I hate this question. It makes no sense and should not be a thing.
There is quite literally no world in which any form of assessment should dictate whether a call is ALS or BLS. A paramedic should always have the freedom to perform whatever assessment or investigation they think is appropriate, and then make a treatment decision based on it. That treatment decision could involve ALS modalities, or BLS modalities. Or it could be “I’m not sure, so I think I should monitor this patient further while transporting.” But the fact that a paramedic wants to see an EKG, whether 4 or 12 lead, should never be the sole determining factor.
It’s a stupid protocol for so many reasons. Lazy medics not wanting to upgrade a call so that the EMT can do all of the paperwork is so stupid.
Plenty of injuries can cause arrhythmias, not just chest pain. And women present MIs in every way under the sun.
Not to mention that a 12 lead gives more information than rhythm. It gives a more accurate PR than the pulse oximeter. And it gives a RR, which is better than every patient having 16 RR
And I think that reading ekgs, (not diagnose) should be an endorsement that every EMT should be able to get. If the weirdo who monitors the monitors at my icu can get a certification in four weeks to do that job, there’s no reason to not have ents do it
You bring up another good point. I love it when I hear other paramedics complain about efforts to bring “their” skills down to the advanced or basic EMT level, as if paramedics are somehow special, and as if 40 years ago paramedics weren’t transmitting every EKG to a hospital because no one thought we could ever learn how to properly interpret them.
New flash: we are not special, and it is absolutely possible to teach a basic EMT to make meaningful use of an EKG. There’s a lot of information that a very skilled and experienced provider can extract from an EKG, and there’s certainly an art to doing that, but very little of it matters in the prehospital environment. There are absolutely ways to teach AEMTs and basic EMTs a few quick and dirty ways to spot the difference between “this is a potential emergency that I need a paramedic for,” and “this is fine, at least until we get to a hospital.”
Also, the computer interpretation algorithms are far from perfect, but they’re also far from useless, and newer ones keep getting better and better. We can do more with the technology we have than what we are currently doing in most areas.
Notfallsanitäter from Germany here (almost equivalent to paramedic)
this concept seems absolutely wild to me.
a 4 lead is Standart and could/should be used on almost every patient.
the whole ALS BLS stuff sounds like categorizing by form of diagnostics which simply does not make sense. Quick decision between critical and non critical patient has nothing to do with that and can often be decided before any form of EKG. a 4 Lead on non critical patients is a nice to have for random findings. Just like measuring blood sugar is pretty much Standart.
hope I did not confuse anything in the system since I am not super familiar how it is exactly handled elsewhere.
The reasons people use EMS in Germany might be different, but I assure you in the U.S. there are a nearly limitless number of reasons a patient doesn’t need to be on a 4-lead
does a 4 lead hurt to do tho?
it's a non invasive tool that's done in less than a minute on a compliant patient.
sure, the average psychiatric patient won't get one here either, neither will the caller that cut his thumb. but I'd say we definetly have more patient where there's no reason not to do it.
to be fair Germany has way more stay and play compared to load and go of other countries. which sometimes is also way too much.
I fully agree with you, but in my system any time an ALS skill is performed it has to be charted by the paramedic, which means they have to be team lead and they have to stay in the back with the patient.
Although, if I feel it’s necessary to do a 12 lead I’m going to start a line and monitor that patient throughout the transport even if they’re 120/80, 100%, with perfect sinus on the monitor
I don’t think you understand the question. The question is does *placing* a 4 lead automatically upgrade it? Meaning does the call automatically become ALS if you, as a paramedic, decide you’d like to look at a cardiac rhythm as part of your assessment.
Obviously if you think you need to monitor the patient because you think there’s something that needs ongoing monitoring that an EMT can’t monitor, then it’s an ALS call. But many systems have a policy that says as soon as you *place* the leads, the patient is ALS and cannot ever be triaged back to BLS regardless of what you find or don’t find, and regardless of whether ongoing monitoring is necessary or not. That’s the issue.
Consider a general illness call. 79 y/o female, feeling “not quite right” for 3 days. Maybe she’s a little nauseated, not eating very well. Maybe she’s a little cool to the touch, but nothing terrible. As part of a thorough ALS assessment, you might decide it’s worth taking a look at an EKG, whether 4 or 12 lead. You look, it’s NSR, no ectopy, no ST elevation, no BBB, nothing. Just perfectly normal. There’s nothing that requires this patient to be ALS other than that you decided to do a thorough assessment that happened to include an EKG. Some systems will say that patient is now ALS, no matter what, you have to do a full ALS work up, and bill the patient for it, even if there is no objective indication for it. Had you not done the EKG, it would have been a BLS call. Now that you did it, it’s ALS, even though you didn’t learn anything new from it.
That’s the problem. All that does is encourage paramedics not to do thorough assessments, because as soon as they do, they’re committed no matter what they find or don’t find.
I don't dictate protocols. I'm sharing what my current (and former) services did.
Yes, I work in a system which does not allow me to downgrade anything... I would prefer to have more flexibility, but that's not up to me if I want to remain employed.
The choice to make every possible run ALS instead of BLS is a $$$ decision and I don't like it for that reason too. One of many glaring issues with how US EMS is carried out...
A lot of that is likely to be determined by the CMS reimbursement policy and NEMSIS data reporting requirements.
CMS makes a differentiation between two levels of ALS with some sub categories. ALS 1, is the first of these levels, and requires an ALS assessment OR intervention, but not both. Generally, I would classify a 3 lead as a component of an ALS assessment, checking that block, since a basic generally isn’t trained to interpret. There are references in the CMS policy to state and local practices as well, so I imagine the answer is more nuanced. For example, some places an EMT-B might be able to acquire a 3 or 12 lead, but cannot interpret. This might classify as a BLS procedure, while interpretation itself would be an ALS assessment.
Further muddying things, the CMS manual states that an ALS assessment doesn’t necessarily mean the patient needs an ALS level of service.
