# STEMI transfers



## cruiseforever (Feb 18, 2015)

When we started to do STEMI transfers many years ago.  It was normal practice to hang a Nitro drip, Heparin drip.  Over the last few months they have disappeared on most of our transfers.  Now the ER gives a bolus of Heparin and have us give Nitro as needed.  Their goal is to have the pt. on the road in less than 30 minutes.  The last one I did, a pt. walked into the ER..  20 minutes later was on the road.

It sure makes the transfer to stretcher and then back to cath. lab table easier.  Our transport time is approx. 30 minutes by ground.  Wondering what is happening in your area.


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## DesertMedic66 (Feb 18, 2015)

All 3 of our hospitals are STEMI centers so we don't do transports. If for some reason they needed to transport a patient on nitro or heparin drip it would be a CCT or air ambulance call or the patient would have to be DCed from those for an ALS transport.


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## Tigger (Feb 18, 2015)

Your ALS cannot take those drips? I guess I often forget how much CCT differs in California with having RNs on board and whatnot. 

Most of our STEMIs still go down on heparin and a fair few have nitro running as well. Our hospital could be quicker, but I don't think it's the drips that are slowing them down, I think they're just useless. We usually take their pump to speed things up though our ambulances all have their own MiniMed pumps on them as we initiate our own nitro drips in the field for STEMIs.


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## DesertMedic66 (Feb 18, 2015)

Tigger said:


> Your ALS cannot take those drips? I guess I often forget how much CCT differs in California with having RNs on board and whatnot.
> 
> Most of our STEMIs still go down on heparin and a fair few have nitro running as well. Our hospital could be quicker, but I don't think it's the drips that are slowing them down, I think they're just useless. We usually take their pump to speed things up though our ambulances all have their own MiniMed pumps on them as we initiate our own nitro drips in the field for STEMIs.


These are the only medications that ALS can monitor during transport:
i. Intropin (Dopamine)
ii. Isoproterenol (Isuprel)
iii. KCl of < 40mEq/1000cc
iv. Morphine Sulfate
v. Xylocaine HCL (Lidocaine)


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## TRSpeed (Feb 18, 2015)

It's county specific because where I work in CA we can Transport Heparin or Nitro drips.


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## DesertMedic66 (Feb 18, 2015)

TRSpeed said:


> It's county specific because where I work in CA we can Transport Heparin or Nitro drips.


For CA those medications are listed under CCP medications however your LEMSA is able to put in a request to allow normal medics to give those meds.


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## Angel (Feb 19, 2015)

we have to be cct trained to take those drips. and since there arent any classes....


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## Handsome Robb (Feb 19, 2015)

The only time we do STEMI transfers are from our LII satellite center to their main hospital, from the VA or one other small hospital in the area if it's something more complex than a simple single stent placement. We can take NTG and heparin infusions on standing orders though. Any ground medic here can take SCT transfers. We can take amiodarone, dope, epi, heparin, hydroxocolbalamin, ABx, lidocaine, NTG, KCl, TPN and versed. 

The scary ones are the ones from the small, non satellite hospital where you get a RN a IABP and an RN plus a slap on the *** and "drive like the wind, champ. The only one I've had was a patient who ended up with a spiraled LAD at the small hospital and they arrested during transport. I had to prompt the RN to change the IABP to a pressure trigger rather than the ECG trigger.


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## Sunburn (Feb 19, 2015)

We don't have heparin for prehospital care in the whole country. When I get a call for STEMI all I can do is basic MONA (morphine, oxygen, nitro and ASA) therapy and hightail it to the hospital. Which is a tad more than 2 hrs away.


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## Carlos Danger (Feb 19, 2015)

DesertEMT66 said:


> These are the only medications that ALS can monitor during transport:
> i. Intropin (Dopamine)
> ii. Isoproterenol (Isuprel)
> iii. KCl of < 40mEq/1000cc
> ...



That seems like an odd list?


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## CANMAN (Feb 19, 2015)

Cath labs could care less about if the Heparin and Integrilin get transferred/are running upon arrival to the cath lab. Most times they are D/C'ed and tossed in the trash prior to patient even being draped. 

Our goal bedside times for STEMI flights is 10minutes or less bedside time. Aircraft stays running we go inside to get patient. One provider gets paperwork signatures and quick report, second provider packages patient, places them on monitor, and obtained brief HPI from patient. Heparin and Integrilin will get pulled and we will take with and restart in the aircraft if we have time. Tridil we will transfer at bedside. All our referral hospitals normally have the paperwork together when they call and I would stay we meet our goal time 90% of the time. 

