STEMI...How Can we Improve??

[Craig Alan Evans]

Wolfman Harris,

Very good reply. To answer a few of your concerns:

In #3 I am trying to advocate that anyone can perform the 12 Lead EKG to be interpreted by someone else. This would go far to make my 5 min goal attainable. In many systems across the globe a BLS provider will make contact with the patient prior to an ALS provider. This section is just to make the point that applying electrodes is not an ALS skill.

When a say a no drip policy I mean no medication drip that will slow down onset to balloon time. Drips don't save lives, reperfusion does.

Finally skipping the ED altogether I feel can be a bit dangerous as a disecting aneurism is a fatal AMI mimicker and should end up on an operating table not a cath table.

 

[Craig Alan Evans]

Also Wolfman,

In response to your concern about placing arbitrary benchmarks like a 5min 12 lead: We need to set goals and standards. If we aren't aiming at anything we will never hit what we are shooting at.

 

[fast65]

Fast 65 where do I begin?

Let's skip the part where you imply that improving our vocation will actually cost money and go straight to the part where one of your arguments against improving our STEMI response is that lazy medics and medics who believe that EMS is a glorified taxi service wouldn't like it so therefore we just shouldn't try. :wacko:

I'm afraid that based upon your sardonic signature that we are simply going to have to agree to disagree. I hope that your participation in a forum such as this places you in the "not lazy" and the "No Cadillac EMS Taxi" category of prehospital providers.

If we are going to improve we need to start somewhere. I think we can agree that improving STEMI times and performance is a worth while endeavor. If so any improvement will do. You have to evaluate your own system. Where can you improve? What would be the next step?

I'm not trying to be curt with my response just calling it how I see it. Please correct me if I have it wrong. Sometimes quite a bit of the tone and intent is lost in the written word.

My apologies for not making the intent of my post clear. I am not advocating AGAINST your plan, I am simply saying that it will cost money and with that, a great deal of time. You're plan seems to be a good base to work from, but there are certain areas that need addressed further.

I'm not saying that we shouldn't try, I'm just pointing out that it isn't as simple as your post makes it seem; now I apologize if that is taken out of context, as you said, a great amount of tone is lost on the internet. I am just pointing out that there will likely be some opposition to an increase in our education, or to an increase in our duties; again, that is not to say that I am against improving our STEMI care, because I am not.

I would love nothing more than to have an increased scope of practice (so to speak), but with that needs to come an increase in education as you know. However, that is an entire discussion all together.

Don't mistake me as a cynic based upon a simple saying, it is simply a quote that sums up my opinion of certain things. That aside, I am not a believer in the "you call, we haul" policy, nor am I of the opinion that the bare minimum is acceptable.

 

[WolfmanHarris]

Also Wolfman,

In response to your concern about placing arbitrary benchmarks like a 5min 12 lead: We need to set goals and standards. If we aren't aiming at anything we will never hit what we are shooting at.

Agreed, but our standards must be based on sound clinical judgment and evidence. Certainly we can encourage providers to aim for quick 12 lead acquisition and may even coach that a 12 lead within the first 5 minutes can help shape your diagnosis, but when we set and enforce a standard arbitrarily we risk encouraging cook book medicine. Pt contact to balloon time is a defensible standard. Pt contact to 12 lead time isn't. If in the process of QI we see that a crew was on scene for 15 minutes before acquiring a 12 lead, or was en route and redirected based on a 12 lead done on route, we can use this in coaching crews to determine what process lead to those delays or missed calls; but it's not chute times and shouldn't be treated as such. Though at this point I feel like we may be arguing style more than substance.

As far as stopping in the ED goes, I find the dissecting aneurysm a bit of a straw man argument. While certainly I see the possibility, I find it unlikely that it will get missed. Our directives do exclude Pt. with a SBP <80 mmHg refractory to field intervention and unsecured airway or pt's that cannot be ventilated effectively.

 

[Craig Alan Evans]

Fast 65,

Very good response. I agree. It's going to take a lot of work and money. But I truly believe we need to be advocates for our vocation. If we find ourselves surrounded by cynics and non believers then we have a few choices. 1) change them 2) be changed by them 3) ignore them and concentrate our efforts on those dedicated to progressing EMS.

I choose 1 or 3

 

[Craig Alan Evans]

Wolfman,

Sounds like we are fundamentally on the same page. Excellent discussion. Thank you!

 

[Veneficus]

Craig,

It is not that I disagree with you, I don't.

