Allowing EMTs to perform an ECG should not be controversial

Allowing EMTs to perform an ECG should not be controversial

I live in Louisville, KY, which is the epicenter for heart disease in the United States. My state ranks 49th out of 50 states for heart attack mortality. This is a complex issue with many contributing factors, including access to care, patient education, health insurance, cooperation between EMS and hospitals, among others. The thing is: heart disease is our number one killer. So it matters.

We have been building a regional heart attack network at our institution. Patients with acute heart attack are best served by emergency percutaneous coronary intervention (PCI). It’s amazing. One minute the patient is writhing and literally dying, and in the next moment after a PCI they are pain free and getting up off the table. I’ve been on interventional call this last week and spent a couple of late nights in the cath lab. Needless to say, I was looking forward to the family vacation and getting away to recharge my batteries.

I arrived at the airport with my family and was walking toward the TSA area when I saw him. Off to the side was a middle-aged man slumped against the wall. He was ashen with a light sheen of sweat on his forehead and his hand on his chest (Levine sign). I’ve seen this look a thousand times. This guy is having a heart attack. I go over and identify myself as a cardiologist to the security guard and ask, “Can I help?”

The man pleads: “Can somebody make this chest pain go away?” I think, yes I can. Let’s go. I’ll take you up to the cath lab and have this over in 20 minutes. Except, I’m outside the TSA line at the airport. I don’t have my cath lab team or my fluoroscopy machine or my angioplasty balloon. Heck, I don’t even have an ECG. What a helpless feeling. There is one guy in the building, me, that can stop this heart attack and I am stuck just watching.

EMS is on the scene minutes later. Yes, the cavalry has arrived. I tell the EMS personnel that I’m a cardiologist and I think this guy is having a heart attack. “We need a 12 lead ECG now.” The EMS personnel respond: “We can’t do an ECG because we are a basic life support ambulance.” Are you kidding me? I think to myself.

An abnormal ECG is the portal to entry for heart attack care and the key to unleashing the fury of modern day medicine to save this guys life. Once the ECG is abnormal, a cath lab team can be activated.

EMS in my county—an urban area–is great and they do a wonderful job. But it turns out there is up to a 50% chance that when an ambulance pulls up on a scene they can’t provide even an ECG. It’s the same in many areas in my state and throughout the country. If a paramedic is on board then an ECG is done at the scene and it is transmitted to the PCI center. However, for a variety of reasons, in most locales, basic EMTs are not allowed to perform ECGs. This means the diagnosis of heart attack has to wait until arrival in the ER. That’s a significant delay–and it makes no sense.

ECGs are cheap to do, easy to perform and confer no risk to the patient. The accompanying computer software correctly recognizes a heart attack the vast majority of the time. The recently released heart attack guidelines for the US have as the second recommendation “performance of a 12-lead ECG by EMS personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI.” Furthermore, just last month in JACC Intervention a study was published showing a greater than 50% reduction in mortality with pre-hospital activation of the cath lab during STEMI care.

Back to our patient. We gave him aspirin and I told the EMT to go to the nearest PCI center—although without an ECG there would be no pre-activation of the cath lab. I called the PCI center and identified myself as a cardiologist, I don’t practice at that institution, and explained the situation to the ED physician. Once the patient arrived at the PCI center he was diagnosed with a heart attack and underwent successful PCI.

Standing there with this patient and not being able to offer any more than aspirin, oxygen and rapid transfer to a PCI center was a very frustrating and helpless feeling for me. It strengthened my resolve to improve the process of heart attack care.

I am working with our state EMS board to allow all EMTs to perform ECGs. We have to improve access to state of the art heart attack care.

Acute heart attack care is surely a complex issue, but allowing EMTs to perform an ECG should not be controversial. It should be an easy step forward in treating our number one killer. Time is of the essence. Speed is life and death.

William C. Dillon is an interventional cardiologist and can be reached on Twitter @Wmdillon.

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  • mdic2md

    The bigger issue is not the use of ECGs by BLS providers – it is why the EMS dispatcher chose a BLS unit to respond to a chest pain patient. This is a staffing and dispatch issue – not a call to allow EMTs to perform EKGs.

  • Trishul Tunga Reddy

    Timely Article. I am a rural ER physician in SW Virginia. Our hospital system is trying to do exactly what you described. We do not do PCI’s at our hospital and it’s really a waste of critical time for the patient to arrive at our hospital and then do EKG, call the transfer coordinator, get the helicopter ready.. all of which is waste of resources. Recently I heard that the EMT’s are being trained to do EKG and then fax the EKG directly from the location to the nearest ER where a physician could read it. If the physician feels it’s a STEMI, he would relay the message to EMT’s and they would directly take the patient to PCI available center. I think that is being efficient.

  • Tom Bouthillet

    mdic2md: There are many areas of the country where EMS is volunteer BLS. There’s no legitimate reason they should not be allowed to obtain and transmit a 12-lead ECG.

  • James W Hooper

    Regardless if this was a dispatch error or not, there is no reason that an EMS provider, regardless of their level of certification should not be able to perform a 12 lead EKG and transmit it to the receiving facility. Paramedics aren’t anointed with defib gel and given the right and responsibility of placing a patient on a 12 lead EKG. (12 leads weren’t really an option when I went through Paramedic school. All my 12 lead training came afterwards) We are responsible for interpreting them, however. That’s not what is being asked for here. If we really want what’s best for our patients, then we need to be sure that everyone EMS provider knows how to properly place a 12 lead EKG, hit the Analyze button and then know how to transmit it to the appropriate facility. We have had “Time is Muscle” for 20+ years. Here is a simple way to save some time, thus saving muscle.

