# STEMI...How Can we Improve??



## Craig Alan Evans (Mar 8, 2012)

The reason we perform 12 Lead EKGs in the field is to find out if the patient is having an acute MI. EMS has made great strides in the recent past to make sure their ALS providers have been trained to perform and interpret 12 Lead EKGs. So what can we do now to make it better? I serve on the regional STEMI committee for my area representing prehospital providers within 30 minutes of a PCI center and I have put a lot of thought into this very topic. We all know that time is muscle so simply put we need to remove absolutely every obstruction that causes any delay from the time the coronary artery is first blocked to the time the cardiologist clears the obstruction and returns coronary perfusion to the cardiac tissues. Sounds like a good plan. The first step is to form a regional STEMI committee and bring representatives from each step of the patient’s journey to the same table so we can all get onto the same page. I could write an entire article on the importance of this aspect alone but today let's look at the improvements I see the prehospital system can contribute to the cause.

1) Patient Education: We need to educate the public as to the importance of arriving at a PCI center when their chest pain occurs. By dialing 911 and getting the prehospital system involved they will have decreased their onset to balloon time tremendously. In my area most of the extended times to a PCI center have come from inter facility transfers and not from prehospital initiation.

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. Door to balloon times are misleading as we need to start recording and improving first healthcare contact to balloon time. This is the 21st century and EMS around the nation needs to acknowledge they are not just a ride to the hospital; they are not just there to fix life threatening conditions and then hand the patient off to the ER. EMS should encompass all the initial actions just as if the patient walked into the front door of the ER. This should include patient registration, placing a gown on the patient, and any other initial actions or treatment taken by the ER in the first 10 minutes. If you want to know what actions and interventions EMS should be adding to its tool box all you need to do is watch what occurs in the first 5 minutes after you arrive with a critical patient. If you see any standard treatment or intervention occurring immediately then that is something EMS should be considering implementing into their protocols.

3) Prehospital 12 Leads: As I said previously we have made great strides in this area but what we have done is only scratching the surface. Most EMS systems have 12 leads on the ambulances staffed by paramedics. We need to extend that out at least another tier and make sure every fire truck and BLS provider can perform a 12 Lead EKG. Any patient suspected of having an acute coronary event should have a 12 lead as one of their initial vital signs. It is not an ALS intervention to place stickers and attach cables to a patient’s chest. Everyone should be doing it. Sure, paramedics are needed to interpret the squiggly lines, but certainly not to attach the cables and print out an EKG and have it waiting for the arriving paramedic to interpret. I have seen far too many paramedics perform an initial assessment and then move the patient to "their office" and then perform a 12 lead EKG. This is flawed thinking. 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. As we all know the first step of any 12 step improvement program is recognizing the problem. We can do nothing to improve the patient’s journey to a PCI center until we first recognize they are having a STEMI.

4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see. It is not that the hospital doubts our ability to interpret EKGs, although, in some parts of the country this may be true. It is simply a team sport. If the physician and the paramedic were standing beside each other when the 12 lead came out of the machine they would both look at it. It's just best practice to share this type of information. Just like all the prehospital providers hand the EKG off and show it to each other on the scene. This is just not the type of information you keep to yourself and the cost of falsely activating the cath team is extensive. You want as many people involved in this decision as possible. False activations occur in the ER. We do not need any bad press from false activations occurring from a prehospital EKG. If paramedics feel this is an insult to their intelligence...get over it. Anything that slows down onset to balloon time needs to be eliminated, and that includes your pride.

5) STEMI ??: So the squiggly lines look bad...what next? I propose a two tiered prehospital response to a possible STEMI:

     a) Confirmed STEMI: This is a patient that both the prehospital providers and the ER physician agree is a STEMI. The EKG has been transmitted and everyone is on the same page so game on. The PCI team should be activated and every barrier that will slow down the time to the patients cath should be removed. The patient should be placed in a hospital gown and their groin should be shaved. No drips should be started and any interventions routinely performed by the ER physician should be moved to the prehospital arena such as heparin or integrelin boluses. If a chest x-ray is required prior to the patient going to the cath lab then a portable chest should be waiting in the ER and it should be performed on the EMS stretcher and then the patient should be immediately transferred to the cath lab. If your EMS system has extremely long transport times to an ER or PCI center and your STEMI patient would undergo TPA at the closest ER then this should be moved into the prehospital arena. IF the training or care level of the EMS system does not support this effort then a plan should be put into place to make it so. Whatever requirements your nearest PCI center will require prior to the cath being performed on a patient should be implemented in the prehospital setting. This is where it is crucial to have all the stakeholders at the same table with one goal in mind, decreasing the time from event to balloon.

     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.

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.
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.
8) STEMI Drills and QA/QI: We should be continually evaluating the system and looking for improvements. STEMI drills will make sure the machine stays well oiled and ready to perform when needed. Any improvements in time, procedures, and interventions that can be safely incorporated into the prehospital setting should be implemented as they become available.

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!