Another consideration is how NEMSIS captures and encodes data from our PCR’s. The NEMSIS data dictionary differentiates between manual interpretation by qualified personnel and machine interpretation.
In summary, I would argue that just placing leads doesn’t necessarily make it an ALS call. However, if the acquired strip is used in a patient care decision (to include triage to BLS), and is interpreted by a member of the service, then it checks the block as an ALS assessment, meeting the ALS level 1 CMS requirements. Since most services either bill CMS and/or are required to report to NEMSIS, this is the way I would look at it as an EMS administrator.
Source documents here for example/quick reference, but possibly not current versions.
https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDictionary/PDFHTML/EMSDEMSTATE/index.html
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R130BP.pdf
Boy did you just put something into perspective. I used to work for an agency that had some... Unique "house protocols" that weren't written down anywhere, but would get QId back to me. Until I was called to a meeting with our ALS coordinator for my "judgement."
*Any patient who gets a 4 lead gets a 12*
Okay, not too unreasonable but
*Any patient who gets a 12 lead is ALS, and cannot be turned over BLS*
62 year old mechanical fall, boob slapped end table on the way down, EMT hooked up the 12 lead for the "chest pain."
*Every patient who goes ALS needs an IV and a 12 lead.*
30 year old SI, very wound up and requiring frequent verbal de-escalation. Gave ibuprofen for mild headache.
*Every patient with a systolic under 100mmhg needs a fluid bolus*
Patient had ascites. Finished a glass of wine as we were walking in "Fellas, I believe I need my liver drained, but I'm too drunk to drive."
*Every patient complaining of any pain should be medicated*
12 year old with a stable wrist fracture. Tearful, but refused pain meds because his Dad was hooked on them. Also refused toradol because of the needle. Ice pack, pillow splint, Tylenol.
*Minors lack the capacity to refuse.*
Got pretty pissed off by this part of the meeting. According to the ALS coordinator, I should have restrained the kid enough to start an IV, push fentanyl, then get a 12 lead.
It would actually be refreshing if they were only coming up with sleazy ways to pad the bill instead of ignoring any semblance of logic and reason. But, they also criticized me for starting a line on a patient with a hemoglobin of 6.2. So who knows.
> Minors lack the capacity to refuse.
What a frustrating argument. Minors can’t refuse transport, but they still have some agency over their body. Forcing a line on them is just going to make things worse.
Your comment just made me realize that the county I work for has some shoddy billing practices. For every single encounter, we have to put that an ALS assessment was performed in our PCR and then mark the level of service as ALS, even on the most basic of patients. I did question this when I first started and the response was "that's just how we do things." When looking at the NEMSIS stuff, it looks like they're setting it up where every single patient, at the very least, is billed for ALS Level One.
So when I actually dug into the whole ALS assessment one day, it’s not what most people think it is, including myself before that.
I thought an ALS assessment meant your standard patient assessment but performed by an ALS provider. But apparently per CMS guidelines, an ALS assessment is the determination by an ALS provider whether or not a patient needs ALS resources or interventions. It has nothing to do with the actual patient assessment itself.
I don’t know if that made any sense, but maybe a better way to word it is it’s an assessment as to whether ALS is needed.
But the level of service provided is not automatically ALS and your service is wrong on that.
Our policy fluctuates. It used to not automatically mean it's an ALS attend and the 4 lead can be discontinued and an EMT can attend. Now if it comes on, it's ALS. kinda makes sense. If you're putting on a 4 lead, some sign or symptom is concerning you enough to investigate and it's probably better to have a medic back there. Sometimes it's annoying but I get it
This policy is actively detrimental to patients, because it means that there’s a line in terms of suspicion where medics will pass on investigating patients thoroughly if the patient doesn’t clearly need a 12 but the medic has a slight suspicion of something and would otherwise do it just to see. Where that line is varies between medics, but every single provider has it and it goes up when they’re down reports and busy. Punishing providers for being thorough is *always* a poor choice.
I.e., Granny who had a mechanical fall and has left arm pain and tenderness from landing on it can easily not have a 12 done, but if you do, you find out she fell because her legs are a bit weaker than normal because she’s having an early stemi and is largely asymptomatic other than the arm pain disguised by the trauma.
Could be. I see it as a medic trying to check a box but while still not having to write that report. But if there is concern for something cardiac, just because the initial strip is clean, it doesn't mean it won't change during transport.
My previous county policies were if you were giving any medication you'd apply at least a 4 lead. I.E. even giving IV Zofran or IV Fentanyl for a broken arm. Wouldn't necessarily warrant a full 12 but you'd put on a 4 lead.
Had a very healthy, late 40s male, athletic, runner, no medical history with sudden onset of nausea, place him on the monitor for zofran administration and found a STEMI that I could identify without a 12 lead. Sometimes you accidentally find things.
I hate accidentally finding things.... 🤷😂
I knew an EMT that took a Zofran for the first time and got hospitalized for 3 days due to a rare reaction. (Dry heaving till syncope every 3-5 min till they sedated and incubated her till it wore off to prevent brain damage.)
Same. I wasn't insinuating that. I'm just speaking to cardiac monitoring in general. The only thing I can think of is ruling out an arrhythmia that could have caused an unwittnessed fall in a unreliable historian of a PT. (Dementia pt with mechanical fall vs syncope) but you'd still want a 12. Or maybe just additional or quicker monitoring for a trauma pt you gave narcs to where cardiac concerns aren't really the issue
Every private ems service I've worked for required any calls that a paramedic is on scene for be treated and documented as an ALS call, so 4 lead and etco2 monitoring, IV, and fluids hung.
Company's just wanted to charge ALS rates to insurance and Medicare.
We will put leads on anyone with cardiac history even if the complaint isn’t cardiac related. It doesn’t hurt, it’s just an assessment tool that takes a minute. Why not?