(except on shaving cath patients, I disagree with that because shaving increases surgical infection rates and the guidline is not to unless you absolutely have to and then to immediately start ab therapy)

But on the heart of the matter I think you have many good ideas in your original post.

I think paramedics absolutely can be trained and given the tools they need to implement just about everything on there. Including tpa administration. (pocket ultrasound is a fine tool, and cheaper than most at about $5K)

Forgive the pun, but I am an operations type guy, the plan no matter how good, needs to be able to work in the real world.

A major part of that real world is cost and cost/benefit ratio.

Which brings us to healthcare funding again.

In the US, prior to the latest recession 47 million Americans were without health coverage. An uncounted amount underinsured. (just as bad with things like 80/20plans with high deductables)

The stats I read this week put medicare/medicade at 24-26% of GDP.

Hospitals are reimbursed far below cost in many cases.

These 2 things create an environment where costs need to be controled. Medically, cost to benefit both in screening and treatment need to be at least reasonable.

Who will absorb the cost of training? Can your department afford to pay for the education and associated staffing costs with adding perhaps hundreds of hours of additional education?

The up front fee of more units and staffing so as not to create a dangerous over utilization scenario of existing crews as calls increase?

How do they recoup losses from indigent populations?

Will the cost of these treatment modalities take money and resources away from primary disease prevention?

Some of the things you mention are rather easy to implement at low or almost no cost. Those should be instituted right away.

But then you start get into some grand ideas.

Which again are doable, but only if you also find the money to do it.

 

[systemet]

1) Patient Education

This is a good idea, but I think it's often failed to make a big impact on time-to-presentation in practice. I think there's probably greater benefit in training paramedics to be more aggressive in seeking out STEMI in atypical presentations, e.g. dyspnea, weakness, back /abd. pain, syncope, etc.

2) EMS vs. ER...The first 10 minutes should be the same: I am a firm believer that the patient's hospital stay should begin at the time the paramedics walk through the front door of the patient's residence.

Agree 100%, and believe that under ideal circumstances, the patient should only step foot in the ER if they're being treated medically with tPA, or PCI in is unavailable. Otherwise providers should be going straight to the cathlab.

Door to balloon times are misleading as we need to start recording and improving first healthcare contact to balloon time.

I think both have value. The door-to-needle measures the efficiency of in-hospital processes, and is probably an important benchmark. But I agree with the spirit that anything being done by EMS should be with the goal of shortening the time to reperfusion therapy.

3) Prehospital 12 Leads:Our goal should be a 12 Lead within 5 minutes of patient contact by any prehospital provider. How long should we wait to find out if they are having the big one? Any barrier in your EMS system that prohibits a 12 lead EKG from being acquired within 5 minutes should be removed.

Agreed. In my old job we performed a 12-lead before NTG to evaluate for RVI. It was absolutely done on scene, and we certainly strived to do it quickly. Unfortunately I don't think the time-to-12lead was benchmarked when I left.

4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see.

Agreed. This should be done, where technically possible. The goal of this should be to direct the patient's care. Personally I think that a positive ECG should result in plavix + enoxaparin, and then either tPA, or direct transport to PCI. If you connect with a physician, they should have access to real-time information about cathlab status across the potential transport area, and should be able to stratify the patient to either treatment arm, select an available PCI suite (if possible / desirable), and at least initiate the process of having them prewarned.

b) Non-Confirmed STEMI: This is a patient that the ER physician has not seen the EKG but EMS suspects a STEMI. No drips, rapid transport, and all the interventions listed above outside of activating the cath lab, pre PCI treatments, or TPA should be implemented.

This is trickier, as it's asking paramedics to risk-stratify patients and make a decision as to whether the patient should undergo fibrinolysis or primary PCI. I think this decision has to be made in collaboration with a physician, especially if we talking about giving tPA prehospitally.

There is a study somewhere from the UK suggesting that paramedics were able to evaluate 12-leads for STEMI with a specificity equivalent to that of physicians (at a lower sensitivity), i.e. they were reluctant to call borderline cases. But I think the real benefit from physician oversight is partially in preventing the odd disastrous ECG misinterpretation, but mostly in providing that treatment decision about PCI vs. prehospital fibrinolysis.

Le May MR, Dionne R, Maloney J, Trickett J, Watpool I, Ruest M, Stiell I, Ryan S, Davies RF.Diagnostic performance and potential clinical impact of advanced care paramedic interpretation of ST-segment elevation myocardial infarction in the field. CJEM. 2006 Nov;8(6):401-7.