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## Veneficus (Mar 8, 2012)

*sounds great*

Who pays?


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## Craig Alan Evans (Mar 8, 2012)

Who pays for what?


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## Rettsani (Mar 8, 2012)

I think the question was asked in reference to the Text written by you.

This all sounds very expensive. -_-


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## Veneficus (Mar 8, 2012)

The whole thing.

Educating and training paramedics to provide increased interventions.

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

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

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.

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.

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

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

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

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? 

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

How about a untreated or subclinical GI bleed?

Esophageal varicy?

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.

Who pays for the helo rides? how much?

Safety equipment for air med doing scene runs?

Drills. Who is paying for the overtime and resource cost? 

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

How much over triage/treatment is acceptable?

It all costs money.


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## Craig Alan Evans (Mar 8, 2012)

I disagree.  It is not expensive to create a STEMI committee and plan on how to improve times.  It shouldn't be expensive to query your nearest PCI center and ascertain what interventions they require before performing a cath.  It is fairly inexpensive to formulate a local plan to ascertain a 12-Lead in less than 5 minutes.  If you do not presently have 12-lead machines you can start with a modified chest lead EKG that will be fairly diagnostic.  My intent was not to lay out an expensive plan.  It was to put my opinion out there based on the system I work in and see what everyone's thoughts were around the world and hopefully learn something.


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## Rettsani (Mar 8, 2012)

In what for a world are you living ?

To ensure the functionality of a system, you must first invest. Ever considered what a 12-lead ECG with data transmission system costs?
Alone this component of the system will cost as much as a new car ...


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## Craig Alan Evans (Mar 8, 2012)

Educating and training paramedics to provide increased interventions.
Yes, expensive

Equipment, you need some way to transmit, something to transmit to.
Yes, could be expensive or you could develop a system based on existing technology like 3g, picture of EKG with an iPhone or iPAD and email to a predetermined receiving email at the ED.  

Collaborative patient registration, sure, the technology exists, who buys the toys?
Simply garnering key patient demographic info and passing it along prior to arrival is not expensive.

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.
This is correct.

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.
Yes, more units on the road means more business.

What is the plan for the patients where the EKG fails to pick up the pathology?
Give me an example.  

Istats are a great tool, but not really practical prehospital, daily controls, refrigerated cartriges, etc.
ISTATS are not practical in the field at this time.

TpA from a protocol? I could think of a dozen ways that could go wrong.
Me too.  I included this option into my discussion for more rural areas where the patient would be receiving TPA at the nearest receiving facility that is located greater than 30 min from the location of the call.

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? 
No STEMI detected by what means?  If there is no STEMI detected then the patient is not treated as a STEMI patient.


Are you going to give him the TpA prior to determining if he has a ruptured aneurysm?
No.  Absolutely not.

How about a untreated or subclinical GI bleed?
They should not receive TpA either.

Esophageal varicy?
Definitely not.  Are you implying that Esophageal varicies or a GI bleed will present as a STEMI.  I have not seen this before.

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.
They should not be sitting on the stretcher longer than a few minutes.  The idea is that you do not waste time at a PCI center transferring them to a ED hospital bed just so they can then be wheeled to the cath lab, clearly a waste of time.

Who pays for the helo rides? how much?
The patient or the patient's insurance.  The same people who pay for the ambulance rides.

Safety equipment for air med doing scene runs?
Not sure what you are getting at here.

Drills. Who is paying for the overtime and resource cost? 
Each individual locality or company.  Try to incorporate the drills into straight time or continual ed.  Several options here.  

Why should a doc or hospital lose time or take an operating theatre (cath lab) out of service for it with associated cost?
No need to take a cath lab OOS to practice transferring a patient over to their bed or learning how to prepare the patient for a cath.  I'm sure they don't take these resources OOS to train techs in the cath lab.

How much over triage/treatment is acceptable?
Please expand on this question.  Not sure what you are asking here.

It all costs money.
Yes. I agree 100%.  It all costs money and we should be in the business of moving our vocation forward and providing better patient care at all times.  If you are not moving forward in EMS you are moving backwards.  Please don't construe my answers as curt or brash I'm just trying to address your flurry of questions.  lol  I appreciate the discussion.  Thanks!
__________________


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## Craig Alan Evans (Mar 8, 2012)

I don't think it has to cost that much.  Maybe the EKG but the transmission systems on the market are very overpriced and there is a better way.  We have existing technology in place. Most of us carry them in our pockets.  Just a thought.


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## Craig Alan Evans (Mar 8, 2012)

One of the main points of my discussion was obtaining a 12 lead in less than 5 minutes from patient contact.  Are you not performing 12 leads in the field now?  Do you think a 12 lead on a potential STEMI patient can wait?


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## Rettsani (Mar 8, 2012)

We write a lot of 12-lead ECG 's, but our device can not transmit data. The devices are just too expensive. The appointment for PTCA, runs  by cell phone, without data transmit. This clarifies for us, by the emergency physician on site.