If we do a STEMI scene flight, local provider's transmit the 12 lead, and we will go straight to the lab from the field.


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## DesertMedic66 (Feb 19, 2015)

Remi said:


> That seems like an odd list?


Well I am in SoCal...

Those medications are in addition to the normal NS, D10, etc


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## Carlos Danger (Feb 19, 2015)

DesertEMT66 said:


> Well I am in SoCal..



Oh I understand.

But whoever is writing those regs....why would they allow dopamine but not norepi or dobutamine? Potassium but not magnesium? Morphine but not fentanyl? Lidocaine but not amiodarone? I wonder what their rationale is.

Are they actually using Isuprel out there?


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## Carlos Danger (Feb 19, 2015)

double post


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## CANMAN (Feb 19, 2015)

Remi said:


> Oh I understand.
> 
> But whoever is writing those regs....why would they allow dopamine but not norepi or dobutamine? Potassium but not magnesium? Morphine but not fentanyl? Lidocaine but not amiodarone? I wonder what their rationale is.
> 
> Are they actually using Isuprel out there?



Agree 110% Maryland is the same way man for single medic ground provider's. Makes no sense.


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## DesertMedic66 (Feb 19, 2015)

Remi said:


> Oh I understand.
> 
> But whoever is writing those regs....why would they allow dopamine but not norepi or dobutamine? Potassium but not magnesium? Morphine but not fentanyl? Lidocaine but not amiodarone? I wonder what their rationale is.
> 
> Are they actually using Isuprel out there?


Honestly can't answer that. I'm in a very isolated part of the county. The only drips I have ever seen medics with out here are your normal NS (which BLS can do in out area). It makes no sense at all


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## Smash (Feb 19, 2015)

Sunburn said:


> We don't have heparin for prehospital care in the whole country. When I get a call for STEMI all I can do is basic MONA (morphine, oxygen, nitro and ASA) therapy and hightail it to the hospital. Which is a tad more than 2 hrs away.


 Why are you not thrombolysing with that sort of prehospital time?


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## Tigger (Feb 20, 2015)

How many here are able to transport thrombolytic agents? It is our hope to begin doing so in the next year though we generally only have a 40 minutes transport time from community hospital to cath lab.


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## Smash (Feb 20, 2015)

Tigger said:


> How many here are able to transport thrombolytic agents? It is our hope to begin doing so in the next year though we generally only have a 40 minutes transport time from community hospital to cath lab.


We thrombolyse in rural areas.  Metro areas generally have plenty of access to PCI in short timeframes.


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## drl (Feb 20, 2015)

In my IFT service, we do STEMI transfers fairly often, and they're almost always CCT with heparin running, and often nitro as well.


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## Sunburn (Feb 20, 2015)

Smash said:


> Why are you not thrombolysing with that sort of prehospital time?



It's very different between US and Cro. None of us have thrombolysing agents in our vehicle, since EU guidelines prefer PCI anyway. Our goal in pre-hospital is to save border areas of AMI heart by using nitro and morphine and prevent thrombus from growing by using ASA as anti-platelet therapy.
Trust me, there's a huge difference in our and your funding since we are government owned public service.


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## Burritomedic1127 (Feb 20, 2015)

Here in Mass, we can transport 3 infusions running at once. Anything over 3 turns the call into a CCT, but if the crew/company is comfortable its fair game to leave it ALS


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## systemet (Feb 21, 2015)

In my area we're able to transport any IV medication that we're comfortable with.  We carry TNK on all the ALS trucks, and use it fairly often, as we have limited PCI resources. We also have IV nitro, and access to Plavix, Brilinta and Enoxaparin. Generally we take the hospital's pumps if they're running multiple infusions.

One of our limitations is that not all of our trucks are ventilator-equipped or have the ability to monitor arterial lines. So we sometimes have to call for additional resources in those situations.


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## Vegeta182 (Feb 21, 2015)

I work in a very rural area with the closest cardiac cath lab 2 and a half hours away. So you can say I have a lot of time in the back with STEMI transfers. Mostly here they are on heparin drip with nitropaste very rarely will I have a nitro drip.


