If you have difficulty reading ECGs, you may want to try visiting the Prehospital 12 Lead ECG blog (http://ems12lead.blogspot.com/), a great resource on cardiac rhythm analysis. In this interview, we speak with creator Tom Bouthillet about his tips on ECG interpretation.

What were your reasons for starting the website? When and why was it launched?

I started the Prehospital 12 Lead ECG blog in October of 2008. I had been teaching acute coronary syndromes and 12-lead ECG interpretation in various UMBC-affiliated Critical Care Transport (CCEMT-P) programs around the country, and was struck by the fact that there is a real need for enhanced education in this area.

Particularly with the success of the D2B Alliance, the advent of the AHA’s Mission: Lifeline, and the development of regional STEMI systems around the country, there is unprecedented attention being given to door-to-balloon times, so it’s increasingly important that paramedics be able to interpret a 12-lead ECG.

It’s also worth remembering that the ACC/AHA guidelines recommend measuring first medical contact-to-balloon times. We’ve come to call this “E2B” or “EMS-to-balloon,” although some health care professionals think E2B stands for “evaluation” to balloon or “EKG” to balloon.

Regardless, it’s clear that we’re not doing STEMI patients a favor by delivering them to hospitals incapable of prompt, expertly performed primary PCI, assuming that such a hospital is available within a reasonable distance. Of course, there is not broad agreement on what that reasonable distance is, and many barriers stand in the way.

For example, not all EMS systems are equipped with 12-lead ECG monitors. In some jurisdictions, ambulances are not allowed to leave the county. Many community non-PCI hospitals may be concerned about loss of revenue, especially since their reimbursement is based on an acuity index. STEMI patients have a high acuity index, so when they lose STEMI patients, they’re paid less for everything else.

Because 12-lead ECG interpretation is not generally part of a paramedic’s initial education, in many EMS systems the ECG has to be transmitted to the hospital for physician interpretation, which is expensive and can have a high failure rate depending on the location. Relying on computerized interpretation is a possibility. However, while the ***ACUTE MI SUSPECTED*** message has a fairly high specificity, it’s not particularly sensitive, so it misses a lot of STEMIs. Poor data quality can also lead to false positives.

The ideal solution is to train paramedics to read the 12-lead ECG with a high degree of accuracy, with a special emphasis on the STE-mimics (left ventricular hypertrophy, left bundle branch blocks, benign early repolarization, hyperkalemia, pericarditis, paced rhythm, and so on). Even then, there might be difficulty getting the emergency physicians to trust the paramedic’s judgment. One of the main thrusts of the D2B Alliance has been granting emergency physicians the authority to activate the cardiac cath lab. So, cardiologists had to learn to let go and trust their colleagues in emergency medicine. Obviously, granting paramedics this kind of authority is necessarily a step-wise process, and requires a lot of communication and robust quality feedback mechanisms.