feel is is a wonderful thing if it is readily available. But, to call for another rig or a mutual to get it to the scene holding up treatment and/or transportation to a destination for more definitive treatment. And, you cant blame the nurses for being uncomfortable with a piece of machinery that they do not have access or information about. I can understand where they confusion may come in, but it is so much easier in the hospital setting to say stop CPR and just have someone remove their hands so that the doctor can have total body access for any procedures that may need to be done. Just because a piece of equipment is beneficial in the field doesnt mean that it is helpful in the hospital setting and vice versa......prime example..your basic family doctor.

[Guest alsfirefighter]

Its just as simple to push a button and have the machine stop and it comes nowhere near any areas where any procedures may need to be performed. I agree with you on waiting for it, but I've never had to being the department that has it carries it on the BLSFR unit. Only additional comment is based on cardic arrest, I don't see much more definitive care then what we perform, well those of us that follow ACLS protocols aggressively. The nurse in question rides for a VAC in the area that is aware and introduced to the device and also has seen it every time that agency gets a code. It has been my experience for some time now between working the field and my time in the ER as a tech that fibrinolytic treatments for MI are giving way to antiplatelet meds and then to the cath lab.

[STAT213 332]

Ok, so I reading along with this discussion about 12 leads and a few things come to mind.

1) Destination determination is up to the paramedic. Closest, most approrpriate facility. For MI, that is a facility with a CATH LAB, not an ED doc with a bottle of TNK/TPA, etc.

2) Someone said that they don't waste time with a 12 lead in lieu of other more important interventions. Such as??? 12 lead is the standard of care. Sorry if you think other wise. You as a paramedic should be performing one, and interpreting it to determine your destination. Yup, there are other factors that go into diagnosing a subtle ischemia like lab work, but the 9/10 CP with changes is pretty easy to determine, and you're doing your patients an extreme disservice (with today's knowledge and understanding) by taking them anywhere without a cath lab.

3) Where is the rest of the ACLS protocol? Nitro drip? Lopressor?

Have to go on a job, more to come...

[WAS967 97]

1) Destination determination is up to the paramedic. Closest, most approrpriate facility. For MI, that is a facility with a CATH LAB, not an ED doc with a bottle of TNK/TPA, etc.

Most of the medical directors I have talked to would disagree currently and state that closest facility (cath lab not being a factor) is the most appropriate. Our protocols also do not presently support passing one hospital without a cath lab in favor of one with a cath lab.

2) Someone said that they don't waste time with a 12 lead in lieu of other more important interventions. Such as??? 12 lead is the standard of care. Sorry if you think other wise. You as a paramedic should be performing one, and interpreting it to determine your destination. Yup, there are other factors that go into diagnosing a subtle ischemia like lab work, but the 9/10 CP with changes is pretty easy to determine, and you're doing your patients an extreme disservice (with today's knowledge and understanding) by taking them anywhere without a cath lab.

Such as Oxygen, IV, ASA, NTG, Morphine. 12-Lead is diagnostic, not therapudic. If I have a person with with 9/10 substernal chest pains radiating to thier left arm and jaw (insert other classic signs/symptoms here) then I don't need a 12-Lead to tell me whats going on. I'm only one person usually working with people who really don't know much about the ALS side of things. If I've gotten the above done and I have time to get a 12-Lead done, or I can talk an EMT through how to do it, then so be it. If not, then it can wait to the ER where they have more hands that can take care of it.

3) Where is the rest of the ACLS protocol? Nitro drip? Lopressor?

Good question. Show me a system around here that carries Tridil. I don't know any. It requires very specific dising which can't be accomplished unless you carry IV Pumps. I dont know many 911 systems that have IV Pumps unless they also do transports. I also know of very few that carry Lopressor (none in this region).

[Medic137 6]

I agree with WAS. If I think a patient is having an MI, I treat it as he described and usually get to the 12 lead as we're backing up to the ER. Just as well since you don't get a good read in a bouncing ambulance.

I'll do the 12 lead in the house if the symptoms are more vague.

Either way, until the protocol is changed it would be hard to justify bypassing the local hospital to go to a cath lab.