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## Craig Alan Evans (Mar 8, 2012)

Rettsani,

Are you a physician or do you have a physician with you on the ambulance in Germany?


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## Brandon O (Mar 8, 2012)

I find that the best solutions are invariably local rather than broadly applied, because conditions vary. The biggest one may be how far your hospitals are, and how many of them are PCI-capable.

The issue is two-sided:

1: How can we streamline the process for STEMI patients to get from EMS to the cath lab? Your ideas are good. Probably the most important thing is getting early 12-leads and having providers who can reliably recognize ST elevation (not too difficult, I think). That way they can get to the right destination, and ideally activate from the field and facilitate things in other ways.

2: How can we reduce the impact of "false positive" activations of the above process? This ends up being the key, because local hospitals complain about losing business from diversions, it's bad for the patients, and it's a resource hit to the receiving centers to keep activating for nothing. If it's too egregious it breaks the system, or the parties just won't buy in to start with. The two popular solutions to this seem to have been train the hell out of your medics (works for smaller systems), or transmit the ECGs. The latter doesn't necessarily solve the problem, because doctors mess it up too, but it can be easier than really getting a whole region to reliably differentiate ST elevation. The technical challenges are large, though, not through any concrete obstacles but just through real life; people are on different devices that don't talk, and nobody's really stepped up to do this elegantly. One upside, though, is that Physio at least has a system for BLS 12-lead transmission -- just hook up electrodes and push the button -- so that's an option to extend your capabilities too.

Are you familiar with the AHA Mission: Lifeline program?

Edit: by the way, a multi-tiered activation system has been used in Boston and seems to work. "Suspected" STEMIs are met at the door by the doc to over-read; "Definite" STEMIs are (or should) go straight to the cath lab.


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## Craig Alan Evans (Mar 8, 2012)

Yes...I am familiar with the AHA Mission: Lifeline program.  My discussion is centered around the prehospital component.  You have hit the nail on the head with your analysis.  It seems simple in discussion.  I work in an area that is within 10-15 minutes from a PCI center and the medics don't always obtain a 12 lead here until after the patient is moved to the unit.  Way too long in my opinion.  One case I know of the medic ran the 12 while en route to another hospital that was in the opposite direction from the PCI center and it was a big MI.  Not an ideal situation.


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## fast65 (Mar 8, 2012)

I'm gonna have to agree with Vene here, this plan costs money, plain and simple. 

Educating paramedics to provide increased interventions is not cheap, it's going to require a decent amount of time and money. It's not going to be as simple as having your medical director come in and teach a 3 hour class on administering TpA, it's going to take time, and time equals money. This is a particular problem for the rural areas in which you suggest it is implemented.

The technology for transmitting EKG's over 3G or WiFi may not be expensive in the larger metropolitan areas, but in the rural setting it just won't work. There's a vast majority of my district that I hardly have cell service, let alone have 3G or access to WiFi, what's the solution there? It won't be cheap, that's for sure.

I won't continue on with the expenses, as it's kind of been covered already, but the fact of the matter is, a lot of agencies won't be able to afford all of these changes. Rural departments are having a hard enough time keeping paramedics on staff, or evening staying open, paying for extra training and equipment is out of the question. 

Expenses aside, there are a couple of other issues I see. It's not going to be easy to change the inside view of EMS. There are plenty of paramedics out there who have the very idea that we exist just for the serious calls, or just to provide a ride to the hospital, I work with a few of them. Convincing them to expand their skill set and use it appropriately is asking them to change their ways, and again, that is not easy for some people.

In conjunction with that, you have a lot of paramedics who have just become lazy over the years, and asking them to perform duties such as patient registration or placing the patient in a gown, will not go over well. 

Those are just some of the concerns I see with this plan.


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## Rettsani (Mar 8, 2012)

Craig Alan Evans said:


> Rettsani,
> 
> Are you a physician or do you have a physician with you on the ambulance in Germany?



I am something like an EMT-P. We run ambulance service in the Rendezvous system. The Ambulances are on the fire and rescue Departments and the emergency physcian vehicles are at the Hospitals. Ambulances and emergency physcian vehicles are alarmed at the same time here in the regular for AMI.  The paramedics and EMT-P are the first at the site most of the time. They supply the patient until the doctor arrives at the site.


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## Brandon O (Mar 8, 2012)

One thing I would like to see is the "harm" of bringing someone to the wrong ED reduced. As it is, oftentimes just be tagging the door at a community hospital you've sentenced the patient to an extra 30 minutes before reperfusion, even if the cath lab is down the street; they'll have to go through the whole rigmarole there before they can be finally transferred. It would be nice, particularly in areas where the PCI hospital may not be far off, if referring hospitals got on board with an "escape" protocol where suspected ACS patients got a 12-lead immediately upon arrival, the physician interprets it at the bedside, and if a STEMI is present (or high-risk NSTEMI), with no major suspicion of other confounders (dissection?), and the times are right to skip tPA, the patient goes right back out the door and back onto the same ambulance for transfer to the PCI center. No new lines, imaging, labs, questions; no need to call and get them accepted; treat it just like the medics had taken that 12-lead in the field and gone directly to the right destination.

