Posted by: medicblog999 | March 19, 2010

Im not saying!…..Im just saying!

Zoll E-Series

I am known for a saying at work :

“If you are going to do a 4, do a 12!”

All I am saying is that if you are concerned enough about a patient to put on a 4 lead ECG, then why not go the full hog and just put on the chest leads too.

Some may say it is a little bit over kill, but how on this earth can you fully assess someones heart when only looking at leads II, III and aVF.

As I said at the beginning,

If you are going to do a 4, do a 12!

Do you agree? Feel free to say no if you dont.



  1. First of all, I completely agree with putting everybody you want to monitor to a twelve-lead. Some folks I work with do what they call a “poor-man's twelve-lead” and hit the 12 Lead button to get a print out and interpretive statement (eek!) with the six standard and augmented limb leads. I think this gives a false sense of security. Nowhere else in medicine do clinicians use anything less than a twelve-lead (or a modified nine-lead where that is all that is available) the attempt diagnosis.Lead II (et cetera) is for monitoring.As a side question, I noticed on the Torsades v. V-Tach v. V-Fib post a while back that there you also used II, III, and aVF as your monitoring leads. It was asked then why you chose these leads, due to possibility of unrecognized interference or artifact since all three leads use the same positive electrode. Do you have any comments? Are these your usual monitoring leads for any particular reason?

  2. Yep I agree too, if you are worried about someone enough to want them to be on cardiac monitoring, you should definitely acquire (and interpret yourself!) a full 12-lead ECG.However, staff in my trust were once criticised a while back for using too many stickies and too much ECG paper, and told to do fewer 12-leads – figure that one out!

  3. I'm actually going to have to disagree here. I believe that 12 leads in the field are pointless. Unless a medic is having trouble interpreting the rhythm. Our treatment plan is going to be the same with a 4 lead or a 12 lead. I personally believe it is a waste of time. This is my personal opinion.

  4. Hi Medic199,Thank for the comment and I appreciate that this is your personal opinion but…Really??”Unless a medic is interpreting the rhythm”A 12 lead can not and should not be used for rhythm interpretation, as unless their is a rhythm strip running along the bottom then there is not enough length on a 12 lead to accurately look at rhythms – Thats what a rhythm strip is for.”Our treatment plan is going to be the same with a four lead or a 12″So what if you patient is having an anterior MI without any reciprocal changes. Leads II, III and avF may look normal, and if you are only looking at inferior leads you may well miss an important diagnosis (remember, many patients present with atypical chest pain, and may not be clutching their chest, be pallid or sweating!)I had a patient just last night on shift who had phoned after feeling sob. O/a he was looking well, not unduly short of breath, but just felt out of sorts. Assessment was unremarkable, but I felt it important to do the full assessment including a 12 lead which showed some fairly significant septal ischaemia which I wouldnt have found without doing the 12.I agree that not every patient needs a 12 lead, but I feel that those who dont need a 12 lead also dont need a 4. I.e. If I am going to do a 4, i will do a 12.Looking at just one view of the heart .i.e. the limb leads is, I believe, doing our patients an injustice.Thank you for the comment, I always like to have a discussion. Please feel free to counter my argument again.Mark

  5. Thanks for the reply, So did this change your treatment plan?

  6. Absolutely!Without the 12 lead, this patient was a 50yr old male with very mild dyspnoea. All obs within normal parameters, and nothing significant to find. For me, he was suitable to stay at home and have a referral to the Urgent Care Team (a team of nurses who come out from the hospital within a couple of hours), who would come and assess him at home for the likes of chest infections etc.However, with an ischaemic looking ECG, he was obviously not suitable to be left at home and required transfer to hospital.This wouldnt have been picked up had I not done and ECG or even if I had done a 4 lead.

  7. (For the record the “like” is an accident.)Do you take every chest pain or anginal equivelant sypmtom patient to a cath lab facility? Do you administer nitro to every chest pain or anginal equivelant symptom patient? If you answered “no” and “yes,” you're really playing with fire. ESPECIALLY the second question. As to the first, time is muscle, and pre-hospital 12-leads save D2B time. And there's medical evidence to back it up.And I really hope you're not suggestiong that a medic having trouble interpreting a rhythm run a 12-lead for help from the computer analysis.