Whitbread M, Leah V, Bell T, Coats TJ. Recognition of ST elevation by paramedics.Emerg Med J. 2002 Jan;19(1):66-7.

6) Transport: The patient should then arrive at the PCI center within 30 minutes. How this is accomplished depends on the local resources and the location of the PCI center. If air transport is the only way then EMS should be authorized to initiate this from the scene as transporting to the nearest ER and then transferring the patient will be an obvious delay.

The benefit of rotary wing transport needs to be balanced against the risks of increasing the number of flights, given the safety record, and the time delay associated with rotary wing activation, as well as the delay that occurs when the crew delays while notifying medevac and then gets turned down.

I would suspect that for many of these patients, tPA, transport to a local ER and secondary transfer for rescue by ground, if necessary, might be a better strategy.

If there's no rule outs for fibrinolytics, I think they're probably a better option than flying the patient, if there's a long transport time. Few helicopter transports are going to get anyone anywhere in 30 minutes from notification.

7) No Bed Transfer: It takes time to move a patient from an EMS stretcher to a hospital bed. The patient should be moved directly from the stretcher to the cath table. If the patient needs to be seen in the ER for any reason they should stay on the EMS stretcher and be ready to roll to the awaiting helicopter or to the cath lab, whatever is the next step of the journey to a successful PCI.

I think the treatment decision should be made by a physician while the patient is still be treated in the field. If the crew arrives before the cathlab is prepared, they can treat in the hallway outside the suite. If the patient decompensates and needs resuscitation that can't be provided by the crew, then the ER is an appropriate stop.

If we're going for fibrinolysis as a strategy, then the ER is an appropriate destination.

I cannot stress enough that this is a team effort. All phases of the system from the patient, the dispatcher, to the intervening cardiologist need to communicate with each other and develop a cohesive plan with only one goal in mind, the well being of the STEMI patient!

Agreed.

 

[systemet]

I just re-read this, and realised that I come across a little strongly in places. Please don't interpret this as disrespect, as I value your opinion highly, and recognise that you have much greater training and education in this area than I do. However, I'm quite passionate about this area, so please forgive me where my passion comes across too strongly -- I don't mean to cause offence.

Educating and training paramedics to provide increased interventions.

I think the cost of this depends on how many paramedics you have, and what background they're starting with. If they already have a degree of familiarity with 12-lead, it may be a case of refreshing that knowledge and talking a little about STE mimics, and contraindications to fibrinolysis, and a little about reperfusion arrhythmias.

Equipment, you need some way to transmit, something to transmit to.

Yeah. The cost of this is going to vary by setting. An urban environment with a functioning 3G network is going to present different challenges to a rural environment with no functioning cellular coverage, as people have pointed out. A well-funded urban/suburban system may already have data transport capabilities.

At it's simplest, most monitors can simply be plugged into a phone line and used as a fax. This could then be evaluated by a remote physician.

Collaborative patient registration, sure, the technology exists, who buys the toys?

If a system has purchased monitors that aren't telemetry / fax capable, then there's going to be a cost. I would guess that many systems have purchased this capability but aren't using it.

All these costs have to be viewed against what a PCI procedure costs, the cost of a unit dose of thrombolytics (which is likely going to be given in the hospital if it hasn't been given in the field, in the right population). The cost savings may be in ICU time, cardiac rehab, etc.

You do end up in a situation where you may be asking a municipal entity, or a private company to pay for equipment where the cost saving is going to be for the treating hospital. This is probably much simpler to organise in a public health care system.

You are going to screen every patient for a STEMI or even every at risk patient for a STEMI? You couldn't possibly limit it to classic textbook presentation.

I think it's negligent of any paramedic not to perform a 12-lead on anyone with syncope, chest pain, abd pain above the navel, unexplained upper back pain, weakness, syncope, presyncope, etc. We should be doing this already.

Given the relatively small number of things that we have good evidence for, spending a few minutes to 12-lead a high percentage of our patients seems like a worthwhile effort.

I think what you do have to do, to reduce costs, is to train the paramedics to read 12-lead properly, and accept that the physician is going to get some false notifications. You don't want to have the individual provider scared to fax / transmit an ECG, but you also don't need to see 300 left bundle branch blocks, or clear BER.

Resources, if you have every patient who thinks they might be having a stemi call 911, you will probably need a few more unitson the road.

