# Survey Uncovers Deficiencies in Heart Attack Care



## VentMedic (Feb 17, 2009)

http://www.emsresponder.com/article/article.jsp?id=8989&siteSection=1
*Survey Uncovers Deficiencies in Heart Attack Care *
*American Heart Association's Mission: Lifeline initiative to use survey data*



> DALLAS, Feb. 16 -- Preliminary results of one of the nation's largest national surveys of Emergency Medical Services (EMS) systems indicate the need for improvements in the way heart attack, specifically ST-elevation myocardial infarction (STEMI), is managed.


 


> The most significant findings:
> 
> -- *Only half of EMS systems have 12-lead electrocardiograms (ECGs), used** to detect STEMI, on 75 percent or more of their vehicles.*
> -- Of EMS systems with 12-lead ECGs:
> ...


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## marineman (Feb 18, 2009)

Interesting read. It never specifically mentions in the article but is it safe to assume that they only included ALS services in this study or did they include BLS services to sway their numbers to help make a case for more money? Of the biggest issues mentioned the one that I would like to see change locally is that we have no way of transmitting an ECG to the hospital. We can interpret them and sometimes the docs will activate the cath lab based on our interpretation alone but it's not a standing order or anything. I understand that no matter how good you are at reading ECG's often the way to determine defects is by comparing and looking for changes in multiple ECGs, this is why I want to be able to transmit. 

Any monkey with an hour of training can pick up the textbook case of ST elevation in 2 contiguous leads and activate the lab but it's the subtle changes that keep cardiologists in business.


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## Airwaygoddess (Feb 18, 2009)

What I find frustrating is how the area were I and many others want to see more progressive care given for MI's >>> STEMI Protocols   Makes me crazy is our medical director......... :glare:  ** I hate politics...........


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## downunderwunda (Feb 19, 2009)

Treating suspectedMyocardial Ischaemia/Infarction is easy. 

Firstly lets look at some facts.


ASA is proven to assist those with this ailment
Nitro - spray or sublingual tablet is proven to reduce preload & afterload.
These patients need High Flow Oxygen

With this in mind, does it really matter, unless you ar going to thrombolyse the patient what the rhythm is?

Get on scene, suspect the problem in your mind, administer the drugs - yes i know i neglected morphine - & get the hell to hospital. 

It aint rocket science. Lets not make it harder than it really is.


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## firecoins (Feb 19, 2009)

downunderwunda said:


> Treating suspectedMyocardial Ischaemia/Infarction is easy.
> 
> Firstly lets look at some facts.
> 
> ...



Transporting a patient to a hospital with a cath lab can be lifesaving. I realize not everyone has the option but my system does.  Its better than transporting to the closest facility and having them call for a stat IFT to a hospital with a cath lab. Time is a factor.


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## Ridryder911 (Feb 19, 2009)

downunderwunda said:


> Treating suspectedMyocardial Ischaemia/Infarction is easy.
> 
> Firstly lets look at some facts.
> 
> ...



I would attempt to discuss or debate this; only if you truly understood cardiology. 

R/r 911


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## reaper (Feb 19, 2009)

downunderwunda said:


> Treating suspectedMyocardial Ischaemia/Infarction is easy.
> 
> Firstly lets look at some facts.
> 
> ...



I had some hope?


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## medic417 (Feb 19, 2009)

downunderwunda said:


> Treating suspectedMyocardial Ischaemia/Infarction is easy.
> 
> Firstly lets look at some facts.
> 
> ...



If you know how to read and interpet an EKG properly there is much more.  If that is the only thing allowed in your service you need to really push for it to advance.  And please tell me "get the hell to hospital" is not meant to mean administer a "diesel bolus".  EMS needs to grow to actually performing medicine not being a horizontal taxi.


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## downunderwunda (Feb 19, 2009)

> Transporting a patient to a hospital with a cath lab can be lifesaving. I realize not everyone has the option but my system does. Its better than transporting to the closest facility and having them call for a stat IFT to a hospital with a cath lab. Time is a factor.



firecoins, does this mean you agree with me? 