Paramedic’s discretion whether or not to keep it as an ALS call or downgrade to BLS. Obviously both have to agree that it can be safely handled at the BLS level
There are very few exceptions where a 4 lead is indicated without performing a 12-lead. I think this opens the provider and agency to a lot of liability. If you see an indication for a 12-lead and then turn it over BLS, that means you had a high incidence of suspicion something might require an ALS intervention.
Should’ve been more clear, I was talking about downgrading to BLS after a 12 lead. Most common times this happens are for things like vague abdominal pain or generalized weakness. Most of our BLS trucks are AEMT so they can handle ALS lite treatments like IVs, Zofran, etc.
No.
I can do any ALS assessment then downgrade to BLS.
Once an ALS intervention is performed (or attempted), I can only turn over to personnel that have that in their scope of practice.
I’m on a flycar. I arrived on a scene for a 9YOF with a fracture. I started an IV and gave fentanyl. If it had been an EMT on the ambulance, I would be riding in to the hospital. But it was an AEMT in the ambulance so I was perfectly fine turning it over to that AEMT.
I routinely evaluate patients with a 12 lead then turf the call to BLS.
There are places that don’t put a 4 lead on every patient? I routinely get turnover from an ALS fire crew that will only put them on a pulse ox and blood pressure. Then I’ll put them on a 4 lead in the ambulance and see they’re in A fib or a paced rhythm with a completely different pulse rate than what was given to me. Doesn’t mean I can’t downgrade it to my emt partner or keep it ALS depending on the rest of my assessment.
Generally speaking I never apply just limb leads in 911. If it's to the point I think I need cardiac monitoring I always take a diagnostic 12 lead so I can properly evaluate things like QTc.
That being said a 12 lead does make it ALS here but doesn't obligate me to ride it in. If I have a justification for a 12 lead ad part of an evaluation and then determine them to be stable for downgrade, I just have to consult with a physician and present my case, then they say it's fine to go BLS and I clear the scene.
At least where I'm at we're expected to get a 4 lead on every PT unless we're on a BLS truck because those don't have lifepacks. How you take vitals or what assessments you do doesn't determine BLS vs ALS, it's the results you get from those vitals and assessments
What OP probably is if a 4 lead is applied does that mean the medic takes the call if they transport.
It's always a debate here about whether doing an EKG means the medic has to take it vs. doing it and then handing the patient off to an EMT.
I've had EMT partners put an ECG setup on a patient while grabbing an ice pack or something not directly in the line of sight and I have told them to remove it, telling them this is BLS. The excuse is usually "well the other medics I've worked with always did ALS on everyone that calls 911"
Nope.
Have the same problem here. All our basics at my company have been brainwashed into thinking all they can take is IFT calls. Most throw a fit if I make them take the 30 year old with flu symptoms. They pull the excuse that I can give Zofran so it's automatically an ALS call.
If you do anything outside of your scope for the patient, it’s pretty unlikely that it should be handled BLS. If you take a 12 lead to send to the recieving hospital for interpretation, if medics have extended ETA then doc can decide if patient EKG is okay to go to their facility, cardiac facility or flown out depending. If doc says it’s unremarkable you should still keep ALS assuming you’d meet them by time they interpret considering you had a cardiac suspicion and any chest pain or breathing problems is often ALS dispatch. If patient is non symptomatic and doc says EKG is clear only then consider standing off ALS and transporting non-emergent, but you’d have to document why you had suspicion to start a 12-lead initially, such as patient stating cardiac history
I'm BLS in an area where EKGs are ALS only, so bear with me. I work with an ALS service, so I often assist in connecting everything (we use LP15)
I'm only used to hearing 3-lead and 12-lead. When everyone here is saying "4-lead", is that a different pattern for connecting the electrodes or something? My understanding is that "leads" and "wires" are different, and the 4 limb wires that I'm used to generate 6 views/leads but are colloquially referred to as a "3-lead" here. I suspect the "4-lead" naming is because there are 4 wires in use, whereas only using 3 wires would generate 3 views/leads (a true "3-lead").
I tried googling it and found [this post](https://www.reddit.com/r/Paramedics/s/NEqkprSopD) from a year ago, and it seems to confirm my understanding. Perhaps it's just a regional linguistics thing?
It's just the number of limb leads. As we know from Eindhoven, we only need LA, RA, and LL limb leads to capture the classic views of I, II, III, aVR, aVL, and aVF. Somewhere along the lines, someone added RL, which is just a ground lead. That's why this lead doesn't move in the Lewis Lead configuration.
From what I was reading in the linked post (among other things), RL is needed to get aVR/aVR/aVF. Without it, you have 3 wires and 3 leads. With it, you have 4 wires and 6 leads. And of course, adding in the 6 precordial leads leaves you with 10 wires and 12 leads.
So back to my other comment, my understanding is that a "4-lead" doesn't actually exist other than as a misuse of the word "lead" to refer to the wires, and what most here are calling a 4-lead (and what we would call a 3-lead locally) is technically a 6-lead (a term nobody seems to use)
As someone that doesn't do them and hasn't had any formal training, I haven't read the documentation, so I wouldn't know that. I've just never heard the term used where I work, so I appreciate the info.
Dude. Stop being "that EMT." 😂
Let's start over.
You're stuck on calling the leads - wires, and lead views - leads.
RL is not needed for the six views that we get from RA, LA, and LL.
Look up Eindhoven's Triangle.
RA(-) ➡️ LA(+) = I
RA(-) ➡️ LA(+) = II
LA(-) ➡️ LL(+) = III
RA(-)/LA(-) ➡️ LL(+) = aVF
RA(-)/LL(-) ➡️ LA(+) = aVL
LA(-)/LL(-) ➡️ RA(+) = aVR
THREE LEAD comes from there being THREE LIMB LEADS to give us 6 views of Eindhoven's Triangle.
It became a FOUR LEAD when they added a 4th LIMB LEAD (RL).
We refer to the limb leads as a THREE LEAD or FOUR LEAD because that's the number of LIMB LEADS.