  8. Hi Matt,Sorry I missed the question on the Torsades Post.The only answer that I can give for using the inferior leads is that they are the default leads for when monitoring a rhythm. I can, if I want to swap out any of those to use any of the other leads for monitoring (if I have put the chest leads on), but for the intially 'quick look' before the chest leads go on, it defaults to II, III and avF.

  9. I apologize, 12 leads are not pointless for some people. We only have one hospital we can go to. They have no cath lab.

  10. I'm just a student, but I'll throw my two cents in. I agree that with any medical patient if you're gonna take a peak at their heart, you might as well go ahead and have a good look, though per my understanding with trauma patients if you're just going to take a quick look at their heart there's probably no need (or time!) for a 12-lead (though I could see the need for one if, say, your patient is at risk for crush syndrome and you want to look for electrolyte imbalances post-extrication).

  11. I don't know how everyone was taught to interpret EKGs, so I don't claim that this applies to everyone, but I use this systemic approach:Rate, Rhythm, Interval (including AV blocks and hemiblocks), Axis, Hypertrophy, Infarction.With the limb leads, we can accurately determine the rate and the rhythm, certainly. We can probably determine the intervals, although sometimes I find it easier to see in a precordial lead. We can identify AV blocks. We can get a rough idea of the axis, although to be more precise, we should be looking at all six limb leads simultaneously on a print-out. Things we really need the twelve lead for: hemiblocks, hypertrophy, and especially infarctions. Can we fix infarction prehospitally? No, not really, although as others have said it certainly does affect our treatment plan. Does anybody “fix” hemiblocks or hypertrophy? No, they are symptoms of other problems. But there is still value in learning to recognize and report these findings. Medicine values data points, and it can be a mistake to exclude some just because we can't push a drug or stick a tube in it to fix it.

  12. I get what you are saying Medix199 – you can only take the pt to the one facility regardless & probably same treatment regardless of what a 12 or 4 may tell you. However there are different areas/jurisdictions that have several options open to paramedics, for example we can thrombolyse, take to PCI (9-5pm) or call a doc out.

  13. i agree with Matt in that is a step by step process for interpretation, but doing a 12-lead just cause you are doing a 4-lead is not what i believe to be a correct thought process. I understand that if you think you are concerned enough to put them on the monitor then why dont you do everything. a great example of this v. fib, what is a 12-lead going to show that the 4-lead did not, nothing but more v-fib. Now i always err. and if i am even 1% concerned i do a 4-lead, but that is because i am fairly new paramedic and i am probably more cautious and up-tight than more experienced individuals. 12-leads are an essential part of our scope and should be used when appropriate.

  14. I guess I have to concede that I am unlikely to do a twelve-lead when working an arrest. If I throw someone on the monitor and see a lethal rhythm, then by all mean I am going to carry on with my treatment. I had intended my comments to refer to more-or-less stable patients (they probably have to have a blood pressure for me to take the time).

  15. Hi Rocky.Obviously, you would not do a 12 lead for a V-Fib, that would be inappropriate, but you would do one, if you got a ROSC and you had time, wouldnt you? Just in case you needed to divert them to PPCI? The point is more about the general patients that we get. For example, I routinely do a 12 lead ECG for any elderly person who has fallen over who cannot categorically state that it wasnt a simple trip and fall. Now many people wouldnt even get the monitor out, there are others who will do a 4 lead “just to check”. These are the sort of cases where I would do a 12 lead – to be thorough and give my patient the best care possible. I firmly believe that the 12 lead should not only be pulled out for the patient who you may feel is likely to be having an MI, but should be utilised in a multitude of other cases, but as you say “when appropriate”Give it a try for a couple of weeks. Whenever you do a 4 lead, do a quick 12 instead, and then let me know how many cardiac problems you picked up on that you would have missed before. They may not need your direct treatment, but they also may never have been noted before.Thanks for the comment.

