The importance of pre-hospital ECGs

The last issue of Prehospital Emergency Care (PEC) published a couple of articles about prehospital ECGs, including this one: A Prospective Evaluation of the Utility of the Prehospital 12-lead Electrocardiogram to Change Patient Management in the Emergency Department.  (If you have access to this journal or article, please let me know–I can’t find any way to access it, even after trying several hospital databases).

This article discusses how prehospital ECGs can capture clinically significant abnormalities that aren’t always found in the first ED ECG, and that these prehospital ECGs influence the physician’s treatment plan roughly 20% of the time.

Two questions came to mind after reading that abstract.  First, how good are paramedics at interpreting ECGs (specifically those that change the clinical course of a patient), and second, what about lead placement?

The first question is less pertinent to the article, but if the prehospital ECG is the deciding factor in a patient’s clinical course, paramedic providers should also recognize this sign.  A quick PubMed search, however, suggests that this might not always be the case.  An article from PEC last year concluded that, despite extensive training and a high level of confidence, ED physicians cannot rely solely on paramedic providers to activate the cath lab.  That stings a little bit.  But that’s a conversation for another time.

More concerning is if prehospital ECGs are truly capturing the “clinically significant” ECG abnormalities that influence physicians’ treatments.  One 2012 study looked at how the displacement of electrodes by one intercostal space can affect the ECG interpretation about 20% of the time. Another found that precordial lead displacement significantly affects ECG morphology; however, it did not extrapolate to clinical significance.  (This study also commented on the classic over-breast/under-breast dilemma faced with precordial lead placement! Skip to the discussion to see what they say).

Not only does lead placement affect the accuracy of the ECG, but lead displacement is common even in the hospital setting and when done by clinical ‘experts’ identifying correct sites for placement.

Perhaps then, we should put a little more consideration into our ECG skills and lead placement.  It’s easy slap some leads on in roughly the right places, but that really isn’t good enough.  So here’s some FOAM incase you (or your partner[s]) need a refresher on correct lead placement!

EMS 12-Lead’s Lead Placement Diagrams

LitFL’s Lead Positioning 

CPR Score Sheets

Clinical Scoring_Fotor

I’m working on a CPR improvement program for my agency.  The goal, more than anything else, is simply to practice skills we don’t perform very often.  More specifically though, we want to work on both the clinical aspects as well as the leadership and management aspects of running a resuscitation (you might be noticing a theme with some of my interests).

So another medic and I (you know who you are) have been working on the logistics of it.  It took a little bit of time and consideration, but using the High-Performance CPR Toolkit and a number of CPR leadership studies, we developed these score sheets to quantify, evaluate, and track the quality of simulations in our company.

Leadership Scoring_Fotor

My question to you is, do you have something similar at your company or training institution?  What do you think of the scales on the clinical sheet?  I feel as though those are hard to develop until you actually see a scenario or two.  Any feedback would be greatly appreciated.

*I found the tense discrepancies in the leadership scoring sheet and fixed it on the original

**the clinical evaluation includes QCPR data that allows us to look at compression depth, rate, etc.

Resuscitation Management Guidelines

As a new paramedic, I’ve spent a lot of time thinking about my new role as a leader and manager.  As myriad recent studies have shown, effective leadership during CPR events leads to better outcomes.  That’s to be expected.

My question is, can we create evidence-based resuscitation management guidelines that can be considered in all resuscitation events.

Using the Incident Command System as a point of inspiration, is there a process that prehospital providers can use to manage every call they take, from a nursing home fall to a traumatic code.  The goal is to have a mental checklist of sorts that is a formalization of the thought process that occurs fluently in experienced medical providers in order to create a structure that considers the steps for effective team-building.

With this as my springboard and using evidence-based medicine as my backboard, this is what I’ve come up with:

1) Pre-Plan— With very few exceptions, prehospital providers have some period of time in which they can preplan their approach to a call based on dispatch information.  This window of opportunity, even if only brief, is crucial for the provider moderating their own thought process and for communicating with their partner(s) about the way in which they want to handle the call.

One simulator-based study of physicians in CPR scenarios found that clinical outcomes are negatively affected by shortcomings in the process of ad-hoc team-building and deficits in leadership.  Establishing some sort of team unit, initiating a structure, and mentally preparing for the scenario ahead may be the largest luxury (regarding resuscitation management) afforded to pre-hospital providers responding to emergencies.

2) Establish Yourself as the Leader— This point encompasses a couple of points.  First of all, the lack of a defined leader  leads to poorer outcomes when there is any question of hierarchy during a resuscitation.  As noted in the above study, establishing a structure eases information flow, which is obviously crucial in resuscitation situations.