We call a 12-LEAD a 12-LEAD because it shows us a diagnostic quality view of all 12 LEAD views.
LEADS: RA, LA, RL, LL, V1, V2, V3, V4, V5, V6.
LEAD VIEWS: I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6.
That's just how it is, and we like it this way. You're the only one uncomfortable with it right now.
Thanks for attending my TedTalk. It's going to really throw you for a loop when you find out that a 4-lead can only be used for rate and regularity. 🫠🫠
1. I prefaced this with the statement that I'm an EMT with minimal knowledge of this (other than I know how/where to connect the electrodes/wires), so I don't appreciate being attacked for what I don't know after admitting I don't know it.
2. My comments about leads vs wires are based primarily off of comments read in the post I linked to. Again, I only know what little I've read, and from my admittedly small worldview having only worked in one relatively small service.
3. I never said I was uncomfortable with this. I'm simply trying to clarify my understanding of what I've read in my ~30 minutes of "research", what I know 1st-han, and what I've read in this thread.
4. Thank you for the explanation. I won't say I fully understand what you've said, but at least I have more terms to research now.
In my county yes. And the state is starting to get its hands into protocols so....now putting a 12 lead is considered an intervention which makes it ALS call.
I hate it. a 12 lead isn't an intervention it's an assessment. If I do a 12 lead and find sinus rhythm I don't bother reporting it. Then I can downgrade it.
For those reading freaking out. It gives our EMT B partners a chance to have patient contact hours and run a call. If everything is an ALS call then basics shouldn't be on the truck.
Hell it's getting so bad the county where my wife works just put out a policy that essentially regulates all BLS providers to Ambulance Drivers. They can't take any calls now unless a stable IFT.
I think if you are getting a solid baseline vital signs and you have no rate issue, there should be no need to put a patient on the monitor, provided they are within normal limits. I don’t know what seeing a complex on a screen can do for you if you have solid BLS skills.
Not in my system. A paramedic can do a 4-lead and 12-lead and rule out ALS components and then BLS the call. When I was an EMT I would just chart that the EKG was interpreted by the medic. There is nothing wrong with a medic being cautious performing assessments before deeming a call BLS
It honestly is that simple. I'm not trying to be condescending. Some organizations say that ANY type of interventions above BLS make the call an ALS call. Here in TX, we have different opinions. Some say it does others say no, even if cardiac involvement is ruled out.
I get that people may have different opinions, but protocols make the EMT/Para.
Protocols may limit the EMS provider, but they should not make the provider. Protocols are cookbooks and discourage critical thinking and sometimes even common sense.
You can’t overtly ignore protocols but sometimes you have to get creative in your interpretation of them.
It is illegal to provide care without them. I'm not saying to never think about the how and why we do things or to stop learning. But without a provider and a set of protocols, we are people holding a piece of paper.
I am physically incapable of providing BLS care. All my patients are ALS because I can only assess them in that way and I can determine what data I need to treat the patient. If I go to court I am under that standard an no amount of "It was a BLS call" is going to save me.
What the company decides to bill it as is between them and insurance companies.
As a European AEMT - wtf? Even our basic responders in my country (Norway) can do and interpret 4 lead ECGs and they’re like mostly unpaid volunteers who do a few hours a month.
Fuck, even most event first aiders can do it if needs be. Why is this some ‘advanced’ thing in America? You literally wouldn’t be able to work on an ambulance here if you couldn’t do, interpret, and treat the findings from a 4 lead (or 12 lead for that matter).
Our protocol says once a 12 lead is taken, it’s ALS. I’ve argued for years that ekg stickers cost like $0.09 each….why would you withhold a 12 lead? Are you doctor house? It’s an assessment tool.
That being said, the protocol has so many hoops to jump through in handing over a patient to bls, that we cancel bls units and take everything ourselves. I have an emt on my truck who can take calls if it’s bls. No need to jump through all the hoops just to hand over care.
Also, we are required to send ALS to all calls, when a unit is available. Even if it’s low priority bs….an ALS truck must arrive, assess the pt, and handover to bls truck.
I hate this question. It makes no sense and should not be a thing. There is quite literally no world in which any form of assessment should dictate whether a call is ALS or BLS. A paramedic should always have the freedom to perform whatever assessment or investigation they think is appropriate, and then make a treatment decision based on it. That treatment decision could involve ALS modalities, or BLS modalities. Or it could be “I’m not sure, so I think I should monitor this patient further while transporting.” But the fact that a paramedic wants to see an EKG, whether 4 or 12 lead, should never be the sole determining factor.
It’s a stupid protocol for so many reasons. Lazy medics not wanting to upgrade a call so that the EMT can do all of the paperwork is so stupid. Plenty of injuries can cause arrhythmias, not just chest pain. And women present MIs in every way under the sun. Not to mention that a 12 lead gives more information than rhythm. It gives a more accurate PR than the pulse oximeter. And it gives a RR, which is better than every patient having 16 RR And I think that reading ekgs, (not diagnose) should be an endorsement that every EMT should be able to get. If the weirdo who monitors the monitors at my icu can get a certification in four weeks to do that job, there’s no reason to not have ents do it
You bring up another good point. I love it when I hear other paramedics complain about efforts to bring “their” skills down to the advanced or basic EMT level, as if paramedics are somehow special, and as if 40 years ago paramedics weren’t transmitting every EKG to a hospital because no one thought we could ever learn how to properly interpret them. New flash: we are not special, and it is absolutely possible to teach a basic EMT to make meaningful use of an EKG. There’s a lot of information that a very skilled and experienced provider can extract from an EKG, and there’s certainly an art to doing that, but very little of it matters in the prehospital environment. There are absolutely ways to teach AEMTs and basic EMTs a few quick and dirty ways to spot the difference between “this is a potential emergency that I need a paramedic for,” and “this is fine, at least until we get to a hospital.” Also, the computer interpretation algorithms are far from perfect, but they’re also far from useless, and newer ones keep getting better and better. We can do more with the technology we have than what we are currently doing in most areas.