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## TheLocalMedic (Feb 25, 2015)

We have a hospital here that cannot do interventional caths so we get called from time to time to take STEMI patients to one of the other hospitals.  We treat it like a scene call... come in code 3, tell them they better have paperwork ready in one minute and then swoop them up and out the door we go.  They usually have enough time to slap some nitro paste on, give them some heparin and lovenox and aspirin by the time we roll out, but we try to keep our time in the ED to 5 minutes or less.  They know the drill now, so it's a pretty streamlined process.  We had several this last year that had times of less than 30 minutes from first EKG to being on the cath lab table across town.


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## ERDoc (Feb 25, 2015)

STEMIs that come in by EMS don't even come off the EMS stretcher at the rural hospitals where I am.  They get a PO dose of Brillinta, a heparin bolus and SL nitro prn while waiting for a call back from the cardiologist.  This keeps our door to door time usually under 20 minutes.  The EMS crews in this area can transport all sorts of drips but the cardiologists don't want to waste time setting up the drips since what they need is a cath lab.


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## Ewok Jerky (Feb 25, 2015)

ERDoc said:


> STEMIs that come in by EMS don't even come off the EMS stretcher at the rural hospitals where I am.  They get a PO dose of Brillinta, a heparin bolus and SL nitro prn while waiting for a call back from the cardiologist.  This keeps our door to door time usually under 20 minutes.  The EMS crews in this area can transport all sorts of drips but the cardiologists don't want to waste time setting up the drips since what they need is a cath lab.


Why not just bypass the local hospital and transport directly to a STEM receiving center?


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## ERDoc (Feb 25, 2015)

I ask the same thing every day.


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## Ewok Jerky (Feb 25, 2015)

ERDoc said:


> I ask the same thing every day.


Do medics have the authority to bypass with a suspected STEMI ?


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## ERDoc (Feb 26, 2015)

Apparently not.  Our cath lab is about 30-45 minutes away with L&S.


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## RocketMedic (Feb 26, 2015)

My current employer has pumps and we can take literally whatever's running on them if we need to, to include blood and thrombolytics. However, we are about an hour from metropolitan Houston and generally fly our CVA and STEMI patients due to the lack of a local cath lab.

My recent employer used a CCT truck for STEMI transfers whenever possible. When not available, we could either call our Texas medical control via on-duty supervisor and get permission to transport (slow) or DC and sprint (fast). Guess which one happened more?


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## RocketMedic (Feb 26, 2015)

One of the dumbest system designs I ever worked in required us to bring STEMI patients to our base hospital regardless of whether or not they were closer to the Las Cruces cath lab cluster due to an interpretation of EMTALA and "we can start thrombolytics". T or C to LC is about 50 minutes, but add in glacier-slow transfer paperwork and we're at 2 hours minimum...


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## medicaltransient (Feb 26, 2015)

Anyone ever transported a STEMI from a non-PCI hospital past one or more PCI hospital to a PCI hospital that is contracted or affiliated with the original hospital? Is that legal? I have done it.


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## Carlos Danger (Feb 26, 2015)

medicaltransient said:


> Anyone ever transported a STEMI from a non-PCI hospital past one or more PCI hospital to a PCI hospital that is contracted or affiliated with the original hospital? Is that legal? I have done it.



Done it many times.


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## Tigger (Feb 26, 2015)

medicaltransient said:


> Anyone ever transported a STEMI from a non-PCI hospital past one or more PCI hospital to a PCI hospital that is contracted or affiliated with the original hospital? Is that legal? I have done it.


What law would a physician ordered transfer violate?


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## cruiseforever (Feb 26, 2015)

medicaltransient said:


> Anyone ever transported a STEMI from a non-PCI hospital past one or more PCI hospital to a PCI hospital that is contracted or affiliated with the original hospital? Is that legal? I have done it.




Almost every transfer.


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## medicdan (Feb 26, 2015)

medicaltransient said:


> Anyone ever transported a STEMI from a non-PCI hospital past one or more PCI hospital to a PCI hospital that is contracted or affiliated with the original hospital? Is that legal? I have done it.


Unfortunately I have as well. My region's understanding is that if the patient becomes unstable (or less stable at any time), we can divert to the "closest appropriate" facility. Of course, OLMC should be involved, if at all possible... 

As hospital consortia grow, and EMRs grow more fragmented, sometimes this makes sense, for continuity of care... sometimes.


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## Brandon O (Feb 26, 2015)

Tigger said:


> What law would a physician ordered transfer violate?