That'll probably happen right after pigs fly, though.

Edit: just as a note, I believe South Dakota actually got a grant to set up their area with 12-leads (see http://www.codestemi.tv/ ). It's not easy to make these systems happen, and you have to get the right parties to buy in, but it's possible. Cardiac arrest systems of care are dealing with similar stuff. No single pieces, all very much an interlinking chain...


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## Rettsani (Mar 8, 2012)

Show me a patient who chooses at the right time the emergency call. It would be a dream....:unsure::sad:

 here is  taught ...
- Maximum tolerable delay PCI over lysis 90 minutes
-  time from first contact to PCI (contact-to-balloon) <120 minutes
- time from emergency call to lysis (call-to-needle) <60 Minutes 
- Time from initial contact to prehospital lysis (contact-to-needle) <30minutes
- Time from arrival to emergency room for lysis (door-to-needle) <20 - 30 minutes
- Time from arrival to the emergency room PCI (door-to-balloon):
a) with Announcement by the ambulance service <30 minutes
b) without notice by the ambulance service <60 minutes


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## WolfmanHarris (Mar 8, 2012)

Craig Alan Evans said:


> The first step is to form a regional STEMI committee and bring representatives from each step of the patient’s journey to the same table so we can all get onto the same page. I could write an entire article on the importance of this aspect alone but today let's look at the improvements I see the prehospital system can contribute to the cause.



This may just be a quirk of the mixed public/private system of the USA, but with the increased regionalization of health care in Ontario there are not an abundance of PCI centres nor is there any disincentive for any service or hospital to transport a patient there. 



> 1) Patient Education: We need to educate the public as to the importance of arriving at a PCI center when their chest pain occurs. By dialing 911 and getting the prehospital system involved they will have decreased their onset to balloon time tremendously. In my area most of the extended times to a PCI center have come from inter facility transfers and not from prehospital initiation.



Agreed. We need to cut times from symptom onset to seeking help. Interfacility transfer times have been cut in my region significantly. When a Pt. presents to the two (of three) hospitals in the region that are not the PCI centre and the hospital identifies a STEMI by 12-lead, they will not delay care for bloodwork or serial ECG. They will call our dispatch, book a stat transfer and a crew will attend and transport the Pt. the same as if they recieved the STEMI call in the community.



> 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.



We compare apples to apples when judging our STEMI bypass system. Pt. contact balloon time for EMS is compared to Pt. contact at ED (at our PCI centre) to balloon time. We don't currently track times spent by the pt. in ED at our non-PCI centres before our contact with them as we don't have access to that data as an EMS service. We track symptom onset to balloon time though on all pt.'s though that's a somewhat inexact number.



> 3) Prehospital 12 Leads: As I said previously we have made great strides in this area but what we have done is only scratching the surface. Most EMS systems have 12 leads on the ambulances staffed by paramedics. We need to extend that out at least another tier and make sure every fire truck and BLS provider can perform a 12 Lead EKG. Any patient suspected of having an acute coronary event should have a 12 lead as one of their initial vital signs.



I don't agree with placing increased skills without requisite knowledge in the hands of providers. Our BLS and ALS providers all perform 12/15 lead acquisition and interpretation, but our BLS (Primary Care Paramedic) providers have a two year college diploma to enter practice and ALS (Advanced Care Paramedic) a further year. We want to have sensitivity for STEMI certainly, but without proper education to identify and rule out STEMI-mimics we won't have specificity and the cost to the system for false activation increases quickly.



> 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?



On all Patients? If so, I disagree. ECG quickly, but when warranted. 
Time is of course important in the effective treatment of STEMI's, but let's not lose site of how long this condition has likely been developing before Pt. contact. I'm afraid I don't have supporting data, but within my own Pt.'s, symptom onset to pt. contact times of multiple hours are the rule, not the exception. With a window for treatment of less than 12 hours from onset and within two hours of patient contact, is six minutes to ECG clinically significant? Is seven? Don't delay, but let's not be too quick to apply arbitrary benchmarks.



> 4) Transmitting EKGs: It is absolutely imperative you find some way of transmitting the 12 Lead EKG for the receiving ER physician to see. It is not that the hospital doubts our ability to interpret EKGs, although, in some parts of the country this may be true. It is simply a team sport.



I don't disagree with the sentiment, I disagree with the system design. Let's cut the ED right out of the loop at in the process make some real cuts in Pt. contact to balloon time. In my system with activate the cath lab by cell phone from the field on our interpretation only, we transport to the cath lab and bypass ED directly going right into the PCI room. Certainly we bring the ECG's, but they're going right to the cardiologist when they take report from us. We have the ability to transmit and did during the STREAM thrombolytics trials, but don't use it now that the trial has ended.



