# New STEMI protocol in Riverside County, CA



## jgmedic (Apr 8, 2010)

So I just wanted a few opinions from people who work in better EMS systems than mine. We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field. Doesn't matter if there are elevations or depression, unless the monitor readout states Acute MI and the pt is having chest pain, it goes to the closest. I think this is absolutely ridiculous, the last 3 STEMI's I've had have been pain-free, Anyone else run into a similar protocol?


----------



## JPINFV (Apr 8, 2010)

Well... there goes Riverside LEMSA as being my favorite counter example to the fire based systems in LA and Orange Counties...


----------



## ah2388 (Apr 8, 2010)

id be very reluctant to follow such a protocol.


----------



## Veneficus (Apr 8, 2010)

jgmedic said:


> So I just wanted a few opinions from people who work in better EMS systems than mine. We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field. Doesn't matter if there are elevations or depression, unless the monitor readout states Acute MI and the pt is having chest pain, it goes to the closest. I think this is absolutely ridiculous, the last 3 STEMI's I've had have been pain-free, Anyone else run into a similar protocol?



While I think it is sad, it is not ridiculous.

If providers have been grossly overtriaging patients, then they are not performing well enough to make the determination. Apparently the powers that be feel the machine is doing a better job than the providers, do they have numbers to back it up? I am guessing ""yes."

I have no idea about this service, but generally if you are going to start pressing alarm buttons, you have to have an acceptable level of accuracy. The old school idea of "just in case" is no longer valid. Like all of healthcare, cost/benefit is coming under scrutiny.

I keep telling people, it is better to play a system than slip through a crack. If you think your patient maybe falling through a crack, it is very easy to convince them they are having chest pain. However, if you are wrong, you made the call, responsibility falls to you, not the BS "I was just following protocol" defense.

I like to ask "why" and go right to the top. I am sure the medical director has some reason to back up his decision. Ask.


----------



## TransportJockey (Apr 8, 2010)

Instead of making this protocol, I'd start teaching the medics how to read a 12 lead. They obviously need the extra practice


----------



## Shishkabob (Apr 8, 2010)

jgmedic said:


> We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field.



Wait wait wait... they are afraid of misdiagnosed EKGs, so they rely on a computer diagnosis that is often wrong itself?


Anyone else think that's odd?


----------



## Veneficus (Apr 8, 2010)

Linuss said:


> Wait wait wait... they are afraid of misdiagnosed EKGs, so they rely on a computer diagnosis that is often wrong itself?
> 
> 
> Anyone else think that's odd?



the question is which is wrong more often?


----------



## Shishkabob (Apr 8, 2010)

The fact that either / or is wrong often is sad in and of itself.


----------



## firecoins (Apr 8, 2010)

I am sorry but that is ridiculous.  The medics need to be retrained on 12 leads but calling a Stemi when it isn't is much better than the reverse.


----------



## dmiracco (Apr 8, 2010)

WOW, thats pretty sad and ridiculous. Sounds like maybe that service should just have Intermediates on the trucks if all they want you to do is read what the machine prints out. 
SO either most of the medics there cant read a 12 lead and need more training or the Administration,Training officer needs a wake up call into the current world of EMS or perhaps they need training themselves. 
I know nothing about his service but based on what was written that is one of the most ignorent things I have heard of in EMS in a long time. 
Hopefully that will be changed for the benefits of the patients that are served in that county.
What you are going to see is A LOT of false positives from the machine.


----------



## MrBrown (Apr 9, 2010)

Dude seriously that is pretty sad.

Rather than rely on machine interpretation and if the Firefighters aren't up to the task of being trained in how to interpret a 12 lead, at least transmit the bloody thing and have a doctor look at it, or a nurse, or you know, a janitor who happens to be wandering by coz I bet he can be taught to interpret a 12 lead!


----------



## trevor1189 (Apr 9, 2010)

Regardless of this protocol, if the medics think stemi, the should be transmitting and allowing the doc to make the call if this protocol restricts them from doing so.


----------



## Veneficus (Apr 9, 2010)

*because perspectie is my thing*

Reading over the responses here, There is considerable focus on STEMI, not on the nature of the ACS as a whole. 

If you need "chest pain" and a machine that can see ST elevation in multiple leads, it rules out any "abnormal" presentation. Even if you were to base treatment on the 12 lead readout alone, I am sure we are all very much aware the reason we have a classification called "NSTMI."

If a written protocol states you need a high degree of certainty it is a STEMI to transport to a cardiac facility, that seems like it purposefully excludes a significant number of patients who very well could be in need of specialty care.