> I would attempt to discuss or debate this; only if you truly understood cardiology.
> 
> R/r 911



I do understand cardiology. I also know the limitations of EMS. Rid, regardless of what we think, if we do not do a 12 lead in the fied, it can be done at hospital. End of story.



> If you know how to read and interpet an EKG properly there is much more. If that is the only thing allowed in your service you need to really push for it to advance. And please tell me "get the hell to hospital" is not meant to mean administer a "diesel bolus". EMS needs to grow to actually performing medicine not being a horizontal taxi.



Yes, I agree, but, what can you do, in the field, regardless of what you know, other than ASA, Nitro, Oxygen & morphine? Unless of course you are fortunate unough to thrombolyse, but i did say that in my original post.

medic417, read ALL of my posts, you will see I am an advocate for EMS moving forward & in particular challenging doing what was always done as being right in favour of evidence based practice. 

Patients with STEMI need a cath lab. If that is not an immediate option, they need thrombolyasis. This is *proven* to reduce the amount of damage to the myocardium (but I dont know cardiology according to rid!). This is, in many ways time critical. So, now you also want to fiddle fart on scene, wasting more time, reducing the chances that this patient can recieve throbolytic treatment, or increasing the chances of infarction to the myocardial tissue??????

Please. Accept the fact that EMS has limitations. My service is currently trialing the use of thrombolytics in the field. It does make a difference to the patient outcome. Isnt that what EMS is about, making sure, where possible, we have a positive outcome on the patient & their family rather than being self centered & worried about 'how much knowledge' we have & if we can diagnose their 12 lead ECG in the field?


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## medic417 (Feb 19, 2009)

downunderwunda said:


> Yes, I agree, but, what can you do, in the field, regardless of what you know, other than ASA, Nitro, Oxygen & morphine? Unless of course you are fortunate unough to thrombolyse, but i did say that in my original post.
> 
> medic417, read ALL of my posts, you will see I am an advocate for EMS moving forward & in particular challenging doing what was always done as being right in favour of evidence based practice.
> 
> ...



So you would not treat any of the arrythmias that are present in the ekg?  As soon as you recognized elevation and depressions that correspond with MI are you saying no more should be done?  Can't you do treatment while enroute to the hospital?  The only thing that really needed to be sitting still for was the 12 lead.  

As to limitations?  Yes but we in EMS have not even touched the tip of the ice berg of what EMS should be.  Hopefully increased education will lead to much more aggressive treatment leading to better patient outcomes because needed care will not be delayed so long.  Knowledge is the key to patient outcomes improving.


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## downunderwunda (Feb 19, 2009)

medic417 said:


> As to limitations?  Yes but we in EMS have not even touched the tip of the ice berg of what EMS should be.  Hopefully increased education will lead to much more aggressive treatment leading to better patient outcomes because needed care will not be delayed so long.  Knowledge is the key to patient outcomes improving.



This will only happen when EMS is give total autonomy over their destiny. Yes we have guidlines to work within, but until ALL EMS is capable of making decisions, WITHOUT the need to refer back to medical control, what you have said will never happen.


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## medic417 (Feb 19, 2009)

downunderwunda said:


> This will only happen when EMS is give total autonomy over their destiny. Yes we have guidlines to work within, but until ALL EMS is capable of making decisions, WITHOUT the need to refer back to medical control, what you have said will never happen.




With increased education that comes closer to a reality.  I have never worked in a mother may I system so I can not imagine not thinking for myself.  Yes I still have written guidelines but I have lots of flexibility.  Even if we stay under control of a medical director greater education would allow guidlines to even be broader allowing even more freedom in our treatment.