> False activations occur in the ER. We do not need any bad press from false activations occurring from a prehospital EKG. If paramedics feel this is an insult to their intelligence...get over it. Anything that slows down onset to balloon time needs to be eliminated, and that includes your pride.



Once again education and QI is key. We have an extremely low false activation rate, but they do happen. With regular communication between the PCI lab and the service these can be mitigated and used as an opportunity for education. How does adding more people assessing the patient prior to activating the cath speed up onset to balloon time? By activating from the road the team is ready and waiting when we roll in.



> 5) STEMI ??: So the squiggly lines look bad...what next? I propose a two tiered prehospital response to a possible STEMI:
> 
> a) Confirmed STEMI:
> - The patient should be placed in a hospital gown and their groin should be shaved.



Interesting idea and worth considering.



> - No drips should be started and any interventions routinely performed by the ER physician should be moved to the prehospital arena such as heparin or integrelin boluses.



What is the rationale for no-drips? Here we just coordinated with the PCI lab that peripheral lines must be started in the R-arm only so as not to interfere with their treatment. I do find the heparin and integrelin bolus idea very interesting; unfortunately given the provincial directive we operate under we won't see that added to our scope unless as part of a research study in the foreseeable future.



> - If a chest x-ray is required prior to the patient going to the cath lab then a portable chest should be waiting in the ER and it should be performed on the EMS stretcher and then the patient should be immediately transferred to the cath lab.


See above. Skip the ED all together. 



> - If your EMS system has extremely long transport times to an ER or PCI center and your STEMI patient would undergo TPA at the closest ER then this should be moved into the prehospital arena.



Agreed.


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## Craig Alan Evans (Mar 8, 2012)

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.


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## Craig Alan Evans (Mar 8, 2012)

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.


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## Craig Alan Evans (Mar 8, 2012)

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.


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## fast65 (Mar 8, 2012)

Craig Alan Evans said:


> 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:
> 
> ...




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.


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## WolfmanHarris (Mar 8, 2012)

Craig Alan Evans said:


> 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.


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## Craig Alan Evans (Mar 8, 2012)

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


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## Craig Alan Evans (Mar 8, 2012)

Wolfman,

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


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## Veneficus (Mar 9, 2012)

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.


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## systemet (Mar 9, 2012)

Craig Alan Evans said:


> 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.


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## systemet (Mar 9, 2012)

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.  



Veneficus said:


> 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]


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## truetiger (Mar 9, 2012)

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.


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## Outbac1 (Mar 9, 2012)

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.


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## Veneficus (Mar 9, 2012)

systemet said:


> 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.


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## WolfmanHarris (Mar 9, 2012)

truetiger said:


> 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.


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## systemet (Mar 9, 2012)

Veneficus said:


> 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.


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## Flyhi (Mar 9, 2012)

*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


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## Craig Alan Evans (Mar 9, 2012)

truetiger said:


> 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?


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## Craig Alan Evans (Mar 9, 2012)

Outbac1 said:


> 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.
> ...




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


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## truetiger (Mar 9, 2012)

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.


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## 18G (Mar 9, 2012)

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.


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## Veneficus (Mar 10, 2012)

18G said:


> 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.


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## cruiseforever (Mar 10, 2012)

truetiger said:


> 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 have had cases were I did a 12 lead and it showed a STEMI.  Started treatment with ASA, Nitro, O2.  Buy the time I had the pt. in the ambulance the STEMI was no longer showing up.  If I would have given just the meds. before the 12 lead I would have lost alot of time before a cath lab would have been activated.


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## Brandon O (Mar 10, 2012)

cruiseforever said:


> I have had cases were I did a 12 lead and it showed a STEMI.  Started treatment with ASA, Nitro, O2.  Buy the time I had the pt. in the ambulance the STEMI was no longer showing up.  If I would have given just the meds. before the 12 lead I would have lost alot of time before a cath lab would have been activated.



This is an extremely good point. Even if the changes don't disappear, the earlier you get in the first 12-lead, the more serial recordings you'll be able to capture. Plus, if (for instance) you take one at the patient's side and one in the truck, that may be enough to determine your transport destination; you can compare the two for dynamic or progressing changes. If you only have one by the time you're loaded up, you may be stumped, and at that point in the call you pretty much need to start rolling somewhere.

Also: depending on your area, even with a field activation the cath lab may take much longer to prep than your transport time. The sooner you can make the call, the more time you're giving them.


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## Outbac1 (Mar 10, 2012)

Craig Alan Evans said:


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



 Nirvana!! That's a bit optimistic.  
 They are always hiring. US EMT-Ps can challenge our ACP exam. However, what's required from our Immigration Dept. I can't help you with. 

I suspect you don't really want to move. But if you did, it has been done. There are foriegn trained medics who have immigrated and taken paramedic jobs.


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## Outbac1 (Mar 10, 2012)

Flyhi said:


> 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.
> 
> ...