I think you're going to increase scene times. For negative ECGs, this is going to be a minimal increase. But for positive ECGs, if you're giving thrombolytics you're going to want 3 or 4 providers on scene, with preferably at least 2 of them being paramedics. And the scene times may be a little longer here.

That being said, this is sort of time well-spent. If you pull a second ALS unit to thrombolyse a STEMI, what are the chances that that unit is going to really be more useful somewhere else? That rare time-sensitive ALS call could come in, but how many situations really benefit from early ALS? The STEMI is clearly one.

What is the plan for the patients where the EKG fails to pick up the pathology?

Repeat ECGs, standard therapy, ER transport. Possibly field evaluation for cardiac markers for NSTEMI. The scene delay is probably not important for most of these patients.

Istats are a great tool, but not really practical prehospital, daily controls, refrigerated cartriges, etc.

I agree, but there are other solutions available that are more paramedic-friendly, even if you may lose some sensitivity. We're now talking NSTEMI management anyway. As I'm sure you're aware, enzymes aren't required to decide what form of reperfusion therapy should be used in STEMI.

TpA from a protocol? I could think of a dozen ways that could go wrong.

I think this is why you need the physician oversight. While well-trained paramedics can probably recognise STEMI quite well, you can catch the occasional mistake. If you have a good set of inclusion criteria, you can defer a subset of high-risk patients for further inhospital evaluation.

We don't have to replicate the inhospital process, just produce a system that works prehospitally with a low error rate and a net benefit.

In particular, I think you need the physicians for the fibrinolysis versus PCI decision.

What happens when you have a 65 y/o male patient complaining of chest or abd pain, history of CAD, uncontrolled HTN, and no stemi detected?

Transport to the ER. No STEMI = no 'lytics, no cathlab.

Are you going to give him the TpA prior to determining if he has a ruptured aneurysm?

This gets to be more of a concern if the patient has a proximal dissections that causes coronary artery occlusion, and produces ECG changes suggestive of STEMI. Then, I think you have to hope you get lucky, and that the patient's history or presentation causes the paramedics and physician to withhold the tPA.

While it's insensitive, a decent protocol would consider bilateral blood pressures prior to lysis. I'm not sure that a CXR is going to be routinely done in the ER prior to tPA, and that risk of thrombolysing a TAA that's missed on CXR and doesn't get further evaluation remains there.

I accept that it's a real risk, and that having evaluation by a physician in an ER environment is going to mitigate that risk. But any risk to a rare subset of patients with TAA has to be balanced against benefit to a more common group of patients with acute STEMI presenting in an environment where timely reperfusion therapy can only be provided by paramedics.

How about a untreated or subclinical GI bleed?

Remains a risk in the ER. How long does stat bloodwork take to come back? How anemic can they be before the ER will decide to withhold tPA?

Granted, the options to treat this complication in an ambulance are extremely limited, and it would be better to avoid this in the first place --- something a physician examination is more likely to do. But it's the same risk / benefit. Is the additional risk of inadvertent tPA to a small group of patients with subclinical GI bleed and STEMI in the prehospital environment versus the ER outweighed by the benefit of early tPA?

Esophageal varicy?

Same problem, though, right? You would know better than me, but I can't think the the ER is going to routinely do contrast CT before giving 'lytics or punting to cathlab.

If the patient sits on an EMS stretcher, that unit is out of service. You once again need more units. At the very least more stretchers.

But at least the unit is out of service for a good reason. And I think it's a more reasonable use of healthcare resources to have a crew sitting with a stretcher outside the cathlab doing their best impression of critical care nursing, than having the delays associated with an ER admit, or trying to develop some sort of equivalent system in the cathlab.

As you point out earlier, there's definitely potential issues with who's going to pay here.

Who pays for the helo rides? how much?

I don't think the helo rides are a good idea, unless the patient is in cardiogenic shock, and even then, I'm not convinced.

Also, I don't think that this is that many patients. I think the number of patient presenting to most EMS systems with acute STEMI is tiny compared to the number presenting with major trauma, for example.

Why should a doc or hospital lose time or take an operating theatre (cath lab) out of service for it with associated cost?

They're getting the patient anyway. Or at least someone is. I would assume the goal here isn't to take large numbers of patients who would otherwise receive tPA and send them to PCI. All we're doing is getting them to the cathlab faster, and saving ER time / dollars.

The inconvenience for the cathlab is going to be in false-positive activations, which should be partially mitigated by physician oversight. Or in the patients who code after activation and don't make it to angio. Otherwise they were going to have to move around electives for a primary PCI anyway.

