Paramedics Can and Should Become Experts in 12-Lead ECG Interpretation


When prehospital 12-lead ECGs were still relatively new to EMS (1995-2000) we advised paramedics to maintain a high index of suspicion. We cautioned them about atypical symptoms, especially in women, the elderly, and diabetics. We asked them to obtain a 12-lead ECG for the so-called anginal equivalents, including:

  • Epigastric pain
  • Jaw, neck, or arm pain
  • Exertional dyspnea
  • Nausea and vomiting
  • Diaphoresis unexplained by ambient temperature
  • Unexplained weakness or fatigue

Paramedics went out into the world and performed thousands of 12-lead ECGs on patients whose pre-test probability of acute STEMI was relatively low. When poor data quality triggered the ***ACUTE MI SUSPECTED*** message, or baseline abnormalities like left bundle branch block, left ventricular hypertrophy, paced rhythm, bifascicular block, or ventricular aneurysm were present, paramedics erred on the side of caution and announced “Code STEMI”.

Why wouldn’t they? Our trauma systems had operated this way for decades, with over-triage designed into the process. Paramedics are trained to think about what might be wrong. As a consequence, we ended up with the “false positive” issue that has been the subject of a lot of research and discussion today.

We have collectively spent millions of dollars on various “solutions” to transmit the 12-lead ECG so that a “qualified physician” can decide whether or not to activate the cardiac cath lab or have EMS bypass the local non-PCI hospital.

While I have no problem in philosophy with ECG transmission, the process can be cumbersome, it does not always work, there is no guarantee the person on the receiving end of the transmission is an expert in 12-lead ECG interpretation, and politics often come into play when considering whether or not to bypass non-PCI hospitals.

An obvious solution (that is almost always dismissed) is to teach paramedics to become experts in 12-lead ECG interpretation.

One well-known national leader in STEMI care told me unequivocally that it would be almost impossible, or at least very impractical, to educate paramedics to interpret 12-lead ECGs at this level.

We sent man to the moon 45 years ago, but it’s just not realistic to expect paramedics to be able to identify STEMI, STEMI equivalents, and STEMI mimics on the 12-lead ECG!

“They aren’t even interested in that much education,” I have been assured.

As a consequence, STEMI identification has been reduced to “find the J-point and count the millimeters of ST-segment elevation” — a system perfectly designed to make paramedics fail.

The “experts” are wrong about paramedics.

We want to be excellent at our jobs and we can learn anything we set our minds to.

I’m willing to bet my professional reputation on it.

Until now, no one has told paramedics two critically important truths about 12-lead ECG interpretation.

  • STEMI is not the most common cause of ST-segment elevation amongst chest pain patients
  • The arbitrary millimeter criteria don’t work

Let that sink in for a moment!

Our 12-lead ECG course has not been “dumbed down” for paramedics! In fact, most of our first 100 subscribers were physicians. Your medical “rank” has absolutely nothing to do with your ability to interpret a 12-lead ECG.

Our curriculum is accredited and offers continuing education credits for paramedics, nurses, and physicians! New people are signing up for our program every single day. That’s great, but that’s not why we created this course.

We created this course to transform STEMI care at the system level.

12-lead ECG transmission can supplement but should never replace a thinking clinician. Let’s show the house of medicine that the solution to reducing false positives was standing in front of us all along.

Contact us today to discuss how together we can help improve patient care in your EMS system, your hospital, and your community.


About author

Tom Bouthillet
Tom Bouthillet - 25 posts

Tom Bouthillet (@tbouthillet) is Editor-in-Chief of (@ECGTraining) and Fire Captain/Paramedic in South Carolina where he is the Emergency Cardiac Care Program Manager and the STEMI and CARES Site Coordinator of his fire department.

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