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## Aidey (Feb 19, 2009)

downunderwunda said:


> ..... if we do not do a 12 lead in the fied, it can be done at hospital. End of story.
> 
> ....Patients with STEMI need a cath lab. If that is not an immediate option, they need thrombolyasis. This is *proven* to reduce the amount of damage to the myocardium (but I dont know cardiology according to rid!). This is, in many ways time critical. So, now you also want to fiddle fart on scene, wasting more time, reducing the chances that this patient can recieve throbolytic treatment, or increasing the chances of infarction to the myocardial tissue??????
> 
> .... Isnt that what EMS is about, making sure, where possible, we have a positive outcome on the patient & their family rather than being self centered & worried about 'how much knowledge' we have & if we can diagnose their 12 lead ECG in the field?



I don't know about Oz, but where I am we can activate the cath lab team based on our field diagnosis after interpreting the 12 lead. Not doing a 12 lead on a chest pain patient in my service is a good way to get your butt chewed out by the ED doc, the supervisor and our MD sponsor. Not doing one in the field just because they can do one at the hospital can cause a serious delay in how long it is until the patient can be in the cath lab getting definiative care. 

No on is saying that we should be "fiddle farting" on scene, but we aren't just taxis either. We need to provide treatment to the patient. Period. Delaying a minute or two to get a clear 12 lead means that I can start to treat the patient. By not doing one I may save a minute on scene, but I'm wasting 10 minutes not treating them while we are en route to the hospital. 

If you can't properly interpret and diagnose a 12 lead where I work you will not work there for long. It has nothing to do with being self centered, it has to do with being able to provide the patient with the best care as soon as possible. 

In both STEMI and non STEMI situations it definitely matters what the rhythm is. You can easily kill a patient by ignoring a rhythm or mistreating one.


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## firecoins (Feb 20, 2009)

downunderwunda said:


> firecoins, does this mean you agree with me?


I think 12 leads should be done in the field.  It only takes 30 seconds and they are not terribly hard to interpret. I think you simplified stuff in your first post.


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## downunderwunda (Feb 20, 2009)

firecoins, 

yes i simplified it. Too many people in EMS want to make it more than it is. Lets look at fact. DIFINITIVE care is what is required for these patients. The arguments I have read from yourself & others such as 



> It only takes 30 seconds and they are not terribly hard to interpret





> but where I am we can activate the cath lab team based on our field diagnosis after interpreting the 12 lead



for example. My problem is there are too many so called 'medics' who really have delusions of grandeur. They want to walk into the ER & proclaim they have interpreted the rhythm or diagnosed the patient. I can & do diagnose 12 lead ECG's. I have oversimplified it because I have seen the mentality of those who want to believe they are better than everyone else, wasting time on scene. If you look at all of your protocols, they are written for the lowest common mental denominator.



> You can easily kill a patient by ignoring a rhythm or mistreating one.



Which ones am I going to kill a patient if i dont do anything but ASA, Nitro, O2 & morphine? I can & have had chet pain patients in my care for up to an hour, with multiple dysrhtmias & havent lost one yet, so please tell me, which ones?


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## medic417 (Feb 20, 2009)

downunderwunda said:


> If you look at all of your protocols, they are written for the lowest common mental denominator.




Speak for yours.  The guidelines we work under leave us the ability to think and to perform.  Our medical director will not allow you to be remain with us if you are the lowest.  You are expected to be aggressive and able to practice medicine.  We are not stuck going line by line.  Sounds like the system you work in needs revamped.


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## CAOX3 (Feb 20, 2009)

downunderwunda said:


> Treating suspectedMyocardial Ischaemia/Infarction is easy.
> 
> Firstly lets look at some facts.
> 
> ...



Acutally high flow O2 hasnt been proven to benefit these pt's.  In some cases it can actually icrease infarct size.


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## downunderwunda (Feb 20, 2009)

CAOX3 said:


> Acutally high flow O2 hasnt been proven to benefit these pt's.  In some cases it can actually icrease infarct size.


If you want to go to that extreme, there is also conjecture to the efficay of morphine in dilation of coronary arteries. Its main use is as an anti-anxiety agent.


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## CAOX3 (Feb 20, 2009)

What extreme?

Im just stating we need to re-think the atitude of slapping on high flow O2 for everyone with chest pain.