How much over triage/treatment is acceptable?

Depends, I think. This isn't a trivial system to organise. I mean, you have to have 24-hour physician availability for ECG analysis. So someone has to have the pager and a laptop, and be prepared to spend maybe 20 minutes talking with EMS, quickly interpreting ECGs, starting the wheels in motion for cathlab / lytics, and is going to be tied up in some way. The better you train your paramedics to actually read ECGs, the more likely you get sent fewer ECGs with a greater PPV. If they just send everything that the LP12 balks at, then the requirement for physician involvement is going to increase near-exponentially.

The physician is there to limit the amount of unnecessary cathlab activation, and to limit the administration of tPA in at-risk patients. I think this is a major expense. Would PCI use increase? Maybe, but I'd almost expect the opposite --- if we catch the patients earlier in the pathology, we'll get a higher proportion of people in the first couple of hours where the benefit from thrombolysis is much higher. So we may end up using a therapy that might not be desirable at a later timepoint, instead of angio.

Is there a cost to the EMS system? Absolutely, in terms of training, oversight, and potentially equipment. Not to mention that the cost of a unit dose of TNK might exceed a billable transport. Those issues have to be addressed. But it's not like the EMS system is running around making people sick. These patients were having MIs to start with, and someone was going to have to give the TNK or do PCI at some point anyway. If we increase survival, perhaps we have associated costs there, but this is probably a good thing. And may be balanced by decreased costs from reduced morbidity.











It all costs money.[/QUOTE]

 

[truetiger]

I agree with Wolfman on this one, how does getting the 12 lead in 5 mins vs 8 mins speed anything up? My MO is to go in and get the patient into the back of my rig ASAP if they want transported. Say I bring in my monitor and do a 12 lead in the house, how will that speed anything up? I'll know 3 mins earlier they are having a STEMI, but I'll still have to get the patient to the rig. By the 8 min mark either way I'll be in the rig with my STEMI patient.

 

[Outbac1]

First, an interesting thread. We here in NS basically do what Craig has suggested.

First some background.
NS operates under what some see as the great evil, "Socialized Medicine". We have a land area about the size of West Virginia and a population of about 950,000. Our Dept. of Health spends about $100,000,000 /yr on Emergency Health Services. This is about $100.00 per person per year in taxes. Under that comes our Dispatch center, Helicopter program, and ground ambulance system. The ambulance system operates about 100 -120 ambulances per day. We have about 800 full time medics. Approx 400 PCP, 90 ICP and 300 ACP. We have one hospital that has cardiac surgery facilities. That is in Halifax with a pop of about 300,000. This leaves a large area and pop without under 30 min PCI availability.

All our medics have the ability to do and transmit 12 leads. This is, for us, a basic skill. Calls of a cardiac nature are expected to have a 12 lead done with the first set of vitals in the first 10 min of the call. All suspected STEMIs are to be transmitted to the nearest regional hosp for the ER DR to confirm. Our PCPs do this and transport to the nearest hosp. They request an ACP intercept. This at least allows the ER Dr to know what is about to come through their door and be ready for it. If an ACP is on the call we have a strict protocol to follow and treat with TNK on scene.
If the pt is within 30 min of the PCI lab the 12 lead is transmitted and if confirmed the pt goes straight to the lab regardless of which medic is attending.
None of this superceeds standard tx, which includes ASA, Nitro, Morphine and transport to hosp.
As to the actual cost of implementing our STEMI protocol I don't know. Undoubtedly many thousands of dollars. The cost of socialized medicine is enormous and not without it's problems. It does bring benifits to the people. Everyone gets the same care. Yes there are abuses, but for the majority of people it is a benifit. I can't imagine what my heart valve transplant and 21 days in hospital would have cost me if I was in the US. I certainly couldn't have paid for it.
We have a higher standard of education and training for all our medics. Gone are the days of a first aid card and drivers license to work on an ambulance. No "On Call", no one takes a rig home, about a one minute response time, GPS mapping, ePCR, universal fleet and equipment stocking. Overall not bad for a little place. A $100.00 per year, sounds cheap to me.

 

[Veneficus]

I just re-read this, and realised that I come across a little strongly in places. Please don't interpret this as disrespect, as I value your opinion highly, and recognise that you have much greater training and education in this area than I do. However, I'm quite passionate about this area, so please forgive me where my passion comes across too strongly -- I don't mean to cause offence.

Passion I can live with.

Being called a menace to patients not so much...

I think it is not clear what I am trying to say. So rather than reply line by line, let me try to be more clear.

