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12-Lead Electrocardiography

The Paramedic's Fate

While Eric Yeargain is no longer with the San Diego Paramedic Program, the info contained here is stil valuable and pertainent to pre-hospital care.

Just like many of the Paramedics educated before 12-lead electrocardiography was used in the prehospital setting, I too missed out on learning anything about it. In fact, I don't recall it ever having been mentioned in my classroom as something that even existed. I guess they figured it was a bit too sophisticated for the times. After all, those were the days when we weren't allowed to start an IV prior to making Base Hospital radio contact and getting an "order." Well, this craft has since come a long way. It has been firmly established in various studies that paramedics can, indeed, interpret the 12-lead ECG. In point of fact, studies I have read on this subject boast 95% or better accuracy rates in the diagnosis of acute myocardial infarction. Why does this matter? Well, the evaluation and treatment of the patient with acute myocardial infarction has evolved to the point where this sort of technology has become instrumental and almost essential to affect the best patient disposition and outcome. The time to "definitive" care such as cardiac cathiterization and thrombolytic therapy relies heavily on the early field diagnosis of AMI. This early identification enables the Paramedic to alert the receiving hospital of the patient having the acute infarction, which in turn, enables the hospital to prepare for their arrival, often times eliminating clinical delays in treatment of 20 minutes or more. Time is tissue! It's a new brand of Paramedicine and we need to catch the train if not already on it.

This is where we come into the picture. Unlike trauma, intraabdominal, intrathoracic or intracranial catastrophe, patients of a cardiogenic nature don't often need an operating room immediately. Sometimes they do. However, cardiology is one territory where a call for enhanced diagnostic and treatment capabilities is loud and clear. The number of chest pain patients that are simply mismanaged or deal with unnecessary delays in treatment is palpable; the primary reasons being limited skills and diagnostic tools. I don't mean to suggest that most paramedics are derelict, I simply intend to assert that we, as a workforce, are undertrained in a domain with vast potential for improvement! We can affect the outcomes of many patients with some augmented knowledge of cardiology and use the 12-lead ECG as one of the provisions to do so. A comprehensive patient evaluation and history taking are still of paramount importance but the 12-lead is certainly of more diagnostic value than anything we have used in the past.

Protocols. Remember those? Well, to me protocols have always been a set of guidelines that are put in place as generic treatment standards. I can't tell you the frequency with which I've encountered a protocol that was simply inappropriate for a specified situation. Did the patients problem fall under a specified protocol? Sure. Did the patient need me to follow that particular protocol to render care that was in his or here best interest? Absolutely not! In fact, if protocol had been followed in each particular case, I aim to guess that some of my patients would have expired. Protocols aren't our enemy, they commonly serve us well. It's just that they remind me so much of the triage system at a mass casualty incident...."designed to do the most good for the most amount of people." That's exactly my point. That's what protocols seem to do. The problem with that line of thinking, however, is that it implies that your resources are limited. In most mass casualty incidents, limited resources are a big problem. In the matter of cardiogenic emergencies, the "limited recourse" is simply the lead II monitor. This is where things change. With the faculty to obtain and interpret a diagnostic quality 12-Lead ECG, the entire concept of a generic protocol governing the management of cardiac emergencies flies right out the door. Now, the way you contrive a particular AMI may be a rapid departure from the universal treatment standards of old. You've just enabled yourself to tailor a treatment plan more specific and appropriate to your patients needs. Does every hypotensive 2nd or 3rd degree heart block get Atropine when pacing is not available? NO! Is there ever a situation where somebody having an AMI gets a liter or more of fluid? YES! Does every uncontrolled atrial fibrillation with multi-focal ventricular ectopy get lidocaine? NO! The list goes on and on but I think you get the point. Lead II monitoring is fabulous for what it was intended: MONITORING. That's it! It's of no diagnostic merit and quite simply inadequate for the job. The 12-lead ECG's dynamic, 3 dimensional appraisal of the heart is the best assessment instrument when an emergency of cardiogenic nature is suspected. Dissimilar to the monitoring lead, it is a snapshot of all 12 leads. They each have their respective places in our repertoire, but neither should be without the other. Being prepared to manage almost anything of cardiac origin makes what we do of true benefit to our caller and will most certainly reshape our thinking.

Is 12-lead electrocardiography the end-all answer to figuring out what the heck is going on with everyone? Well, enough with the rhetorical questions. What is important to know is that the 12-lead ECG is a marvelous tool. It is also important to understand that it is not an exact discipline. It doesn't produce diagnostic changes with every AMI. It doesn't actually rule out an AMI. It does, however, frequently provide us with information highly suggestive of cardiac etiology and is frankly the best single diagnostic tool short of a quality patient assessment available to us at this point.

Many Paramedic systems have realized the importance of this skill for quite some time. Others are just evaluating it's merits. Enhancing our professional status in these times of provider related uncertainty could only be ruled an advantage. Additionally, having more detailed information in the midst of managed care proliferation will clearly aid in the course of patient disposition. Watch for classes or ECG Workshops available in your area and get on the train!