  • Shawn Thomas

    This does sound like a dispatch issue. Any properly set-up county EMS system has a protocol that states that an ALS response is required for any chest pain call.

    I’ve been an EMT for eight years now. I’m also in my senior year of nursing school to complete my BSN. For four years, I was a PCT at a teaching hospital in the CCU. One of my primary responsibilities was obtaining 12 lead EKGs on my patients. It got to the point that the attending cardiologists and fellows trusted my opinion on EKGs over residents, mainly because I did them every day. Now that i’m back on the street full-time while i’m in school, the medics I work with trust me and my co-workers enough to set up and obtain an EKG without an issue.

    My point is that obtaining an EKG can absolutely be a BLS skill. The primary argument against this is that reading an EKG can be difficult; however, chances are that any EMT with this ability would be performing this skill on a daily basis and could pick up solid profiency in this skill in no time. I always tell my classmates that if you can recognize sinus rhythm and some of the basic arrhythmias, then you can figure out when something is wrong. We’re not talking about letting EMTs cath someone in the field; EKGs are non-invasive and if there’s any confusion, medical command is a phone call away.

    • Christopher

      As for it being a dispatch issue, not everywhere has readily available ALS; look at South Dakota for instance.

    • Jason Simpson

      I agree that EMTs/paramedics should do EKGs in the field. But we need to be VERY careful in how we do this. Doing an EKG should NEVER delay transport. We have too many cowboy paramedics who not only want to do the EKG, they want to stay at hte scene and try to analyze it all while the patient is sitting there, getting sicker.

      • Christopher

        Actually we have too many uneducated paramedics who cannot read 12-Leads properly. Obtaining a 12-Lead does not delay transport. You only need to look to the systems in MN, NC, or SD to see that your fears about 12-Leads are completely overblown.

  • Jacob Miheve

    While there may have been a dispatch or staffing issue, even a well staffed and properly set up system can get overloaded such that all the ALS units are tied up when another ALS call comes in. EMT’s should be able to acquire a 12-lead to transmit to appropriate medical control, in order to activate the cath lab quickly. It also becomes a valuable ALS assist skill when an EMT can set up and acquire the 12-lead while the medic takes care of other important issues, or before an ALS chase unit arrives.

    Our agency, and one or two of our neighbouring agencies, have been doing this for about a year now. Speaking from personal experience, it’s nice to arrive on scene and have the BLS crew hand you a good 12-lead strip and tell you they’ve transmitted it and activated the cath lab.

  • Christopher

    EMT acquisition of 12-Leads? Part of the basic scope in NC. If technicians in the ER can acquire them…

    The only people standing in the way of this are the same people who stand in the way of everything. Some folks simply fear change.

  • cbuckleyrn

    So in Kentucky one wants more advanced care in the field while in Washington they want to reduce it. Read Fire Chief revises controversial ambulance plan. How bizzare!!!!!!!!!!!!

  • Rob Burnside

    When I began my EMS career in 1980, we were able to rapidly set up and send Lead II to the ER physicians using just four electrodes, which we did for “any pain above the belly button.” Barring any equipment problems, which were rare, everybody got a good “quick look” and many lives were saved as a result. But to do this, we had to be certified to Paramedic-1 level ( a one year course taken after 120-hour basic EMT training). I see no reason why an ECG training module, perhaps 10 hours or so, couldn’t be added to any basic EMT training regimen anywhere in the country.

  • lauramitchellrn

    We’ve come a long way from suction cups for the pre-cordial leads and having to mark each length of strip (Yes I’m that old. I also remember shock blocks). Anybody in health care should be able to run a 12 lead ECG, it’s not rocket science anymore. It’s up to the physician to interpret it, but he or she can’t interpret what he/she doesn’t have.

    • Christopher

      In many areas of the US, paramedics perform the interpretation of the 12-Lead for activation of the cath lab. Obviously in BLS systems transmission to an MD would have to happen, but it isn’t required.

  • Grinder

    Allow me to clarify a few things that have been brought up, as I work for the service in Louisville that is mentioned.

    Our system is the product of a government that is more “business first” and the rest will work itself out mentality. In hard economic times, decisions have to be made within an operating budget. Right, wrong or indifferent, we’re short on Paramedics (much like everyone else in the world) and ambulances have to be staffed. The product? A service that provides about 40% BLS ambulances.

    In the state of Kentucky, EMT-B’s are not permitted to perform 12-lead EKGs, wirelessly transmit said EKGs (even without “interpreting them” or utilize the cardiac monitor beyond an AED capacity. That’s the state. Not us.

    We’ve been pushing, poking, prodding and begging to expand the EMT scope of practice in the state for quite sometime without much success. We’re still working. Let’s face it… if you know EMS in the state of Kentucky, we’re in the stone ages. Blind nasotracheal intubation is commonplace because the state has no approved TRUE RSI protocol. Do you know how many laughs I get at EMS conferences over THAT?

    In closing, I can assure Dr. Dillion and all readers/commenters that we’re working as hard as we can to move forward with decreasing door to PCI times in STEMI patients. We’re working to make our service the best in the area, despite all efforts to thwart that by people within our organization and outside organizations.

    That’s just a silly street Paramedic’s $0.02.

    I do, however, really appreciate Dr. Dillion’s article, his proactive role in working with the state to improve patient outcomes and generally being a great asset to our community.

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