I do not disagree with the op and I also agree with a majority if not all of your points.

The idea is not the issue. The implementation is.

I summed it up with cost, but let's consider some details.

A hospital has multiple departments, so it can shunt money from a profitable service to a nonprofitable one in the interest of the community.

An EMS agency cannot redirect money paid to a hospital for service unless that EMS agency is part of the hospital. (a good idea I might add)

Which means while money is being saved, it is not having a trickle down effect on EMS. Which means they are absorbing a large percentage of cost, but not seeing any benefit from it.

Saving medicare a few hundred million a year is rather benevolent when you are spending your local money to do it.

At the very least you would need to have EMS reimbursement changed for this to work. Either that or convince your local tax payer that hiking up some taxes for it is a good idea or have your local hospital absorb EMS.

Technology is a fine tool. But professional technology is its own monster.

You can't just transmit health or commercial related material over the general cell phone service.

Even if you have no PHI transmitted, somebody is going to get the bright idea to start selling the information that certain areas are constantly transmitting EKGs. As soon as a billboard goes up across the street adverting medical equipment or healthcare from somebody transported for a STEMI, that person is going to get pissed, and accuse the agency of improperly disseminating that info.

On a more sinister example (I am not a good conspiracy theorist) but what if somebody feels the need or benefit of actually trying to figure out exactly who that info comes from?

You will hear no argument from me that I would rather see an ambulance tied up with a sick patient vs a nonacute one.

But, you don't have to convince me. For more than 40 years the public has been told by whoever provides EMS in an area that response times matter. They believe it in their hearts. So they are not going to accept when they call 911 somebody else was more in need and they had to wait. (especially if their need ends up being greater)

I certainly think that paramedics are capable of being taught when and when not to administer TPA. But regardless of what I think, I want to see the details on how adverse complications are going to be mitigated.

I even agree that many more stemi patients would probably benefit from airmed than trauma patients. But now you are talking about more flights, more danger, more providers, and more aircraft.

In the event you start flying more stemi patients, at airmed prices, cost savings could quickly dry up. Especially when it was not needed. Look how often that is done for trauma.

When it comes to unneeded cath lab activation, yea that costs a few bucks, but I am talking about taking one out of service for a drill or practice. Then add the cost of the doctor or staff to that. (especially lost revenue if you stop a patient from using it for this practice)

You want EMS to put people in hospital gowns? Sure, why not. But you need to realize that if you go cutting peoples cloths to shreds they are going to want compensated. When they don't get it, there is going to be a lot of bad blood and bad PR.

You especially don't want to be chopping off the cloths of fixed income elderly patients, because if they survive you might be putting some economic hurt on them.

I know the "well at least they are live" argument. It wins no points with me. How lucky are you when you have to skip buying your prescription meds, go without food, or miss a mortgage payment, to replace your cloths?

Finally, on the registration side. Many medical device manufacturers actually develop information sharing software. They charge outrageous amounts for it.

The IT people who write healthcare software actually make such intergration an add on to thier basic product. Which means you have to pay 2 people to make this work and both of them border on extortionists.

What we should be doing is easy to agree upon.

It is "how" where the real discussion comes.

 

[WolfmanHarris]

I agree with Wolfman on this one, how does getting the 12 lead in 5 mins vs 8 mins speed anything up? My MO is to go in and get the patient into the back of my rig ASAP if they want transported. Say I bring in my monitor and do a 12 lead in the house, how will that speed anything up? I'll know 3 mins earlier they are having a STEMI, but I'll still have to get the patient to the rig. By the 8 min mark either way I'll be in the rig with my STEMI patient.

I wasn't referring to treating in the vehicle versus in the home though. I'm actually far more a proponent of doing my assessments and treatments before transport. Stair chair, stretcher, packaging, all take time where care is not being provided effectively, especially on an ACS pt. Let's build a working diagnosis, start treatment to relive symptoms, get appropriate resources ready for them and then transport. I'm sure you can argue it either way, but I just needed to be clear that I was not advocating for moving everyone to the truck and working in there.

 

[systemet]

Passion I can live with.

Being called a menace to patients not so much...

I certainly didn't mean to suggest that. My apologies if anything I said could be takken that way.

Saving medicare a few hundred million a year is rather benevolent when you are spending your local money to do it.

I get what you're saying here, and can only imagine that it would be very hard in a US environment. If you're dealing with EMS, even as a private or third service or FD entity, but you have a public health care system, it's a little easier to redirect the dollars.