[WAS967 97]

I've actually had some surprisingly good results in a moving ambulance. First time I ever did a 12-Lead with the LP12s, I was in the back of a CCVAC rig heading to Phelps. We had enough time to do it, and were bouncing all over the place. Much to my amazement it spit out a nice clear tracing and showed me an Acute Anteriolateral MI.

What kind of unit are you using for the 12-Leads at your agency? I've had issues with cables being either loose or just plain in need or replacement. Sometimes a little juggling and crossed fingers/praying get a good read. Other times it just plain doesn't want to work (like the other day where I literally took the chest leads and tossed em over my shoulder in frustration.

I'm definatly in support of going to a facility that can better treat MIs, thus eliminating the so called "middle man". But until our protocols support this, our hands are literally tied.

[MGMedic 0]

WAS967...I agree, if the pt. has the classic symptoms. However, in the case of an Inferior Wall MI, it is very helpful (and ultimately beneficial to the pt) to have the 12-lead before you start with the NTG's and MSO4. There is always time to do the 12 lead. We are expected to do a pre-NTG 12 and then one after every NTG. I haven't found that extends on scene time to the point where I would rather not do it. Also very interesting to plot the changes the NTG/morphine make.

[WAS967 97]

One thing I wish we had is a better way to apply the chest leads. I personally find the chest leads on the LP12 cumbersome, getting tangled often. Does anyone use a third party system like the V-Quick patch system or similar?

[STAT213 332]

Interesting thoughts. I am curious why people have this marriage to their local hospital. I looked through the protocol, and did work in the area as well as other NY areas for a while, and in the WREMSCO protocol, there is the section on destination determination. It does not specifically refer to trauma or to cardiac, just closest MOST APPROPRIATE facility. This applies to stroke, to MI, to trauma, to burns, to hyperbarics, to Jacobi being the envenomation center, etc, etc. Where in the protocol does it say call someone to ask permission? I did not see it. Granted this doesn't mean that its not there. One of the things I noticed while living and working in Westchester was that people had this, well it was almost fear of medical control, and strict devotion to what someone had told them was a truth. Based on what I read, and what I did as a paramedic down there, going to a hospital with a Cath Lab is the most appropriate thing to do.

Another job, more to come....

[Medic137 6]

Part of the problem for those of us working in flycar systems is maintaining good working relationships with the VACs and VFDs that run the ambulances. For the most part the volunteers are leaving their jobs or families to come out and do EMS runs. I try to get them back to what they were doing as quickly as I can. I'm already turning a 45 minute call into a 2 hour call when I insist that a patient with seemingly minor injuries who dumped their motorcycle at 30 mph needs to go to at least a level 2 trauma center. If I do the same with chest pain calls I may find myself alone on scene with an evolving MI waiting for mutual aid from 3 towns away.

WAS: We were issued LP12s about 18 months ago.

[WAS967 97]

I see where STAT is coming from and he brings up a good point. I shall have to look into this further and ask our medical director since it is he that has the ultimate say in the matter and has implied that going to WMC when NWHC is closer with a potential cardiac case is inappropriate.

As far as getting people back home quicker, I say, screw that. I whats right for the patient, not what I think is going to be convenient for the vollys or anyone else. If they don't want to go the extra distance in the interest of patient care, then they can stay home. Case in point. Did an old lady with dementia who called 911 with a panic attack. She was basically worried that nobody was going to "be there" for her. Well, the crew bascially would have been fine with doing the RMA and going back to sleep, and leaving her be. Not me. She was non-compus-mentus and basically IMHO unable to care for herself and a danger potentially. She needed to be evaluated. Company policy in fact won't allow me to RMA her. The crew wasn't to thrilled, especially when we basically had to take the patient against her will. She eventualy went willingly with some convincing, but was none too happy.

[Guest]

What is an envenomation center for? What does non-compus-mentus mean? I could make an educated guess, but I'd rather be sure.

[WAS967 97]

Envenomation center would be a hospital the specializes in the treatment of patients who have been injected with a toxic biological substance, usually from an animal such as a scorpion, spider or most especially snakes.

Compos mentis literally means "of sound mind".

[Guest]

Thank you!