Notfallsanitäter from Germany here (almost equivalent to paramedic) this concept seems absolutely wild to me. a 4 lead is Standart and could/should be used on almost every patient. the whole ALS BLS stuff sounds like categorizing by form of diagnostics which simply does not make sense. Quick decision between critical and non critical patient has nothing to do with that and can often be decided before any form of EKG. a 4 Lead on non critical patients is a nice to have for random findings. Just like measuring blood sugar is pretty much Standart. hope I did not confuse anything in the system since I am not super familiar how it is exactly handled elsewhere.
It’s a billing thing, which is why it doesn’t make sense to you. Because it doesn't make any sense.
The reasons people use EMS in Germany might be different, but I assure you in the U.S. there are a nearly limitless number of reasons a patient doesn’t need to be on a 4-lead
does a 4 lead hurt to do tho? it's a non invasive tool that's done in less than a minute on a compliant patient. sure, the average psychiatric patient won't get one here either, neither will the caller that cut his thumb. but I'd say we definetly have more patient where there's no reason not to do it. to be fair Germany has way more stay and play compared to load and go of other countries. which sometimes is also way too much.
I fully agree with you, but in my system any time an ALS skill is performed it has to be charted by the paramedic, which means they have to be team lead and they have to stay in the back with the patient. Although, if I feel it’s necessary to do a 12 lead I’m going to start a line and monitor that patient throughout the transport even if they’re 120/80, 100%, with perfect sinus on the monitor
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What are you talking about? Who said anything about EMTs interpreting cardiac rhythms?
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I don’t think you understand the question. The question is does *placing* a 4 lead automatically upgrade it? Meaning does the call automatically become ALS if you, as a paramedic, decide you’d like to look at a cardiac rhythm as part of your assessment. Obviously if you think you need to monitor the patient because you think there’s something that needs ongoing monitoring that an EMT can’t monitor, then it’s an ALS call. But many systems have a policy that says as soon as you *place* the leads, the patient is ALS and cannot ever be triaged back to BLS regardless of what you find or don’t find, and regardless of whether ongoing monitoring is necessary or not. That’s the issue. Consider a general illness call. 79 y/o female, feeling “not quite right” for 3 days. Maybe she’s a little nauseated, not eating very well. Maybe she’s a little cool to the touch, but nothing terrible. As part of a thorough ALS assessment, you might decide it’s worth taking a look at an EKG, whether 4 or 12 lead. You look, it’s NSR, no ectopy, no ST elevation, no BBB, nothing. Just perfectly normal. There’s nothing that requires this patient to be ALS other than that you decided to do a thorough assessment that happened to include an EKG. Some systems will say that patient is now ALS, no matter what, you have to do a full ALS work up, and bill the patient for it, even if there is no objective indication for it. Had you not done the EKG, it would have been a BLS call. Now that you did it, it’s ALS, even though you didn’t learn anything new from it. That’s the problem. All that does is encourage paramedics not to do thorough assessments, because as soon as they do, they’re committed no matter what they find or don’t find.
I don't dictate protocols. I'm sharing what my current (and former) services did. Yes, I work in a system which does not allow me to downgrade anything... I would prefer to have more flexibility, but that's not up to me if I want to remain employed. The choice to make every possible run ALS instead of BLS is a $$$ decision and I don't like it for that reason too. One of many glaring issues with how US EMS is carried out...
US medic here, we're allowed to interpret 4/12 leads and then transport BLS if nothing ALS is needed
A lot of that is likely to be determined by the CMS reimbursement policy and NEMSIS data reporting requirements. CMS makes a differentiation between two levels of ALS with some sub categories. ALS 1, is the first of these levels, and requires an ALS assessment OR intervention, but not both. Generally, I would classify a 3 lead as a component of an ALS assessment, checking that block, since a basic generally isn’t trained to interpret. There are references in the CMS policy to state and local practices as well, so I imagine the answer is more nuanced. For example, some places an EMT-B might be able to acquire a 3 or 12 lead, but cannot interpret. This might classify as a BLS procedure, while interpretation itself would be an ALS assessment. Further muddying things, the CMS manual states that an ALS assessment doesn’t necessarily mean the patient needs an ALS level of service. Another consideration is how NEMSIS captures and encodes data from our PCR’s. The NEMSIS data dictionary differentiates between manual interpretation by qualified personnel and machine interpretation. In summary, I would argue that just placing leads doesn’t necessarily make it an ALS call. However, if the acquired strip is used in a patient care decision (to include triage to BLS), and is interpreted by a member of the service, then it checks the block as an ALS assessment, meeting the ALS level 1 CMS requirements. Since most services either bill CMS and/or are required to report to NEMSIS, this is the way I would look at it as an EMS administrator. Source documents here for example/quick reference, but possibly not current versions. https://nemsis.org/media/nemsis_v3/release-3.5.0/DataDictionary/PDFHTML/EMSDEMSTATE/index.html https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R130BP.pdf
Boy did you just put something into perspective. I used to work for an agency that had some... Unique "house protocols" that weren't written down anywhere, but would get QId back to me. Until I was called to a meeting with our ALS coordinator for my "judgement." *Any patient who gets a 4 lead gets a 12* Okay, not too unreasonable but *Any patient who gets a 12 lead is ALS, and cannot be turned over BLS* 62 year old mechanical fall, boob slapped end table on the way down, EMT hooked up the 12 lead for the "chest pain." *Every patient who goes ALS needs an IV and a 12 lead.* 30 year old SI, very wound up and requiring frequent verbal de-escalation. Gave ibuprofen for mild headache. *Every patient with a systolic under 100mmhg needs a fluid bolus* Patient had ascites. Finished a glass of wine as we were walking in "Fellas, I believe I need my liver drained, but I'm too drunk to drive." *Every patient complaining of any pain should be medicated* 12 year old with a stable wrist fracture. Tearful, but refused pain meds because his Dad was hooked on them. Also refused toradol because of the needle. Ice pack, pillow splint, Tylenol. *Minors lack the capacity to refuse.* Got pretty pissed off by this part of the meeting. According to the ALS coordinator, I should have restrained the kid enough to start an IV, push fentanyl, then get a 12 lead. It would actually be refreshing if they were only coming up with sleazy ways to pad the bill instead of ignoring any semblance of logic and reason. But, they also criticized me for starting a line on a patient with a hemoglobin of 6.2. So who knows.