You can't just transmit health or commercial related material over the general cell phone service.

This was done for some time in many regions, and I believe it's still being done in many. But I guess this is region-specific and depends on local privacy legislation.

I certainly think that paramedics are capable of being taught when and when not to administer TPA. But regardless of what I think, I want to see the details on how adverse complications are going to be mitigated.

I think this is difficult. You can teach EMS not to start throwing around drugs and cardioverting at the first sight of every reperfusion arrhythmia. You can try and encourage due diligence in assessing for acute papillary muscle rupture with cardiac auscultation, or giving consideration to the possibility of aortic dissection. I think as a system develops experience, these issues become better addressed.

Unfortunately, I think you have to rely on medical consult, the professionalism of the paramedics, and a good set of inclusion criteria.

Once serious hemorrhage has occurred in the ambulance, there really aren't good options for treatment.

You want EMS to put people in hospital gowns? Sure, why not. But you need to realize that if you go cutting peoples cloths to shreds they are going to want compensated. When they don't get it, there is going to be a lot of bad blood and bad PR.

I think this can be done while obtaining the initial 12-lead in most situations without cutting clothing.

What we should be doing is easy to agree upon.

It is "how" where the real discussion comes.

Agreed, see pm.

 

[Flyhi]

What a nice place to be in : )

Hi All,

Loved this discussion. I have been reading the points & couter points whilst sitting here in Ireland thinking "Wow ..... what a nice place to be in"

No I don't mean Ireland I mean a EMS system that has all levels of EMS pro's trying to make their system even better. I trained in the US and I am NREMT P qualified. I returned home in Aug 2011 and currently work as a medic in one of the busiest stations in the country. Since coming home I have struggled with the EMS system here. Not the daily how to treat a Pt issues but more the why don't we treat them like we did in the States?

My answer is because there is a main difference between The US system being based on a Private EMS system compared to Irelands social EMS system. Let me give you an example of how this ties in with this thread.

If I go out tomorrow night and get to a cest pain Pt. I will do my 12 lead in the house or in my bus if it was a public location. My problem here is not the fact that I can get a 12 lead and STEMI confirmation with in 5 or even 10 mins. It.s no different if I get it in the Bus or the Pt house. Here we have only 4 PCI centres in the entire country. So we confirm the STEMI and get on the road. Usually to the nearest major trauma centre as every other hospital shuts its A&E services after 19.00hrs in the evenings and are no go areas during the weekends. Now we can have anything from a ten min to 1.5hrs travel time to this main hospital whilst this Pt is in mid STEMI. If they fit the thromus protocol the we can at least do a little more that just drive fast and pray they dont code out on us. However for those over 75 and under 90 min travel time we can not TNK. MONA is the most advanced thing we could do if its not going to effect the pre load.

To make it worse on occasions where the Cath Labs in one of the 4 points in Ireland actually do accept the PT we now have situations where we get them to the first point of care, they really do very little else apart from monitor and get the Pt on the list for the PCI.

It a regular occurance to drop a STEMI into the ED only to be called back an hour later for an URGENT transfer from this hospital to the PCI which is a minimum of 1.5hrs on lights all the way. Once we get there the Pt is now in a line of Pt's who had been accepted and has to wait until their turn in the cath lab comes around. That could be 5 + hours later from the first EMS confirmation of the Pt STEMI.



Privately we coud have PCI in every hospital and this would be best for the Pt. However as we are a social system its money and consultants that decide where these PCI centres are located and how many cath labs are kept open 24/7.

Time is muscle for the Pt...... but Money is king for the system and Consultants are like Gods. End result is that the Pt is lucky if they live near one of the 4 PCI centres. If not they are stuck in a system where they as an individual come lower on the ladder of priorties than the Time is muscle fact.

So you can see why I am here reading about some great guys bashing the topic around so it can be improved. Hats off to you guys. I respect everyone of you who either makes the point or counters it. End result is that discussion and debate can sometimes make the wheels of change move. However in Ireland and to some extent over there these wheels will only move to the point where they hit the Money pitfall. Then it either stops, slows or very rarely the money actually speeds it along.

End result is that its great to be in a system that actually discusses weather we can streamline STEMI identification to 5 mins on scene or even if the added training will ever make the difference.



