Deep Six Quick Six

You respond* to an office building to find a 35-year-old male complaining of flu-like symptoms.  He is embarrassed that his coworkers called 911, and states he became nauseated shortly after lunch.  He feels weak and generally punked out, and had one episode of weird unexplained sweating that has now resolved.  His vitals are great and he just wants to go home.  He says he doesn’t need an ED just because he ate some questionable food and got a stomach bug. 

Your partner runs a quick-6 ECG.  For those that don’t know, a quick six is accomplished by putting on the four limb electrodes, resulting in the six frontal ECG lead views.  This is what it shows:

No big deal, there.  Nothing concerning, and nothing that would make you want to look at the V-leads, right?  Sinus at 75, normal axis, no ST or T wave changes.

This is an EMS blog.  You’re not going to fall for that trap, are you?  You ask your partner for the V-leads:

Should the patient go to the hospital now, maybe to get the anterio-lateral MI fixed up? 

Let’s try another one.  It is a hot day when you respond to the park for a 22-year-old male soccer player who fainted.  He is in good shape, feels fine now, and doesn’t really want to make a federal case out of things.  He asks that he just rest in the shade with plenty of water.  You are about to agree, but your partner is new and she runs a quick-6 ECG:

Weird – there is a pathologic left axis.  But otherwise there is no dysrhythmia, no ST changes, and nothing land-jarring to get worked up about.  Don’t overthink things – this is a young, athletic soccer player on a hot day who fainted in the sun.

Oh, what the hell.  It is an EMS blog:

Click to zoom

Brugada syndrome.  Think he needs to go to the hospital now?

I see quick-6 ECGs used often.  I completely don’t understand why.  I have even heard rumors of paramedics teaching this to students and new-hire trainees!  Why would you only seek half of the information?  Do you only do secondary exams on the front of people’s bodies?  Or just from the waist up?  Do you palpate blood pressures often?  Do you start IVs and then blow off taping them down?

If you do, let me be clear: You are a poor paramedic.  I don’t want to work with you.  You are bringing down our profession.

It isn’t 1998 anymore, when we had LifePack10s and couldn’t look at the precordial leads.  Wait – even then we would set up MCL leads.  Medicine and medical technology has advanced.  Keep up – you are getting left behind.  In 2014, twelve leads is the current standard.  Leeching the bad humors, MAST pants, and frontal lead prehospital ECGs are no longer the expected practice.

I timed myself a few times.  I can put on the V-leads in about 45 seconds.

So I have been thinking about this and can only think of three reasons to check only the frontal plane leads.  The first is that CPR is going on.  There is no need to get a 12-lead of VFib or asystole.  It is pretty important to get a 12-lead as soon as possible after return of spontaneous circulation, though.  The second reason to not immediately get a 12-lead ECG is for privacy concerns.  There are patients in an airport concourse, or in the stands of a packed stadium, places like that, for whom lifting their shirt (and maybe hoisting up a left breast) is probably not cool right at that moment.  The obvious answer is to move them to a more private setting, but that isn’t always immediately feasible.  The third reason to not place V-leads is that you are plum lazy.

Do you not care about bundle branch blocks, ventricular hypertrophy, Brugada syndrome, hypertrophic cardiomyopathy, anterior ischemia, septal ischemia, low lateral ischemia, posterior infarcts, Wellen’s waves, and the rest of the long list of findings that the V-leads give you?  Are you really content with being able to name the dog (name the rhythm), measure the intervals, and state the frontal plane axis?  Those three things are why you ran an ECG?!?

Can you think of other reasons to not look at the precordial leads?  I am literally asking – I can accept that there may be reasons that I haven’t thought of.

If it is important enough for a quick-6, it is important enough for a 12-lead.  You’re a paramedic.  Act like it.

*With lights and sirens because 'Uh, no, I guess not' was the answer to "Is his breathing completely normal?"