STEMI...How Can we Improve??

[cruiseforever]

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.

 

[Brandon O]

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.

 

[Outbac1]

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.

 

[Outbac1]

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.
Cheers

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.

 

[Squad51]

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.

 

[abckidsmom]

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.

 

[Aidey]

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.

 

[Handsome Robb]

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.

 

[Flyhi]

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?
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.

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:

 

[Outbac1]

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:

 

[Flyhi]

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