 Just to be sure I'm reading this right. You do have a Thromboembolism protocol to do? It is not available to people over 75? Ireland is half again as big as Nova Scotia with 6 times the pop. How many people are lined up at any one time waiting for an emergency cath? Here, emergency caths bump the others waiting in line. 
 Do you have a flight service to fly people to a lab? 
 It costs a lot to have a cath lab open. The cost of the lab and equipment, the cost and number of cardiologists and nurses to staff it, an OR ready to go for caths that go bad, OR staff and anesthesiologist ready and available.  It's not a simple or cheap thing to set up. It is no wonder there are not more of them there or here. 
 How many hospitals are shut down/open on nights and weekends? All but the smallest rural hosp. are open 24/7 here. The smallest hospitals here that have trouble getting a Dr. for nights are being staffed with nurses and a paramedic, so they remain open for those one or two patients that come in.  Has anything like this been tried over there?
 Always nice to hear how other systems work. We can all learn thingss from others. 

Getting ready for St. Paddys Day? I'm working the night. Should be interesting.


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## Squad51 (Mar 10, 2012)

I'm getting in on this thread a day late, but this is in response to Craig's initial post...

I agree that we can improve as pre-hospital providers in the management of STEMI patients.  We do need to have drills.  Not just STEMI, but Code Stroke and traumas.  I guess I'm saying we can improve on many things we do, but that's another discussion.

As far as the doing "everything" prehospital that the ED does when we arrive with a critical patient, I disagree.  You have to take into the account that the hospital has unlimited resources.  We have a paramedic and an EMT at best.  Placing the patient into a gown is unrealistic.  Especially if you're talking about performing a 12-lead EKG in the house.  You have to disconnect everything to change the pt into the gown.  I'm all for early detection of a STEMI, but you get less artifact if the pt is lying down.  Hook them up to the limb leads within the first 5 min, then get a 12-lead after they are on the cot.  

In most cases there simply isn't enough time to do all the things we do to treat a STEMI before we arrive at the ED.  Let alone adding things.  By the time you do a 12-lead, assess for right ventricular involvement (Which isn't done nearly enough, but getting much better as a whole.), administer aspirin and nitrates, IV, pain control (Morphine, Fentanyl, Nubain<---yeah right), Metoprolol 5,5,5 q5, call a report, transmit the 12-lead, and start a second line.  Tell me when we are going to have time to strip the patient going down the highway by yourself, to change into a gown and shave their groin, while still doing all these things?  And if we are going to go down the road of shaving their groin, we may as well administer them Benadryl too huh?

On the confirmed STEMI vs "non-confirmed" STEMI.  If a paramedic can't read a 12-lead EKG and determine if it is or isn't a STEMI, then they need a refresher on more than just EKG's.  As it was pointed out in earlier posts, not all services can afford an OMG to transmit 12-leads.  Should the patient suffer by not calling a STEMI because the "doctor" didn't "confirm" that it's a STEMI?  Yes, I agree, this is a team effort and the more people who collaboratively agree that it's a STEMI, the better.  But at what cost?  The cost of the pt having a delay in the activation of the cath lab team because EMS couldn't transmit the 12-lead?  I disagree.  After all the goal is to decrease the time to reperfusion isn't it?  We don't the patient any good by not trusting the paramedic's interpretation of the 12-lead.


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## abckidsmom (Mar 10, 2012)

Squad51 said:


> As far as the doing "everything" prehospital that the ED does when we arrive with a critical patient, I disagree.  You have to take into the account that the hospital has unlimited resources.



So does the system that Craig is talking about, but I would argue that "unlimited" is not a fair judgement anyway because only so many people can be acheiving tasks at the bedside before you're making the patient worse.



> We have a paramedic and an EMT at best.



Yep, me too, and honestly, that's how I like it.



> Placing the patient into a gown is unrealistic.  Especially if you're talking about performing a 12-lead EKG in the house.  You have to disconnect everything to change the pt into the gown.  I'm all for early detection of a STEMI, but you get less artifact if the pt is lying down.  Hook them up to the limb leads within the first 5 min, then get a 12-lead after they are on the cot.



You're making excuses.  Sure you can.  "Ma'am, we need to get an EKG.  Can I help you change into this gown and then have you lay back on the couch for a minute?  Thanks.  Family, would y'all please give her a little privacy?  Thank you."

Out of shirt, bra, sweater, into gown, leads on and done.  I usually just unplug the leads from the monitor and leave everything connected because our cots don't ahve the little shelf under the head of the bed.  Keep a gown with the sheets on the foot of the stretcher, and get out of the truck with the bag and monitor on the cot and bring it to the door.  Then everything is right there and convenient and you don't have to send your partner back to the truck.  



> In most cases there simply isn't enough time to do all the things we do to treat a STEMI before we arrive at the ED.  Let alone adding things.  By the time you do a 12-lead, assess for right ventricular involvement (Which isn't done nearly enough, but getting much better as a whole.), administer aspirin and nitrates, IV, pain control (Morphine, Fentanyl, Nubain<---yeah right), Metoprolol 5,5,5 q5, call a report, transmit the 12-lead, and start a second line.  Tell me when we are going to have time to strip the patient going down the highway by yourself, to change into a gown and shave their groin, while still doing all these things?  And if we are going to go down the road of shaving their groin, we may as well administer them Benadryl too huh?