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## Ridryder911 (Feb 20, 2009)

downunderwunda said:


> I do understand cardiology. I also know the limitations of EMS. Rid, regardless of what we think, if we do not do a 12 lead in the fied, it can be done at hospital. End of story.




Only end of the story is your lacking in education of cardiology and the understanding of emergency and critical care. What limitations? What can they do in the ER, that I can't? Still await for a cath team to get ready?

Do you understand right sided AMI, bifascicular and trifascicular blocks and the associated increase morbidity with the use of Morphine?  Or should we have the idea to just run "r-e-a-l fast" to the hospital. The only limitations one can have is limiting one's mind. I have been performing twelve lead prehospital for over 20+ years and in some rural areas thrombolytics. Even used non-portable type ran through a converter and faxed to a cardiologist in a very rural area, so yes it can be done. 

Sure one can await for a twelve lead in ER. Then await for consultation with a cardiologist. Then await for the cath lab to be notified.... Nice move slick, you just increased the time and possibly help increase the AMI size or even increasing the chance of morbidity.  All of this could had been prevented per performing a twelve lead and alerting the ER and possibly cath lab. 

It's 2009, come up to par...

That is the end of the story.


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## CAOX3 (Feb 20, 2009)

Isnt that the norm today?  

This has been the norm around here for years, we are not exactly the most progressive system.   STEMI is an automatic cath lab notification for our ALS providers.


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## firecoins (Feb 20, 2009)

doing a 12 lead does not delay transport.  Its a 30 second procedure.  We can take the patient directly to the cath lab.


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## Aidey (Feb 20, 2009)

downunderwunda said:


> Which ones am I going to kill a patient if i dont do anything but ASA, Nitro, O2 & morphine? I can & have had chet pain patients in my care for up to an hour, with multiple dysrhtmias & havent lost one yet, so please tell me, which ones?





V-Tach....SVT.....etc


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## DevilDuckie (Feb 20, 2009)

What's SVT?


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## reaper (Feb 20, 2009)

PSVT, Vtach, Afib with RVR, runs of PVC's, RVF,STEMI!!!!!!!!!!!!!!!!1


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## DevilDuckie (Feb 21, 2009)

That just draws a bigger blank for me.


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## downunderwunda (Feb 21, 2009)

reaper said:


> PSVT, Vtach, Afib with RVR, runs of PVC's, RVF,STEMI!!!!!!!!!!!!!!!!1




reaper, 

i have transported people with what you are describing with no interventions & surprise surprise, they lived. 

So I will ask again, which ones, left untreated for the 1 hour transport times will be fatal, aside from VT, VF,  asystole pulsless bradycardia etc?


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## reaper (Feb 21, 2009)

downunderwunda said:


> reaper,
> 
> i have transported people with what you are describing with no interventions & surprise surprise, they lived.
> 
> So I will ask again, which ones, left untreated for the 1 hour transport times will be fatal, aside from VT, VF,  asystole pulsless bradycardia etc?




So you are saying that you are a sub par medic?

If you take a pt with PSVT at a rate of 190 or an Afib pt with a rate of 240 and did not treat them for an hour transport, then that is sub par medicine.

I work a service that has thrombolytics for long transports. They are rarely used, as the cath labs do not like them being used.

We also administer Heparin for any active STEMI and Lopressor for any STEMI with out Right side involvement. Neither of these can be used without a 12 lead to confirm ST elevation.

Treating a chest pain pt is not easy as cake, in the real world. We use medicine to help our pt's. Not drive them in, while they suffer more pain and lost cardiac muscle!


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## DevilDuckie (Feb 21, 2009)

Yeah, but what's PSVT?


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## VentMedic (Feb 21, 2009)

downunderwunda said:


> reaper,
> 
> i have transported people with what you are describing with no interventions & surprise surprise, they lived.
> 
> So I will ask again, which ones, left untreated for the 1 hour transport times will be fatal, aside from VT, VF, asystole pulsless bradycardia etc?


 
They all can be. 