Cheers

 

[Craig Alan Evans]

I agree with Wolfman on this one, how does getting the 12 lead in 5 mins vs 8 mins speed anything up? My MO is to go in and get the patient into the back of my rig ASAP if they want transported. Say I bring in my monitor and do a 12 lead in the house, how will that speed anything up? I'll know 3 mins earlier they are having a STEMI, but I'll still have to get the patient to the rig. By the 8 min mark either way I'll be in the rig with my STEMI patient.

I'm not a proponent of that style of EMS. How do you know if the patient needs immediate interventions or not? You must do some type of assessment prior to moving them. Here, we go in and perform a thorough assessment in about 5-8 minutes which includes a 12 lead. If the patient needs immediate interventions we perform them on scene. If the patient is stable emough to be moved we then transfer them to the unit. We are splitting hairs with 5 or 8 min EKGs, but a question to ask yourself is what benefit do you gain by waiting?

 

[Craig Alan Evans]

First, an interesting thread. We here in NS basically do what Craig has suggested.

First some background.
NS operates under what some see as the great evil, "Socialized Medicine". We have a land area about the size of West Virginia and a population of about 950,000. Our Dept. of Health spends about $100,000,000 /yr on Emergency Health Services. This is about $100.00 per person per year in taxes. Under that comes our Dispatch center, Helicopter program, and ground ambulance system. The ambulance system operates about 100 -120 ambulances per day. We have about 800 full time medics. Approx 400 PCP, 90 ICP and 300 ACP. We have one hospital that has cardiac surgery facilities. That is in Halifax with a pop of about 300,000. This leaves a large area and pop without under 30 min PCI availability.

All our medics have the ability to do and transmit 12 leads. This is, for us, a basic skill. Calls of a cardiac nature are expected to have a 12 lead done with the first set of vitals in the first 10 min of the call. All suspected STEMIs are to be transmitted to the nearest regional hosp for the ER DR to confirm. Our PCPs do this and transport to the nearest hosp. They request an ACP intercept. This at least allows the ER Dr to know what is about to come through their door and be ready for it. If an ACP is on the call we have a strict protocol to follow and treat with TNK on scene.
If the pt is within 30 min of the PCI lab the 12 lead is transmitted and if confirmed the pt goes straight to the lab regardless of which medic is attending.
None of this superceeds standard tx, which includes ASA, Nitro, Morphine and transport to hosp.
As to the actual cost of implementing our STEMI protocol I don't know. Undoubtedly many thousands of dollars. The cost of socialized medicine is enormous and not without it's problems. It does bring benifits to the people. Everyone gets the same care. Yes there are abuses, but for the majority of people it is a benifit. I can't imagine what my heart valve transplant and 21 days in hospital would have cost me if I was in the US. I certainly couldn't have paid for it.
We have a higher standard of education and training for all our medics. Gone are the days of a first aid card and drivers license to work on an ambulance. No "On Call", no one takes a rig home, about a one minute response time, GPS mapping, ePCR, universal fleet and equipment stocking. Overall not bad for a little place. A $100.00 per year, sounds cheap to me.

Sounds like Nirvana to me...Are you hiring? Sounds like where I need to be living when I retire. :beerchug:

 

[truetiger]

No one's saying an assessment is not done. I have a first in bag with me if any immediate interventions need to be performed. I'd much rather get the patient to my rig to do the rest of my assessment in a controlled environment with ample lighting.

 

[18G]

A 12-lead needs to be performed as one of the initial interventions on an ACS call. This means as long as the ABC's are good, the 12-lead needs performed within two mins inside the home, business, or wherever. The 12-lead sets the stage on how the patient will end up and can save time that matters. During an MI time matters a lot. A 12-lead acquisition is not a secondary modality.

I disagree with waiting to move to the ambulance to do a 12-lead. Your interventions kinda hang on what that 12-lead shows and is information you want pretty quick to triage you patient to a facility that has what the pt. needs which is PCI. There is no such thing as "stabilize" at a local hospital first. What exactly does "stabilize" a STEMI even mean????

I won't even get into an IFT call I did where I walked in and was getting report from the nurse and causally glanced at the 12-lead and noted a STEMI - inferior wall MI and was brushed off. And not to mention the guy came in with 3rd degree block, bradycardia in the 30s, severe nausea and vomiting and hypotension in the 50's and no one acknowledged the STEMI.

Hospital providers (yes, RNs and Physicians) need more education on STEMI.

 

[Veneficus]

A. There is no such thing as "stabilize" at a local hospital first. What exactly does "stabilize" a STEMI even mean????.

Well said.

This is the same line of BS I hear about in trauma all the time.

Unless there is an airway issue, all it does is waste it.