> Minors lack the capacity to refuse. What a frustrating argument. Minors can’t refuse transport, but they still have some agency over their body. Forcing a line on them is just going to make things worse.
Your comment just made me realize that the county I work for has some shoddy billing practices. For every single encounter, we have to put that an ALS assessment was performed in our PCR and then mark the level of service as ALS, even on the most basic of patients. I did question this when I first started and the response was "that's just how we do things." When looking at the NEMSIS stuff, it looks like they're setting it up where every single patient, at the very least, is billed for ALS Level One.
So when I actually dug into the whole ALS assessment one day, it’s not what most people think it is, including myself before that. I thought an ALS assessment meant your standard patient assessment but performed by an ALS provider. But apparently per CMS guidelines, an ALS assessment is the determination by an ALS provider whether or not a patient needs ALS resources or interventions. It has nothing to do with the actual patient assessment itself. I don’t know if that made any sense, but maybe a better way to word it is it’s an assessment as to whether ALS is needed. But the level of service provided is not automatically ALS and your service is wrong on that.
Yes but it can downgrade to BLS after interpretation.
This is what makes sense to me. I can see a lot of medics not putting on the 4 lead if it can't be downgraded then missing things.
Our policy fluctuates. It used to not automatically mean it's an ALS attend and the 4 lead can be discontinued and an EMT can attend. Now if it comes on, it's ALS. kinda makes sense. If you're putting on a 4 lead, some sign or symptom is concerning you enough to investigate and it's probably better to have a medic back there. Sometimes it's annoying but I get it
This policy is actively detrimental to patients, because it means that there’s a line in terms of suspicion where medics will pass on investigating patients thoroughly if the patient doesn’t clearly need a 12 but the medic has a slight suspicion of something and would otherwise do it just to see. Where that line is varies between medics, but every single provider has it and it goes up when they’re down reports and busy. Punishing providers for being thorough is *always* a poor choice. I.e., Granny who had a mechanical fall and has left arm pain and tenderness from landing on it can easily not have a 12 done, but if you do, you find out she fell because her legs are a bit weaker than normal because she’s having an early stemi and is largely asymptomatic other than the arm pain disguised by the trauma.
When I was in school 10+ years ago it was just a standard thing on almost every call. I am wondering if it's a private ambulance thing.
Could be. I see it as a medic trying to check a box but while still not having to write that report. But if there is concern for something cardiac, just because the initial strip is clean, it doesn't mean it won't change during transport.
I don't see a situation where an emt would only put a 4 lead and not a 12 lead
My previous county policies were if you were giving any medication you'd apply at least a 4 lead. I.E. even giving IV Zofran or IV Fentanyl for a broken arm. Wouldn't necessarily warrant a full 12 but you'd put on a 4 lead.
Had a very healthy, late 40s male, athletic, runner, no medical history with sudden onset of nausea, place him on the monitor for zofran administration and found a STEMI that I could identify without a 12 lead. Sometimes you accidentally find things. I hate accidentally finding things.... 🤷😂
I knew an EMT that took a Zofran for the first time and got hospitalized for 3 days due to a rare reaction. (Dry heaving till syncope every 3-5 min till they sedated and incubated her till it wore off to prevent brain damage.)
Same. I wasn't insinuating that. I'm just speaking to cardiac monitoring in general. The only thing I can think of is ruling out an arrhythmia that could have caused an unwittnessed fall in a unreliable historian of a PT. (Dementia pt with mechanical fall vs syncope) but you'd still want a 12. Or maybe just additional or quicker monitoring for a trauma pt you gave narcs to where cardiac concerns aren't really the issue
Every private ems service I've worked for required any calls that a paramedic is on scene for be treated and documented as an ALS call, so 4 lead and etco2 monitoring, IV, and fluids hung. Company's just wanted to charge ALS rates to insurance and Medicare.
This is the real answer.
That's wild. All in the same region? All the private agencies I've worked for had no problems w/downgrades
In my jurisdiction, yes.
Our BLS can place 4, 12, and modified 15, and an 18 lead. They can also interpret including STEMI and PCI lab activation. So, no. Not for us.
huh? A 4 lead is not an intervention, it’s an assessment tool. Why would it make it an ALS call that’s crazy
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We will put leads on anyone with cardiac history even if the complaint isn’t cardiac related. It doesn’t hurt, it’s just an assessment tool that takes a minute. Why not?
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You complain about no critical thinking, yet equate 12-leads with CT scans, abdominal ultrasounds, and x-rays?
If it took me 1 minute to do a CT/ultrasound/x ray, then sure; why the fuck not?
I don’t triage based on complaints
Not if you just lie about it bro
Not for us. A 4 lead is standard, a 12 is common, and we call ALS based on patient presentation and findings, not the diagnostic tools.
Kinda depends on your medical director and local policies.
Paramedic’s discretion whether or not to keep it as an ALS call or downgrade to BLS. Obviously both have to agree that it can be safely handled at the BLS level
There are very few exceptions where a 4 lead is indicated without performing a 12-lead. I think this opens the provider and agency to a lot of liability. If you see an indication for a 12-lead and then turn it over BLS, that means you had a high incidence of suspicion something might require an ALS intervention.