I would be interested in hearing the med directors logic. Is he just following the primary practice in the area or is there more to it?


----------



## reaper (Apr 9, 2010)

Since over 50% of AMI's are NSTEMI, there are going to be a lot of heart muscle dieing out there. Hell, over 40% have no chest pain, so they are really screwed!


----------



## MrBrown (Apr 9, 2010)

reaper said:


> Since over 50% of AMI's are NSTEMI, there are going to be a lot of heart muscle dieing out there. Hell, over 40% have no chest pain, so they are really screwed!



But they lived in SoCal, they were alreayd partly screwed anyway


----------



## jgmedic (Apr 9, 2010)

Veneficus said:


> Reading over the responses here, There is considerable focus on STEMI, not on the nature of the ACS as a whole.
> 
> If you need "chest pain" and a machine that can see ST elevation in multiple leads, it rules out any "abnormal" presentation. Even if you were to base treatment on the 12 lead readout alone, I am sure we are all very much aware the reason we have a classification called "NSTMI."
> 
> ...



I would love to ask him, maybe I'll try next time I go to his ED. The problem stated in the memo is the overtriaging of "possible STEMI", stating that too much is coming from poor ECG tracings with baseline wandering and poor interpretation, sadly, the most training our medics get outside of school is the initial 12L class given during county accreditation and that's just for AMR, I don't know how the ALS fire agencies do it. This med director recently pulled pediatric intubation due to a series of esophageal tubes, I heard something like 5 in a week, and has recently threatened to pull adult tubes if we don't get our act together. Our division has a pretty good reputation for our clinical skill but it seems like the director is on the warpath, putting us in-line to be another SoCal Mother May-I system.


----------



## dmiracco (Apr 9, 2010)

Sounds like there needs to be a FORMAL 12 lead course put on at that service and it probably would be best if it was someone completely outside of the service that teaches the class.


----------



## TomB (Apr 11, 2010)

So fashionable to beat up on Southern California, even though the STEMI system is thriving and the patients are doing wonderfully. The flaw in your argument is the fact that NSTEMI patients are not treated the same as STEMI patients. Early invasive strategy is not the same as an urgent cath where minutes count. Select NSTEMI patients may one day be fast-tracked to the lab like STEMI patients (perhaps with point-of-care biomarkers and some type of field risk assessment) but that's a ways off in the future, and it will be an add-on to a STEMI system. It's a rare EMS system indeed that makes the decision based 100% from paramedic interpretation (no interpretive statement and no ECG transmission). 99% of the time when I challenge someone who ridicules Southern California, if turns out their own municipality, region, or state cannot compete with Southern California's stats.


----------



## Veneficus (Apr 11, 2010)

_So I just wanted a few opinions from people who work in better EMS systems than mine. We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field. Doesn't matter if there are elevations or depression, *unless the monitor readout states Acute MI and the pt is having chest pain,* it goes to the closest. I think this is absolutely ridiculous, the last 3 STEMI's I've had have been pain-free, Anyone else run into a similar protocol? _

I think this was the key phrase I was focusing in on. It doesn't seem prudent to require chest pain with ST elevation in order to be transported to a specialty center.

This is one of the articles I have seen recently on early invasive treatment of NSTEMI.

http://www.aafp.org/afp/2007/0101/p47.html



TomB said:


> So fashionable to beat up on Southern California, even though the STEMI system is thriving and the patients are doing wonderfully. The flaw in your argument is the fact that NSTEMI patients are not treated the same as STEMI patients. Early invasive strategy is not the same as an urgent cath where minutes count..



But if the goal is early invasive therapy, it seems like it would help more to drop the patient off at the facilty that could schedule it faster than a work up at one hospital, the arrangement of transfer, followed by the process the specialty center would ultimately start there.




TomB said:


> Select NSTEMI patients may one day be fast-tracked to the lab like STEMI patients (perhaps with point-of-care biomarkers and some type of field risk assessment) but that's a ways off in the future, and it will be an add-on to a STEMI system.



You have to start somewhere. As I said above, transporting the patient to the STEMI center seems like it would naturally reduce the time to whatever care is rendered as the STEMI center in all likelyhood has a C/T surgeon on staff who could render additional invasive therapy in addition to interventional cardiology/radiology. By your own logic it would seem that since fast tracking will be built on top of a STEMI center, taking your ACS patient to that ceter to begin with would be a prudent step?



TomB said:


> It's a rare EMS system indeed that makes the decision based 100% from paramedic interpretation (no interpretive statement and no ECG transmission)..