I only find that the documentation is difficult to keep up with on a call with a STEMI, or any chest pain, really.  Go back to that lady above.  If you keep aspirin in the back pocket of the monitor, then when she's laying back for her 12 lead, she gets it then, and you have a time stamp of when the ASA was given for your notes.  

How long is your transport?  You should be able to get everything done in order during any transport...ASA, NTG , IV, more NTG, another 12 lead, move 1 lead for right sided EKG, Morphine, more NTG. Etc. You just stop when you get there, but all these meds are 5 minutes apart in their grouping, just spend a couple of minutes every 5 minutes given meds.

I'm not for shaving groins, our little razors are murder like that, but we can get these things done.  

We have a 30-45 minute transport time, and it's a rare call that I haven't done everything and then some, chatted with the patient the whole way, and finished my call report when we arrive.  It's all about staying focused on the next thing and just plodding along.  There is very rarely a huge hurry, just steady doing the next thing.


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## Aidey (Mar 10, 2012)

I am NOT getting near some guy's junk with a razor while going 70mph! Lol. Plus a poor shave job can increase infection rate because of tiny cuts in the skin. Apparently the hospital IV people have kittens when they see we've done it around an IV site. 

Our average transport time to a PCI center is around 8-12 minutes, and there aren't many over 15. It is possible to have transports approaching 30 mins if you are out on the County borders, but those are pretty few and far between because not many people live out there. We usually do not have time to do all the things described without delaying transport, even with several people on scene. Only so much multi tasking can be done at once and I've had several STEMI pts who were too sick to help us if we had tried to change them into a gown. 

On my last STEMI we were on scene for 4 minutes. I called a STEMI alert based off of the 3 lead (if you saw the ekg and the pt you would understand). The fire medic I grabbed as we were leaving couldn't do the 12 lead without help for whatever reason (he's a idiot). So in 10 minutes I gave asa, nitro x2, started 2 IVs, patched to the hospital after FIVE attempts to get through and then had to do a 12 lead. I had no time to do anything else. I think how much is done out of hospital is heavily dependent on transport time.


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## Handsome Robb (Mar 11, 2012)

18G said:


> 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????



Agreed. Our goal is a 12-lead within two minutes for patients presenting with chest pain along with other symptoms (read: cool, pale. diaphoretic) or anything else that doesn't seem right. We consistently meet this goal and it isn't uncommon for us to bypass the ER and go straight to the cath lab. Sometimes we do stop in the ER for them to acquire their own 12-lead but usually we will run one as we are pulling in and just hand it to the cardiologist who's waiting at the door for us. We have a great relationship with the cardiologists at our local hospitals though and they trust our medics when they call a STEMI in the field. With our short transport times the faster we get a 12-lead and confirm a STEMI the faster the cath lab team can be activated and the wheels can be put into motion to get the patient the definitive care they need. 

There are always variables such as being in a public building or on the street where it is easier to move the patient to the ambulance before doing the 12-lead, primarily for the patient's privacy. There's no reason to delay a 12-lead in a person's home. It takes less than 1-2 minutes to get the patient's shirt off, place the leads and capture the 12-lead.

Edit: While I'm working on getting a 12-lead my partner or the FD can establish an IV, get a fluid bolus started if we are looking at an RVI or Inferior MI and the patient is hypotensive, get some NTG, ASA and Morphine/Fentanyl (if appropriate) on board to get the patient some relief prior to moving them. Maybe it's me being new but I'm a big advocate of pain management and patient comfort. It's one of the few things we can do in the field that provides immediate relief for our patients. 

Along with doing a couple quick things on scene it allows us to load the patient, capture another 12-lead, since the leads are already placed, to begin to establish a trend. Then since we have most everything in place that we need we can get moving towards the hospital.


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## Flyhi (Mar 11, 2012)

Outbac1 said:


> Just to be sure I'm reading this right. You do have a Thromboembolism protocol to do? It is not available to people over 75? Ireland is half again as big as Nova Scotia with 6 times the pop. How many people are lined up at any one time waiting for an emergency cath? Here, emergency caths bump the others waiting in line.
> Do you have a flight service to fly people to a lab?
> It costs a lot to have a cath lab open. The cost of the lab and equipment, the cost and number of cardiologists and nurses to staff it, an OR ready to go for caths that go bad, OR staff and anesthesiologist ready and available.  It's not a simple or cheap thing to set up. It is no wonder there are not more of them there or here.
> How many hospitals are shut down/open on nights and weekends? All but the smallest rural hosp. are open 24/7 here. The smallest hospitals here that have trouble getting a Dr. for nights are being staffed with nurses and a 20 paramedic, so they remain open for those one or two patients that come in.  Has anything like this been tried over there?
> ...