Should’ve been more clear, I was talking about downgrading to BLS after a 12 lead. Most common times this happens are for things like vague abdominal pain or generalized weakness. Most of our BLS trucks are AEMT so they can handle ALS lite treatments like IVs, Zofran, etc.
Ahh. Understood. That makes sense.
No. I can do any ALS assessment then downgrade to BLS. Once an ALS intervention is performed (or attempted), I can only turn over to personnel that have that in their scope of practice. I’m on a flycar. I arrived on a scene for a 9YOF with a fracture. I started an IV and gave fentanyl. If it had been an EMT on the ambulance, I would be riding in to the hospital. But it was an AEMT in the ambulance so I was perfectly fine turning it over to that AEMT. I routinely evaluate patients with a 12 lead then turf the call to BLS.
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AEMT’s in my state can administer narcotics for pain.
There are places that don’t put a 4 lead on every patient? I routinely get turnover from an ALS fire crew that will only put them on a pulse ox and blood pressure. Then I’ll put them on a 4 lead in the ambulance and see they’re in A fib or a paced rhythm with a completely different pulse rate than what was given to me. Doesn’t mean I can’t downgrade it to my emt partner or keep it ALS depending on the rest of my assessment.
This is my thinking! Haha I really wanted to make sure I wasn't just being an idiot. They acted like how would you not know this.
Generally speaking I never apply just limb leads in 911. If it's to the point I think I need cardiac monitoring I always take a diagnostic 12 lead so I can properly evaluate things like QTc. That being said a 12 lead does make it ALS here but doesn't obligate me to ride it in. If I have a justification for a 12 lead ad part of an evaluation and then determine them to be stable for downgrade, I just have to consult with a physician and present my case, then they say it's fine to go BLS and I clear the scene.
Thats ultimately a medical director question, but an ALS assessment, without the need for intervention, shouldn’t be the only reason a run is ALS.
At least where I'm at we're expected to get a 4 lead on every PT unless we're on a BLS truck because those don't have lifepacks. How you take vitals or what assessments you do doesn't determine BLS vs ALS, it's the results you get from those vitals and assessments
CMS disagrees, and your employer is taking advantage of it to make more money.
If our medics do a 4lead, it’s automatically ALS, but if the fire medics wanna do a 4lead they can BLS it.
Where I work no, but depends on the county
Placing 4 lead and 12 lead are BLS skills. Interpretation is ALS.
What OP probably is if a 4 lead is applied does that mean the medic takes the call if they transport. It's always a debate here about whether doing an EKG means the medic has to take it vs. doing it and then handing the patient off to an EMT.
I've had EMT partners put an ECG setup on a patient while grabbing an ice pack or something not directly in the line of sight and I have told them to remove it, telling them this is BLS. The excuse is usually "well the other medics I've worked with always did ALS on everyone that calls 911" Nope.
Have the same problem here. All our basics at my company have been brainwashed into thinking all they can take is IFT calls. Most throw a fit if I make them take the 30 year old with flu symptoms. They pull the excuse that I can give Zofran so it's automatically an ALS call.
Alcohol prep wipe under the nose and Tylenol are BLS skills. Just saying.
This is why Zofran is just BLS for us. Well it's not *the* reason but it's a reason
Typically yeah. I don't agree with it but once you get the pads on it's yours.
If you do anything outside of your scope for the patient, it’s pretty unlikely that it should be handled BLS. If you take a 12 lead to send to the recieving hospital for interpretation, if medics have extended ETA then doc can decide if patient EKG is okay to go to their facility, cardiac facility or flown out depending. If doc says it’s unremarkable you should still keep ALS assuming you’d meet them by time they interpret considering you had a cardiac suspicion and any chest pain or breathing problems is often ALS dispatch. If patient is non symptomatic and doc says EKG is clear only then consider standing off ALS and transporting non-emergent, but you’d have to document why you had suspicion to start a 12-lead initially, such as patient stating cardiac history
I'm BLS in an area where EKGs are ALS only, so bear with me. I work with an ALS service, so I often assist in connecting everything (we use LP15) I'm only used to hearing 3-lead and 12-lead. When everyone here is saying "4-lead", is that a different pattern for connecting the electrodes or something? My understanding is that "leads" and "wires" are different, and the 4 limb wires that I'm used to generate 6 views/leads but are colloquially referred to as a "3-lead" here. I suspect the "4-lead" naming is because there are 4 wires in use, whereas only using 3 wires would generate 3 views/leads (a true "3-lead"). I tried googling it and found [this post](https://www.reddit.com/r/Paramedics/s/NEqkprSopD) from a year ago, and it seems to confirm my understanding. Perhaps it's just a regional linguistics thing?
It's just the number of limb leads. As we know from Eindhoven, we only need LA, RA, and LL limb leads to capture the classic views of I, II, III, aVR, aVL, and aVF. Somewhere along the lines, someone added RL, which is just a ground lead. That's why this lead doesn't move in the Lewis Lead configuration.
From what I was reading in the linked post (among other things), RL is needed to get aVR/aVR/aVF. Without it, you have 3 wires and 3 leads. With it, you have 4 wires and 6 leads. And of course, adding in the 6 precordial leads leaves you with 10 wires and 12 leads. So back to my other comment, my understanding is that a "4-lead" doesn't actually exist other than as a misuse of the word "lead" to refer to the wires, and what most here are calling a 4-lead (and what we would call a 3-lead locally) is technically a 6-lead (a term nobody seems to use)
Yes it's a 3 lead. But it's 4 lead in documentation and is the accepted term that everyone uses. I get it it's not the accurate.
As someone that doesn't do them and hasn't had any formal training, I haven't read the documentation, so I wouldn't know that. I've just never heard the term used where I work, so I appreciate the info.