I wasn't suggesting activation of a cath lab or any other treatment course should be one by EMS. I was insinuating That if EMS suspects some form of ACS with an acceptable level of accuracy, then it would be more prudent to transport to a specialty center thn the closest hosptial which may not be able to render the most effective care called for.



TomB said:


> 99% of the time when I challenge someone who ridicules Southern California, if turns out their own municipality, region, or state cannot compete with Southern California's stats.



I twice suggested finding out directly from the medical director first hand the reasons for his new directive in this thread. 

It is my opinion if a machine is better at reading an EKG than a medic, that medic is faulty regardless of system design. Might as well just teach a basic how to hook up a 12 lead and save the whole system a lot of money by reducing medics.


----------



## irish_handgrenade (Apr 11, 2010)

My service spends a lot of time practicing ekg and 12-lead interpretations. We have had part time medics in the past who had trouble with reading them and they were takin off the truck until they could show the medical director otherwise. This sounds like a lack of education to me and a loss of confidence from your medical director. As for our full time medics most of us are as good if not better at reading a 12-lead than the staff doctors at the local ER.


----------



## Veneficus (Apr 11, 2010)

*The devil's advocate sometimes tries to be me*

What if evidence is showing that similar to the outcomes of BLS with trauma, a set of symptoms with a positive finding from a software algorythm is more accurate a predictor of adverse event and demonstrates better positive outcomes?

There has been significant identification recently that the same mechanisms in trauma are applicable to cardiac emergencies. It is worth considering.

But like I said, when the machine can do a better job then me. I would definately make sure I was more valuable than a machine. Otherwise you run the risk of being replaced with a EMT basic with a 12 lead AED. Not good for job security.


----------



## MrBrown (Apr 12, 2010)

Veneficus said:


> There has been significant identification recently that the same mechanisms in trauma are applicable to cardiac emergencies. It is worth considering.



How do you mean?

I think that once again we see the pitfalls of inadequate education.  Now that Lifepak 12 I lug around is pretty good at diagnosing an acute STEMI however it's not so good for some of the other things.

Still, I would rather trust my knowledge of how to read a 12 lead ECG (which like the Lifepak aint all that good outside of acute STEMI) rather than rely on the computer interpretation.

It does not take a rocket scientist to work out when somebody is having a STEMI; I get one nearly every shift I work I mean wow it's crazy; chest pain, little nausea, maybe vomiting, maybe some arm/jaw/face/neck pain, good story plus ECG changes .... we've all seen them; infact the last one I had said his chest pain went away.  

We do not currently have such a system whereas we can divert staight to a PCI capable hospital however we have simmilar bypass policies for trauma.  In the near future we will probably get such a policy.

Now you can get those patients who don't have ST changes, who are pain free and we've all seen them too.  Wouldn't it be far more prudent in this case to go to the most appropriate facility even if it is over-triage a little or consult with cardiology and maybe send them a strip?

Dang nab it where is that Biophone when you need it.


----------



## irish_handgrenade (Apr 12, 2010)

MRBrown and Veneficus I have to say that I think a lot of your opinions. When I read these questions and I start to make a reply I look at your posts and you guys seem to think similarly(but put your thoughts into words better) as I do. There were some really experienced guys who used to post on this site, I haven't seen them lately, but when they replied to a post they always hated on people and I haven't seen either of you guys do that in the posts I have seen.


----------



## Smash (Apr 12, 2010)

The trouble with relying on the machine interpretation entirely is that they are very specific, but not very sensitive.  That is, if the machine says **ACUTE INFARCT** then your patient is likely to be having an acute infarct.  However if it doesn't say that, it doesn't mean that they _aren't_ having an infarct, merely that the machine hasn't picked it up.

This seems suspiciously like the typical EMS knee-jerk reaction of fixing a symptom (inappropriate transport/treatment decision by medics) with a 'protocol', rather than fixing the cause (lack of provider education/training)


----------



## Veneficus (Apr 12, 2010)

MrBrown said:


> How do you mean?



I mean that because the physiologic mechanisms of pathology are similar. (hybernation, necrosis, apoptosis cascades from reperfusion injury, etc) that similar to trauma, aggresive intervention coupled with mandatory transport to a cardiac center would be beneficial. 

Because of the nature of the cardiac event, the amount of focus on intervention in the US paramedic curriculum, and the non textbook presentations looking like the norm not the exception, it might be beneficial to be less specific when dx and treating a suspected ACS.