Yep you just about got the rough edge of the idea. We have a country that takes 5.5 hrs to drive from tip to bottom and 3.5 hrs to drive across at the widest point. 4.5 million people and only one 999 EMS provider which is the National Ambulance Service. We have 4 PCI centres, 2 in Dublin, 1 in Cork and 1 in Galway. Have a look at the map and see where they are. WE have no HEMS so all Pt transport is by ground. our ambulances will do 140kmp tops usually 120kph. Heres a small excerise for you so you can get an idea of why I am thinking that this thread is so out of this world from my point of view. (In a good way)

http://www2.aaireland.ie/routes_beta/

Go to the above link. Its a map serach engine for Ireland.  Here's a STEMI call I had three nights ago. Put in the location names in the mapping and look at the times involved.

1)Limerick   to Abbeyfeale, Co Limerick 
Pt lived in Abbeyfeale, we took 47 mins on lights to respond to their location. At that we were lucky that we had the crew to send and that we could respond to this call immediately instead of waiting for a crew to clear off a previous task then respond. Got there and confirmed with a 12 lead that we had an Anterior STEMI. 

2) Abbeyfeale to Limerick
Another 50 mins, We had to drive the patient back to Limerick hospital as its the regions only hospital with an A & E that is open after 8pm.

3) Limerick to Cork
After 1.5 hrs in ED and the Pt being outside the max age of 75, we had to transport the patient from Limerick to Cork for the PCI as this is how long it took to get the Pt on the list and accepted by Cork.

4) We arrived in Cork and there were 3 Pt's  who were brough from all over the South end of Ireland for Cath lab. We waited another 6 hrs until all of these were done as every Pt had a STEMI and there is only 1 cath lab open for the entire region on a 24/7 basis.

Now you do the maths on time from EMS confirmation until the time this Pt ended up on the table in the Cath lab?? Crazy eh??

Apart from the usual contra for Thromboembolism we have a max age of 75 and if they are inside a 90 min travel time of the ED then we dont Throm either. This can be a 90 min travel time back to your area hospital not 90 min from a PCI centre. No Pt can be bumped up or down a que for Cath Lab as every Pt in the PCI has a confirmed STEMI anyway.

There is talk of a by pass protocol but the issue here is that we could have gotten to the PT, then driven straight to Cork PCI which would have saved a load of time. However we as medics can not contact the PCI and get a Pt on the list for that point in time. This has to be done from ED doc to Cardiologist in the PCI. Unlike the States where if a medic calls in a STEMI alert or a Stroke alert the medic can decide which hospital to go to that best suits the patients needs. Here we have to return to our maiin hospital,they may Thrombilise and then once a Doc is happy the Pt has a STEMI ONLY then the calls are made and the PCI accept the PT.

Also consider as medics MONA is the most advanced pharma we can provide to the Pt pre hospital. The Docs can do loads more in the A & E and this is one reason why we always come back to the nearest A&E before we get the Pt transfered to a PCI. If we only have a Paramedic crew (EMT I) and no Advanced Paramedic(EMT P) then we can only offer O2, ASA & Nitro SL. NO pressors, beta blockers, Inotropics, NTG drips, Fent, or any other kind of med.In fact those med are not available to any level of pre hospital practioneer overe here ??

Now you can see why I am reading the thread say Wow ..... what a nice place to be in. A system where a few medeics are looking to shave more time off a STEMI call.

Paddy's night is ALWAYS interesting ........ either when your on or off  I always think it's great that a small Island country takes over the world for 1 day every year and we make the world drink for that day :rofl:


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## Outbac1 (Mar 11, 2012)

You do have some tough transports. Here we would have more hospitals open where Drs could thrombo /nitro the pt as req'd. The Drs have far more latitude to thrombo a pt than I do. Most pts would end up in the ICU and go for a cath the next day. What we call a 24hr cath. We have a 30 - 60 min transport cutoff. Anything over 60 min transport would be a field thrombo to qualifing pts. 30-60 min it may be as close to go to the cath hosp as somewhere else so we basically decide that. 
 At the hosp the 24hr caths we take in would get bumped by an emergent STEMI brought in locally. I know they do about 20 - 25 caths a day there. Most we take down one day we take back the next. For some cases, if the helo gods are in agreement, the pt may be flown direct to the lab from a smaller hosp. All hosp. here have a LZ beside them. 

 After the crazy calls last night, for me and the ones others did around the province, I'm glad St. Paddys day isn't closer to a full moon. :beerchug:


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## Flyhi (Mar 12, 2012)

Loving your work  

It all sounds so much like a good common sense approach to the same problem in very similar systems but I am convinced that somewhere in a  room in this country there is a panel of EMS gods who ask themselves " Does this policy make sense??" If the answer is yes then they scrap the plan and reinvent the wheel again 

Thanks for the PM. If you want to PM me some details I will call you for a better chat.

I just found out I am off Paddy's day AND night ...... the Beer Gods are smiling on me :rofl: 

__________________________________________________________________________________________________________________________________

If you are going to be a bear .... Be a grizzly


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