Beyond Basic Training

Although 12-lead EKGs have been part of EMS standards of care for a number of years, there is now an expanding role for EMT-Basics in using this important assessment and diagnostic ability. In BLS systems, acquiring and transmitting 12-leads from the field to more highly trained clinicians in hospitals can substantially improve the timeliness of identification and intervention in patients suffering a particular form of heart attack, specifically ST segment-elevation myocardial infarction (STEMI).

The 12-lead can mean the difference between BLS services transporting adult non-traumatic chest pain patients undifferentiated, or blinded, in their ability to discover STEMI on scene vs. being able to selectively discover STEMI within minutes of the first electrode being applied to the patient. An important point to make is that the goal for BLS should be oriented to data acquisition, in this case getting a 12-lead EKG tracing, as opposed to the more advanced task of interpreting the data.

The extensive training required for consistently accurate 12-lead EKG interpretation does not allow inclusion in the EMT-Basic curriculum and training program. Still, studies have shown that EMT-Basics can quickly and reliably learn the correct technique to acquire a 12-lead EKG and transmit it via a number of mechanisms to an experienced clinician, typically a physician, for analysis. Based upon the 12-lead EKG interpretation, real-time consultation can be given to treating EMT-Basics as to the presence of STEMI and, if present and time-appropriate, transport to a facility capable of emergent percutaneous coronary intervention (PCI). Inclusion of this capability in a BLS system’s standard of care can directly avoid time-consuming interfacility transports, reduce complications from STEMI such as congestive heart failure from weakened myocardial muscle, and even reduce sudden cardiac arrest from myocardial ischemia.

In Oklahoma, we have found more than 61% of the state’s licensed EMS transport agencies are able to acquire 12-leads; however, 92% of those report they use paramedics to apply the electrodes and acquire the reading. Fewer than 10% of agencies obtaining 12-leads transmit them ahead to the hospital. This represents an opportunity to expedite STEMI care that is not yet being fully taken advantage of.

BLS systems have several options in purchasing 12-lead EKG technology, ranging from new or previously owned monitor/defibrillators with 12-lead EKG modules to new-to-market 12-lead EKG devices primarily developed for use by EMT-Basics. One such device is the ReadyLink by Physio-Control (the authors have no financial stake in Physio-Control, and the device is cited for educational purposes alone).  Transmission of 12-leads can occur via cellular-based proprietary systems or, depending upon specific devices, pictures of acquired 12-leads can be taken and sent by text or e-mail using smartphones. Systems are advised to check applicable patient privacy laws and regulations specific to their area before transmitting patient-specific identifiable information. Grants and philanthropic organizations may help fund 12-lead EKG devices and data transmission systems; given that cardiovascular disease is still the leading cause of death in Western civilization, particularly in the United States, prioritizing funding for earlier recognition of acute coronary syndromes is important.

Even in ALS systems heavily populated with paramedics, EMT-Basics can and should have prominent roles in the acquisition and transmission of 12-lead EKGs. As a part of the coordination of care for a patient with suspected ACS, the paramedic should be freed to concentrate on pertinent history, rapid physical assessment and treatment considerations. There is ongoing debate about the benefits of transmitting 12-lead EKGs to receiving destinations, especially if paramedics are on scene. Proponents of transmission, as we are, speak to the benefit of multiple clinicians reviewing EKGs, diminishing the chances of subtle STEMIs being missed. Saddling the paramedic with doing all of the identified tasks in parallel with obtaining the 12-lead EKG can prove distracting at best and dangerous at worst when vital information is missed. Trying to avoid parallel tasks and doing the same things in serial order also poses difficulties in time efficiencies.

Regardless of EMS system type or care capability, when EMT-Basics are incorporating 12-lead EKG abilities in their scope of practice, it should be clearly included in relevant treatment protocols or guidelines. In states that permit EMT-Basics to acquire and transmit 12-lead EKGs, formal training and continuing education should be conducted as part of an organized credentialing process. In areas that currently restrict EMT-Basics from even obtaining 12-lead EKGs, organized advocacy efforts for changing the scope of allowable practice can take advantage of an expanding body of medical literature supporting early and aggressive use of 12-leads by all levels of EMS professionals.

David S. Howerton, NREMT-P, is director of clinical affairs for the Western Division of the Emergency Medical Services Authority (EMSA), the EMS system serving metropolitan Oklahoma City and Tulsa, OK. 

Jim O. Winham, RN, BSN, NREMT-P, is director of clinical affairs for EMSA’s Eastern Division.

T.J. Reginald, NREMT-P, is director of research and clinical standards development in EMSA’s Office of the Medical Director.

Jeffrey M. Goodloe, MD, NREMT-P, FACEP, is medical director for the Medical Control Board that oversees the EMS system serving metropolitan Oklahoma City and Tulsa, as well as an associate professor of emergency medicine at the University of Oklahoma School of Community Medicine.