For example, compare the amount of people who are transported to trauma centers in the US because something "might be wrong." In my experience working at a very busy level I trauma center, far more are transported than require the level of care rendered by such a facility. Nobody would think not to go to a trauma ceneter with a trauma patient. (usually with backboarded patients and all kinds of get up that doesn't really matter.) Why would you not go to a cardiac facility with a cardiac patient?

The conditions leading to an ACS such as HTN, extremis of age, etc. are far more common than surgical trauma. Even if EMS simply identifies risk factors for potential ACS, the work up and treatment plan from a cardiac center could be beneficial in future MI prevention. Just like in Trauma, prevention of the incident, is not only cheaper, but saves many more people than damage control surgery. I stipulate the same could be said for cardiac treatment.  




MrBrown said:


> Still, I would rather trust my knowledge of how to read a 12 lead ECG (which like the Lifepak aint all that good outside of acute STEMI) rather than rely on the computer interpretation.



Me too. 

But if the amount of overtriage of patients is not acceptable to a particular system and is impairinng its function, the rule is set in place for the people causing the problem. Which may be more people than the amount of capable providers.

Smash said it best, it is a provider education and skill issue. When there are provider education and skill issues in the US, the reaction has always been to limit the provider instead of increasing education. I don't like it, but a great many in the US who don't like it have no been able to change it.



MrBrown said:


> It does not take a rocket scientist to work out when somebody is having a STEMI;.



Agreed, but you are well aware of the problems in the US. I doubt I can add anything more you don't already know to the issue of provider failure.



MrBrown said:


> I get one nearly every shift I work I mean wow it's crazy; chest pain, little nausea, maybe vomiting, maybe some arm/jaw/face/neck pain, good story plus ECG changes .... we've all seen them; *infact the last one I had said his chest pain went away.[/*QUOTE]
> 
> This is not uncommon actually. We even see patients who report their pain was relieved by tylenol or some other OTC nsaid which sometimes takes providers away from the ACS mindset. The pain can come and go as well, it doesn't have to be constant. So now a provider must choose, did the tylenol releve the symptom? Did the pain go away from the drug or because the tissue died? Is the pain non specicif or intermittent?
> 
> ...


----------



## EMT_TIFFANY (Apr 12, 2010)

What happened to treat the patient not the monitor? This has been beaten into my head from day one of medic class. My instructor told us that there are still older medics out there that do not know how to read a 12 lead because they have never been taught how or have not had any extra training. Could this be the issue?


----------



## MrBrown (Apr 12, 2010)

EMT_TIFFANY said:


> What happened to treat the patient not the monitor? This has been beaten into my head from day one of medic class. My instructor told us that there are still older medics out there that do not know how to read a 12 lead because they have never been taught how or have not had any extra training. Could this be the issue?



12 lead ECG is not required education in the US.  When the National Standard Cirricula for Paramedic was revised in 1998 most places were still using the Lifepak 10 and all would have had three lead (although you could do a throw-down bootleg nine lead with a LP10).  

New Zealand only got 12 lead prehospital somewhere around 2003 and that was only in a very small area; the predominant provider has had 12 lead since 2007 and it's still a "nice to have" not a "have to have" but with the next system coming out 12 lead interpretation won't be an ALS-only skill anymore.

To say treat the patient and not the monitor is incorrect because ST changes on a 12 lead are one of the primary diagnoses of a STEMI along with cardiac labs and some other stuff I'm not sure exactly what though.  Doesn't matter how symptomatic the patient is, a lot of MIs are pain free esp in the elderly and diabetics or present atypically with no real symptoms.


----------



## boingo (Apr 12, 2010)

MrBrown said:


> Doesn't matter how symptomatic the patient is, a lot of MIs are pain free esp in the elderly and diabetics or present atypically with no real symptoms.



Case in point, last week I had an 83 yo M w/acute change in mental status, family called a few hours later.  We found him conscious, confused but without complaint....with acute inferior wall infarct.  We treated the monitor, he went directly to the cath lab and had a stent placed.  2 days ago we had a patient with 3 days of intermittent cx pain, now with constant pain x 3 hrs, LP12 diagnosis called it NSR w/acute pericarditis, we called it acute anterolateral infarct.  Once again, pt went to cath lab and had LAD stent placed.


----------



## usalsfyre (Apr 12, 2010)

*Treat the patient not the monitor...*

...is another one of those irratating EMS sayings that oversimplifies patient care. If you were only going to treat the patient based on history and physical exam and ignore the monitor, then why lug the d@mn thing in? Diagnostics are around for a reason, use them as a bolster for good history and H&P.