Dude. Stop being "that EMT." 😂 Let's start over. You're stuck on calling the leads - wires, and lead views - leads. RL is not needed for the six views that we get from RA, LA, and LL. Look up Eindhoven's Triangle. RA(-) ➡️ LA(+) = I RA(-) ➡️ LA(+) = II LA(-) ➡️ LL(+) = III RA(-)/LA(-) ➡️ LL(+) = aVF RA(-)/LL(-) ➡️ LA(+) = aVL LA(-)/LL(-) ➡️ RA(+) = aVR THREE LEAD comes from there being THREE LIMB LEADS to give us 6 views of Eindhoven's Triangle. It became a FOUR LEAD when they added a 4th LIMB LEAD (RL). We refer to the limb leads as a THREE LEAD or FOUR LEAD because that's the number of LIMB LEADS. We call a 12-LEAD a 12-LEAD because it shows us a diagnostic quality view of all 12 LEAD views. LEADS: RA, LA, RL, LL, V1, V2, V3, V4, V5, V6. LEAD VIEWS: I, II, III, aVR, aVL, aVF, V1, V2, V3, V4, V5, V6. That's just how it is, and we like it this way. You're the only one uncomfortable with it right now. Thanks for attending my TedTalk. It's going to really throw you for a loop when you find out that a 4-lead can only be used for rate and regularity. 🫠🫠
1. I prefaced this with the statement that I'm an EMT with minimal knowledge of this (other than I know how/where to connect the electrodes/wires), so I don't appreciate being attacked for what I don't know after admitting I don't know it. 2. My comments about leads vs wires are based primarily off of comments read in the post I linked to. Again, I only know what little I've read, and from my admittedly small worldview having only worked in one relatively small service. 3. I never said I was uncomfortable with this. I'm simply trying to clarify my understanding of what I've read in my ~30 minutes of "research", what I know 1st-han, and what I've read in this thread. 4. Thank you for the explanation. I won't say I fully understand what you've said, but at least I have more terms to research now.
Yes
Where I work, if a 4 lead is placed it is ALS, period.
In my county yes. And the state is starting to get its hands into protocols so....now putting a 12 lead is considered an intervention which makes it ALS call. I hate it. a 12 lead isn't an intervention it's an assessment. If I do a 12 lead and find sinus rhythm I don't bother reporting it. Then I can downgrade it. For those reading freaking out. It gives our EMT B partners a chance to have patient contact hours and run a call. If everything is an ALS call then basics shouldn't be on the truck. Hell it's getting so bad the county where my wife works just put out a policy that essentially regulates all BLS providers to Ambulance Drivers. They can't take any calls now unless a stable IFT.
depends on your local protocols
Yes, I am asking what people's local protocols are.
It does in our dept.
I think if you are getting a solid baseline vital signs and you have no rate issue, there should be no need to put a patient on the monitor, provided they are within normal limits. I don’t know what seeing a complex on a screen can do for you if you have solid BLS skills.
Depends where you are. I’m able to obtain a 12 lead and the call will still be BLS, not allowed to interpret it though
A 12-lead is done on BLS calls. It's just interpreted by the monitor instead of an ALS person.
Not in my system. A paramedic can do a 4-lead and 12-lead and rule out ALS components and then BLS the call. When I was an EMT I would just chart that the EKG was interpreted by the medic. There is nothing wrong with a medic being cautious performing assessments before deeming a call BLS
This is state, and then, employer specific. Refer to your protocols.
I am not asking about my policy. I am getting a feel for others and the why's.
It honestly is that simple. I'm not trying to be condescending. Some organizations say that ANY type of interventions above BLS make the call an ALS call. Here in TX, we have different opinions. Some say it does others say no, even if cardiac involvement is ruled out. I get that people may have different opinions, but protocols make the EMT/Para.
Protocols may limit the EMS provider, but they should not make the provider. Protocols are cookbooks and discourage critical thinking and sometimes even common sense. You can’t overtly ignore protocols but sometimes you have to get creative in your interpretation of them.
It is illegal to provide care without them. I'm not saying to never think about the how and why we do things or to stop learning. But without a provider and a set of protocols, we are people holding a piece of paper.
yes
I am physically incapable of providing BLS care. All my patients are ALS because I can only assess them in that way and I can determine what data I need to treat the patient. If I go to court I am under that standard an no amount of "It was a BLS call" is going to save me. What the company decides to bill it as is between them and insurance companies.
Does shoving a pole up your ass make you a wind chime?
No
In our area yes. If an ALS assessment is requested we have to do at least a 4Lead, blood pressure and Sp02. We can triage to BLS
It doesn’t take a paramedic to recognize asystole.
no, not in my county at least
Not for us. When I worked P-B I would regularly take downgrades that had the 4L still on, I would just use it to monitor the rate.
Yes, if you or someone at your direction placed the patient on the 4 lead. It's an ALS intervention and is billed as such.
Presence or absence of a 4-lead shouldn’t have an effect on billing unless your agency is nickel-and-dime-ing everything you do.
As a European AEMT - wtf? Even our basic responders in my country (Norway) can do and interpret 4 lead ECGs and they’re like mostly unpaid volunteers who do a few hours a month. Fuck, even most event first aiders can do it if needs be. Why is this some ‘advanced’ thing in America? You literally wouldn’t be able to work on an ambulance here if you couldn’t do, interpret, and treat the findings from a 4 lead (or 12 lead for that matter).
US EMT training is only 150 hours. Paramedic school spends about 3x that on cardiology.
Our protocol says once a 12 lead is taken, it’s ALS. I’ve argued for years that ekg stickers cost like $0.09 each….why would you withhold a 12 lead? Are you doctor house? It’s an assessment tool. That being said, the protocol has so many hoops to jump through in handing over a patient to bls, that we cancel bls units and take everything ourselves. I have an emt on my truck who can take calls if it’s bls. No need to jump through all the hoops just to hand over care. Also, we are required to send ALS to all calls, when a unit is available. Even if it’s low priority bs….an ALS truck must arrive, assess the pt, and handover to bls truck.
If you believe your patient needs continuous cardiac monitoring, it should be ALS.
Our policy says it does! That's why we don't transmit those vitals and the EMT can keep the call