Having a clear leader on a scene also allows for structure to develop more fluently.  On any fire scene, everyone knows to look for the white helmet talking on the radio (he might even be wearing an “Incident Commander” vest if the scene is large enough).  On an EMS call, the paramedic patch on your arm might clue others in to the fact you’re in charge, but it’s never that simple.  Having a calm, confident presence and presenting yourself as the head-cheese-in-charge facilitates a more fluid resuscitation.

3) Assign Roles– The driving force behind these guidelines is, if you couldn’t guess, structure.  Structure primarily provides some semblance of comfort in chaos but also allows each member of the team to be effective.  When the leader of a resuscitation assigns roles or tasks, it leaves no doubt as to what each team-member should be doing, and (perhaps most importantly) it helps the leader focus on leading.

One of the most cited studies in the resuscitation management literature (that I’ve come across) is from a the European Resuscitation Council, which found that the absence of leadership behavior and explicit task distribution were associated with poor team performance (emphasis my own).

Another most-important piece of literature is the “Lighthouse Leadership” study, also from Resuscitation.  This paper found not only that building a structure in the resuscitation is essential to performing effectively but also that leaders were more effective when “hands-off.”  Those who do so can prioritize treatments, plan the resuscitation, and are more inclined to make changes when needed.  I won’t dwell on it much longer, but this may very well be the most important step in a well-lead resuscitation.

4) Verbalize and Continue Communication Again, it may sound like common sense and/or something that is already regularly done, but explicitly verbalizing treatment plans, exam findings, and changes in patient condition invariably leads to better outcomes.  A formally verbalized treatment plan/plan of attack prior to arrival on scene may be the closest thing pre-hospital providers have to the checklists and time-outs that have made such drastic improvements in the OR setting.  (I don’t have a citation for this one; just start reading everything Atul Gawande ever wrote).

As for continued communication, we all know about the closed-loop communication of the ACLS class room–and I think that certainly is important–but members of the team should not just be a confirmatory echo.  An interesting (but rather limited) simulator study found that unsolicited team-member contributions may prevent critical errors from occurring.  One example of this that comes to mind is the Resuscitation Academy’s suggestion that “EMTs Own CPR.”  This means that even the lowliest, greenest, most wet-behind-the-ears EMT-B should be able to point out that nobody is doing compressions, or that compressions are being performed poorly.  Obviously there are many issues inherent in individuals other than the leader speaking up in those situations, but the idea is to foster the environment where everyone is comfortable contributing to a successful patient outcome.

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I would just like to emphasize again that these are my own musings as I work on becoming a more effective leader, and I welcome any comments/suggestions/ideas that you might have related to creating a framework that could be used for managing any given patient encounter.  Such guidelines could be used for training and teaching, which is a whole other (but important) topic of conversation.

Have you hit someone in the chest today?

Have you hit someone in the chest today?

They started whacking people in Australia.  This is what they found:

Unsurprisingly, defibrillation was substantially more effective. Combining the data from both rhythms, precordial thump resulted in ROSC in 5/103 patients (estimated NNT of 26.2) while defibrillation led to ROSC in 188/325 (estimated NNT 1.7). More concerning, 10/103 (estimated NNH of 10.3) thumped patients shifted into rhythms with poorer prognosis (8 VT -> VF; 1 VF -> PEA; 1 VF -> Asystole).

That’s from BoringEM–all the links to the studies are on his site.  Food for thought and kind of fun, if nothing else.

Pulmonary Embolism. Do we care?

Image

First of all, free up two hours of your time and listen to this: Smart EM Undoes PE.  Now head over to EM Lyceum to read their evidence-based blog post about diagnosing and treating PE in the ED setting.

(Ok, I don’t really expect everyone to be able to do that, but they’re great sites and will help in understanding pulmonary embolism much better.  Even if you don’t check those out, keep following along and check out how the mortality associated with PE may be greatly overstated and know that there is only one not-very-good study to support anticoagulants for treating PE).

Now that you’re extremely well informed on the problems associated with PE diagnosis and treatment, we can have a conversation about what that means for the prehospital provider.  In their podcast, Dr. Newman and Dr. Shreves discuss how they as physicians can have very little wiggle-room to change their practice in the emergency department (due to our medical-legal culture).  So what can we do?

Interestingly, it seems as though we can only improve our practice when faced with PE.  If you consider that the role of EMS in many instances of acute injury and illness is recognition and activation of the system needed for definitive treatment (I’m thinking code stroke, code STEMI protocols), perhaps prehospital providers can play a similar role in identifying PEs.

For example, look at the Wells’ Criteria, one of the go-to diagnostic tools used to identify PE in the emergency department.  EMS providers are certainly knowledgeable and skillful enough to go through each of those scoring criteria, even if we don’t have the ability to do d-dimer testing in the field (a blood test that, when combined with a rule out criteria like the Wells’ Score, eliminates the need for further testing).