----------



## irish_handgrenade (Apr 12, 2010)

sayings like that are around because of scenarios like this, and this actually happened to a medic I know.: Young medic a little full of himself, just at a year in, has a symptomatic cardiac pt. he hooks him up to the monitor and the monitor shows a rate of 400... This should have been the first clue that something was wrong... With out palpating a pulse or listening to the medic student that WAS checking the pulse which was around 70, he hooked up the pads and cardioverted the pt. Needless to say he no longer has a job with that service. treat the pt. not the monitor. the monitor is JUST a tool and nothing more its not there to diagnose your pt... YOU ARE. Well legally not diagnose but you know what I mean.


----------



## EMT_TIFFANY (Apr 13, 2010)

MrBrown said:


> To say treat the patient and not the monitor is incorrect because ST changes on a 12 lead are one of the primary diagnoses of a STEMI along with cardiac labs and some other stuff I'm not sure exactly what though.  Doesn't matter how symptomatic the patient is, a lot of MIs are pain free esp in the elderly and diabetics or present atypically with no real symptoms.



What I meant by treat the patient not the monitor was.... The person who posted this states that unless the monitor says Myocardial Infart (doesn't matter if there is ST elevation or depression) they cannot transport to a STEMI center. That is ridiculous. ST elevation or depression indicates that SOMETHING is wrong (treat patient) but the monitor says nothing about a myocardial infart (not the monitor). If you truly understand how to read a 12 Lead then you can see an infart progressing before it even reads infart. If you wait until the monitor says infart then it's too late more damage has occured to the heart, why not treat them in the early stages?


----------



## EMT_TIFFANY (Apr 13, 2010)

MrBrown said:


> Now you can get those patients who don't have ST changes, who are pain free and we've all seen them too.  Wouldn't it be far more prudent in this case to go to the most appropriate facility even if it is over-triage a little or consult with cardiology and maybe send them a strip?
> QUOTE]
> 
> I'm in agreement with this.
> ...


----------



## DV_EMT (Apr 14, 2010)

as of last monday, Santa Barbara County started their STEMI protocol giving paramedics a 12 lead in the field. Realistically speaking it could work since, ekg interpretation for ST elevation is pretty easy with a 12 lead.  5 lead, doesnt quite cut the mustard.


----------



## zzyzx (Apr 15, 2010)

Yeah, it's fun to bash California. You guys are jumping the gun, however. This new memo says that medics in that county can't call a STEMI. It doesn't say they can't transport to a STEMI center if they suspect an MI, regardless of what they saw on the 12 lead.


----------



## reaper (Apr 16, 2010)

Yes, so they are taking a step backwards from the national standards of trying to reduce door to ballon time. So now that pt has to sit and wait through all the ECG's again, before the Cath team is even activated. So much for heart muscle!


----------



## thegreypilgrim (May 6, 2010)

TomB said:


> So fashionable to beat up on Southern California, even though the STEMI system is thriving and the patients are doing wonderfully. The flaw in your argument is the fact that NSTEMI patients are not treated the same as STEMI patients. Early invasive strategy is not the same as an urgent cath where minutes count. Select NSTEMI patients may one day be fast-tracked to the lab like STEMI patients (perhaps with point-of-care biomarkers and some type of field risk assessment) but that's a ways off in the future, and it will be an add-on to a STEMI system. It's a rare EMS system indeed that makes the decision based 100% from paramedic interpretation (no interpretive statement and no ECG transmission). 99% of the time when I challenge someone who ridicules Southern California, if turns out their own municipality, region, or state cannot compete with Southern California's stats.


While it's true that the STEMI program here in LA County is getting great results, I would argue that the program here (at least the pre-hospital component of it) is successful in spit of itself. In other words, it's an accident. The reason for this is that every other hospital here is a STEMI Receiving Center (SRC) and there are 150+ ambulance companies in operation here, most of which have ALS or CCT transfer services. As such, it simply doesn't really matter that no human eyes actually read the EMS 12-lead until the pt reaches the ED, and the ED physician discovers the STEMI that the machine missed and the on-scene paramedics weren't trained/authorized to identify. If that hospital turns out to not be a SRC, then that ED can do its initial work-up and stabilization protocols while a transfer from any one of the hundreds of private ambulance companies with ALS or CCT capabilities is arranged to take the pt another 15 min. down the road to the nearest SRC. So, the program here might be successful, but I would argue that the fact that it gets good results is not evidence for the idea that replicating it in other jurisdictions would yield similar success.


----------