Well, EMTALA, potentially.


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## DieselBolus (Feb 26, 2015)

Brandon O said:


> Well, EMTALA, potentially.



Have you personally encountered a transfer in which a patient hasn't been stabilized within the sending facility's capability and gets sent out for insurance repatriation? 

It's something we all hypothesize happens, but I've never experienced it.


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## Brandon O (Feb 26, 2015)

It's more of a regulatory thing than the classic dumping situation. Things get tricky when you're not transferring appropriately and needfully. Don't know how this sort of thing would apply, but it's quite possible bypassing a legitimate destination would be considered a violation. [not a lawyer]


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## DieselBolus (Feb 26, 2015)

AFAIK, medics are not regulated by EMTALA. If a medic were to be conscientious enough to transport a patient with an HMO to an in-network facility, thus foregoing an unnecessary IFT transfer down the road, and such decision didn't adversely affect the patient, I can't see why there would be any ramifications.


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## jrm818 (Feb 26, 2015)

Brandon O said:


> It's more of a regulatory thing than the classic dumping situation. Things get tricky when you're not transferring appropriately and needfully. Don't know how this sort of thing would apply, but it's quite possible bypassing a legitimate destination would be considered a violation. [not a lawyer]


 
I've always wondered about this, especially now that I'm in a state where this sort of "keep them in the system" bypassing actually occurs.  I was suprised the first time I saw it.  It seems  scuzzy to me. 

I have done this once, sort-of.  We bypassed several hospitals with a transfer form rural ED to urban VA hospital, lights and sirens (I know, I know) with a patient with deteriorating respiratory function....just to remain in the VA system.  I wasn't comfortable with that either.

For what it's worth, CMS says this: "Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized emergency medical conditions that require specialized services should not routinely be made over great distances, bypassing closer hospitals with the needed capability and capacity." https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf


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## Brandon O (Feb 26, 2015)

DieselBolus said:


> AFAIK, medics are not regulated by EMTALA. If a medic were to be conscientious enough to transport a patient with an HMO to an in-network facility, thus foregoing an unnecessary IFT transfer down the road, and such decision didn't adversely affect the patient, I can't see why there would be any ramifications.



Certainly not, but that would be quite different. Anyway, transfers are the sending physician's responsibility, they'd be the one on the hook here.



jrm818 said:


> For what it's worth, CMS says this: "Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized emergency medical conditions that require specialized services should not routinely be made over great distances, bypassing closer hospitals with the needed capability and capacity." https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf



Yeah. Like many things, for me this'll fall into the "don't know if it's okay, hope I don't have to find out" category. For others, well... just remember that you can always file a complaint if necessary for your patients. Probably anonymously.


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## DieselBolus (Feb 26, 2015)

jrm818 said:


> I've always wondered about this, especially now that I'm in a state where this sort of "keep them in the system" bypassing actually occurs.  I was suprised the first time I saw it.  It seems  scuzzy to me.
> 
> I have done this once, sort-of.  We bypassed several hospitals with a transfer form rural ED to urban VA hospital, lights and sirens (I know, I know) with a patient with deteriorating respiratory function....just to remain in the VA system.  I wasn't comfortable with that either.
> 
> For what it's worth, CMS says this: "Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized emergency medical conditions that require specialized services should not routinely be made over great distances, bypassing closer hospitals with the needed capability and capacity." https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf



Thanks for the link JRM.

And thanks for the input, Brandon.

For some reason, I love this kind of stuff.


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## Brandon O (Feb 26, 2015)

Future lawyer! Unclean!


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## Ewok Jerky (Feb 26, 2015)

jrm818 said:


> I have done this once, sort-of.  We bypassed several hospitals with a transfer form rural ED to urban VA hospital, lights and sirens (I know, I know) with a patient with deteriorating respiratory function....just to remain in the VA system.  I wasn't comfortable with that either.
> 
> For what it's worth, CMS says this: "Hospitals that request transfers must recognize that the appropriate transfer of individuals with unstabilized emergency medical conditions that require specialized services should not routinely be made over great distances, bypassing closer hospitals with the needed capability and capacity." https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf


It comes down to your comfort level continuing transport with the sending orders you've received and what you can do with online med control. If your patient is dump and OMC isn't helping, diverting to closest facility might be in the patients best interest and any repurcussions on you should be limited if there are "issues" with the transfer. Likely the patient would end up getting 're-stabalized and transferred a few hours later.


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