Or maybe that isn’t so crazy.  There’s an interesting study that was done in Slovenia where researchers used the Wells’ Criteria, End-Tidal CO2, and a field D-Dimer to diagnose (or at least effectively rule-out) PE prehospitally.  Basically, if a patient has a low clinical probability of having a PE (low Wells’ score) and has a PetCO2 > 28mmHg, they can be safely ruled out of having a PE even if their D-Dimer was positive.  And if they were clinically suspected to have PE and had a PetCO2 < 28mmHg, those patients were pretty likely to have a PE (93% specific for positive PE).

The question is, at the end of the day, what does it matter?  If Smart EM came to the conclusion that they, as physicians, have little ability to change their practice, AND, if they did, they would be doing even less testing/treating for PE than they do now, why should a paramedic carry around a card with the Wells’ Criteria on it?

It might not change our treatment today or tomorrow, but having a better understanding of this disease process may just help better diagnose patients before they get to the ER.  Or it might help to move the train of thought from PE to some other respiratory disease that we can treat.

I think this is certainly a point for conversation, and I’d love to know what you think.  Especially considering the limited resources available for training prehospital providers AND operating under the presumption that paramedics would like to move into a more professional realm, what is our responsibility for recognizing/interacting with diseases such as pulmonary embolism that are beyond our treatment capacity?

PE Reference Bits

A Brief Note on FOAMed

This blog is called Prehospital FOAM, which sounds like something in which one would bathe.  It’s not.  FOAM(ed) is a new and wonderful movement that is taking the medical community by storm.  Basically, a couple years ago, several ER docs were having a drink after a conference and decided that there was no reason that the internet and social media couldn’t be better utilized to share educational resources and experiences that have been heretofore inaccessible to a large portion of the medical community.  And if our shared endeavor is better care of our patients, hiding away useful knowledge and information seems…stupid.

So now we have FOAMed–a medical “education” (let’s be careful about that, though) for “anyone, anywhere, anytime.”  LifeintheFastLane.com, the real hub and home of FOAMed, defines FOAM as such:

FOAM is the movement that has spontaneously emerged from the exploding collection of constantly evolving, collaborative and interactive open access medical education resources being distributed on the web with one objective — to make the world a better place. FOAM is independent of platform or media — it includes blogs, podcasts, tweets, Google hangouts, online videos, text documents, photographs, facebook groups, and a whole lot more.

This sounds great, and it is, but what we still need to be reasonable here.  This morning, for example, I listened to a podcast from PHARM (see FOAM Sites in the menu) about prehospital intubation in the presence of TBI.  A lot of evidence says that it’s not such a great idea.  But listening to one podcast–even if it is very well done and comprehensive–does not make me an expert, nor does it give me the skills and knowledge base to change my practice.  Not yet.  I still need to read the research for myself, read the textbooks, know the physiology, and THEN (and only then) can I reassess my practice under my protocols.  As Dr. Weingart has said talking about FOAMed, it is not gospel.  It is not knowledge, but tacit experience.  What we need to do is read the literature for ourselves and come to our own informed decisions.  Basically, FOAMed can jump start you in a direction toward better understanding, but it is close to meaningless without the legwork to create a foundation for yourself.

With that said, I hope this site can do a couple of things for prehospital providers: first, I hope to show you some of resources that are readily available and of high-quality to supplement your current education.  Secondly, and perhaps more importantly, I hope to make some of the literature–evidence based medicine that is necessary for real comprehension and knowledge–more accessible for EMS providers who may have never seen a randomized controlled trial before.  Because that is the kind of base knowledge we need for EMS to be respected as a profession.

Please stay tuned and check out some of the sites that are linked already on the page.  The larger community of EMS professionals (I’ll use that word) have every right to be involved in the FOAMed conversation, and I think it’s about time we started weighing in.

**UPDATE–found this video on DEMTed.com, which summarizes some nice points about FOAM**

Sign-Offs Done Right

At my full-time service, signing-off patients is a responsibility reserved for the paramedic, and there’s a reason for that.

While the importance of a well-conducted sign-off is primarily medical-legal in nature, at the heart of the risk is a concern for the well-being of the patient.  There doesn’t appear to be a huge amount of literature on EMS sign-offs, but what there is suggests that we should aggressively encourage patients to be transported and that, although the risk of patient admission/death may be minimal, sick people still sign-off.

Regardless, every sign-off needs to be both performed well and documented well.  This post, from ALiEM, discusses how doctors sign patients out AMA, but I think we can use the same approach in the pre-hospital world.

ALiEM: The Proper Way to Go AMA

**Update**

After writing this post, I created a “macro” of sorts that incorporates elements of this article as well as specific language from my service’s sign-off that I put in my narrative. I would encourage you to create your own, but if you would like an example, my documentation can be found here.