  16. Bit too black and white for me….12-lead on a trauma patient? A 3/4 lead is routine for a shooting/stabbing/MVA/MCA, but a 12-lead is last on my list. A medical call is different, and subject to the complaint and presentation, not to mention experience and intuition of the attendant. As a recently retired, 30-year medic, friend and former co-worker had on a strip of 2″ white cloth tape on his Zoll, in big block letters, USE ONLY IN CASE OF EMERGENCY !!

  17. great response, but i have to laugh when reading everyones blogs people start using TLAand FLA's ( three letter acronym's and four letter acronym's). good luck with COEMS and future endeavors, it's great to have a positive force especially when there is so much negatvie news.

  18. In the system I work in it is actually required that we use the monitor during any ALS intervention. Meds in particular. We also have multiple hospitals to choose from, some with cath labs, and we have protocols for metoprolol and heparin in the event of a STEMI. So I put a lot of people on the monitor that I never run a 12 lead on, almost every ALS patient gets it. And a 12 lead absolutely makes a difference in my treatment modalities.

  19. The difficulty I face in training our guys (I'm in the training division as well as the one who got us to purchase 12-lead capable monitors) is to run 12-leads on more than just chest pain patients. We all know situations where an MI can present differently in certain populations and people with certain histories. Trying to get my guys to run one in the absence of someone c/o the elephant sitting on their chest has been my problem. I'm not trying to brag but myself and a partner were recently submitted for an award on catching and treating an inferior wall MI on a pt who we were called for the fall on and who's only c/o was of bi-lat leg pain. No, injuries, no obvious findings but after finding out he was a diabetic, stated he had a little SOB and thinking we saw a little ST elevation in II and III we ran the 12-lead. Clear as day there was the IWMI. Treated, transported, cathed, bringing us some great home-made Indian food the week after. Situations like that can save lives.

  20. I was quite shocked by the initial comment the 12 leads in the field are useless, although having read on I can see why you'd think that if they can't, due to local treatment protocols, change your treatment, or divert the patient to a more appropriate treatment facility. I guess we're kind of spoilt for choice a little (although there's more I'd like to see!) here for treatment/transport options. Nevertheless, on the whole Mark, I agree with you. I'll tell anyone who's willing to listen that in the vast majority of cases, if they're going to take the time to stick on the limb leads, take an extra 30 secs to do the rest! I'm not certain it would be top of my list in a trauma patient – but am willing to learn differently if there's good cause for it! Great way to kick off a discussion, sir!

  21. Kinda but not really. I mean I'm only an emt-b, but a 12 lead seems kind of overkill for most patients.

  22. I don't know, we don't have 12 lead here so I have no comparison(we also only have one hospital so transport choice is easy). Maybe someday if our medical director gets us 12 lead it may make a difference but given the fairly limited medication and treatment choices we have our 4 lead works pretty well.

  23. You are not ONLY an EMT-B. I could not do my job as a paramedic without the help of capable EMTs. You know the saying, “Paramedics save lives and EMTs save paramedics.” My EMT partner is amazing and she has saved my bacon more then once. One time she talked me into CPR on a severe multi-systems trauma Pt that was pulseless and apneic. So we went to town and the Pt survived and is now walking around and doing great. Per our protocols she met the criteria for Traumatic Death in the Field. I can honestly say I would not have worked her if I had been working with a different partner.

  24. ^.^ Thanks for the encouraging words. I am just freshly certified.

  25. You are not ONLY an EMT-B. I could not do my job as a paramedic without the help of capable EMTs. You know the saying, “Paramedics save lives and EMTs save paramedics.” My EMT partner is amazing and she has saved my bacon more then once. One time she talked me into CPR on a severe multi-systems trauma Pt that was pulseless and apneic. So we went to town and the Pt survived and is now walking around and doing great. Per our protocols she met the criteria for Traumatic Death in the Field. I can honestly say I would not have worked her if I had been working with a different partner.

  26. ^.^ Thanks for the encouraging words. I am just freshly certified.

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