A-fib with new onset can quickly lead to decompensation depending on medical history. As well, A-fib is very dangerous due to clots. If the person cannot be converted quickly, they will need anti-coagulants.

STEMI? That depends on how much of the heart muscle is affected and whether they can maintain cardiac output or if they just throw a lethal arrhythmia to be dead before they hit the floor. It is not uncommon to lose a STEMI within the first 30 minutes.

Right ventricular failure can carry a worse prognosis than left ventricular failure.

PSVT: It all depends on how well the body can withstand sudden hemodynamic changes.

Too many in EMS want a blanket statement made for every medical condition. Since every patient is different, to count on that blanket statement is playing Russian Roulette with someone's life.

Any factor that gives rise to hemodynamic instability has potential to be fatal. Thus, the importance of "ALS" is to maintain hemodynamic stability. The sooner one is aware of any factor for instability, the better prepared one is to gain control and prevent that patient from coding.

How you ever gone back to the ED to see how many of your patients lived for 24 hours after you dropped them off? The "normal" vitals thing means very little when a person is in the compensatory phase. Read the shock thread.


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## downunderwunda (Feb 21, 2009)

Ridryder911 said:


> Only end of the story is your lacking in education of cardiology and the understanding of emergency and critical care. What limitations? What can they do in the ER, that I can't? Still await for a cath team to get ready?
> 
> Do you understand right sided AMI, bifascicular and trifascicular blocks and the associated increase morbidity with the use of Morphine?  Or should we have the idea to just run "r-e-a-l fast" to the hospital. The only limitations one can have is limiting one's mind. I have been performing twelve lead prehospital for over 20+ years and in some rural areas thrombolytics. Even used non-portable type ran through a converter and faxed to a cardiologist in a very rural area, so yes it can be done.
> 
> ...



No it isnt rid. 

First, let me ask you to remove yr head from where the sun dont shine.

Yes i will get another warning for that i am sure.

I transport for up to & over 2 hours. The nearest available cath lab, if attended onthe day is a further 2 hours from there, alternativley we travel 4 hours in the other direction. 

Oddly enough, through prudent use of the drugs we have, through the education we have (which MUST be deficient to your as we are not american (I feel yet another warning for that one), we still manage to get our patients to the cath labs, with little or no further damage than was caused by their delays in calling us.

Yes it is 2009. However, regardless of what is said, the only true & difinitive care for any patient whith ANY cardiac complaint is not in an ambulance but in a hospital. 

That my friend is the end of the story.


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## Ridryder911 (Feb 21, 2009)

Amazing, to acclaim to know and yet represent ignorance. I have discussed care with medics from Australia and was impressed with their knowledge base as well as aggressive treatment in some areas. You are the first one that I have seen that has represented such unknowing knowledge of the results of myocardial ischemia, infarction. 

No one an EMS unit is the most definitve care. Performing a 12 lead was never assumed to do such; rather an assessment tool.

You may have acclaim to have transported without incidence and that is probably by the Grace of God. 

I really suggest that you read not only American studies but International ones (I am sure that they have similar in Aussie land as well) and doubtful any describe to defer from good assessment techniques or delay in cath care. Please produce information that these "wonder drugs" you or local ER's prevent myocardial injuries. I am sure the rest of the world would like to see as well. That is if you can produce such; otherwise you are spouting from down under. 

R/r 911


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## daedalus (Feb 21, 2009)

> EMS needs to grow to actually performing medicine not being a horizontal taxi.


I agree to an extent, but at the end of the day we do in fact bring patients to the hospital. If we want to be able to claim that our core is not transportation, but medicine, we have to have the education and ability to treat and release (not relevant to this thread).


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## medic417 (Feb 21, 2009)

daedalus said:


> I agree to an extent, but at the end of the day we do in fact bring patients to the hospital. If we want to be able to claim that our core is not transportation, but medicine, we have to have the education and ability to treat and release (not relevant to this thread).



Yes we treat and release.  We educate the public.  We deny transport.  We focus on medicine not on driving ever caller where they want to go.  If they need to go we take them while performing medical interventions.


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