STEMI (ST-Elevation Myocardial Infarction)

Dispatch: 8:07 Chest Pain
Enroute: 8:08
On Scene: 8:14
At Patient: 8:15

66-year-old female with 3 out of 10 chest pain X 2 hours. Periodic chest pain for last week. Skin warm and dry. No prior heart hx.

Initial 3-lead strip: 8:16

Vitals, 02 by cannula. 324 ASA PO. Patient shirt removed, put in hospital gown

Initial 12-Lead: 8:19 (Watch V4 in particular, as well as V1-V3 over course of ECGs)

IV # 18 in left AC. 0.4 NTG SL

Depart Scene: 8:21

Hospital called for official STEMI Notification: 8:22

2nd 12-lead ECG: 8:22 (Note LP12 spitting out 12-leads every three minutes.

8:23 2nd NTG SL. 2nd IV # 18 in right AC

(In meantime hospital alerting cath lab team)

8:25 3rd 12-Lead ECG

8:26 Cath Lab team arrives in ED

8:28: 4th 12-Lead ECG Pain now up to a 5.

Begin preparing patient for quick exit from ambulance

8:31 5th 12-Lead ECG

8:34 Out at Hospital

8:35 Transfer Care to ED Doc/medical staff/ cath lab team

8:36 Hospital ECG

Next ten minutes Patient is prepped(additional drugs, procedure discussed, consent given) and then hustled upstairs.

8:50 Patient hits cath lab table.

9:08 Balloon inflated (Hospital Door to Balloon Time – 34 minutes).

Patient has 100% occlusion of Left Anterior Descending artery (The Widowmaker). Suffers arrhythmia. V-Tac. cardio-verted X 1. Then full reperfusion.

Normalized ECG.

***

First there were hospitals, then ambulances, then emergency departments, then EMTs, then paramedics, then prehospital ECGs, and then STEMI alerts with cath lab notifications.

Progress

***

Paramedics Activate Cath Lab for STEMI Patients in Some Areas

26 Comments

  • Ron says:

    Thanks for the update.R9:08 Balloon inflated (Hospital Door to Balloon Time – 34 minutes).Patient has 100% occulsion of Left Anterior Descending artery (The Widowmaker). Suffers arrythmia. V-Tac. cardio-verted X 1. Then full reperfusion. Normalized ECG

  • medicnick says:

    Hey Peter, cool case. This is a great example of a stuttering MI. We’re starting a clinical trial (my employer) for patients like this (www.angel-med.com).This is the kind of case that the EKG Club really likes to have. You might consider posting over there too. It is at http://health.groups.yahoo.com/group/ekg_club/Cheers,Nick

  • Joe says:

    hey Pete first off great job on the stemi. I don’t know if you heard about the IMMEDIATE trial going on down south here you should check it out so far I’ve seen it used once but I do not know if it was the drug or placebo http://www.immediatetrial.com/NewFiles/PartComm/Sites/NewHaven.html this med is going to save lives

  • TOTWTYTR says:

    Nice work in the field Peter. I’m a bit less impressed with the ED response. There is no reason to repeat the 12 lead. Nor is there any real reason for a door to balloon time of 34 minutes. The last MI I transported had a door to balloon time of 15 minutes. That’s not a reflection of EMS greatness, it’s a reflection of a hospital that takes EMS reports seriously and has a cath lab less than 100 feet from the ED. My observation is that it’s not EMS that’s causing needless delays, it’s EDs.

  • MedicThree says:

    Peter–TOTWTYTR–I’m so jealous of both of you. 1, the closest hospital is usually less than 20 minutes(not always in our county). It is a non-surgical facility.The centralized Heart Hospital is about 45 minutes by ground, and only 28 by air(if only helicopters got off the ground the second you asked for them, and didn’t take 10 minutes to load…). I opt for ground 98% of the time.Even then–the recieving hospitals never trust our field “impression”. It drives me nuts. Why bother having medics in the field if you won’t use us. You might as well go back to the goold ‘ol days of EMT-A and just drop the rest of us.Every days I find a little more ammo to go to my Medical Director and try and persuade him to have faith in us–then again He hasn’t updated protocol in 12 years, and hasn’t done any sort of inservice/training with the ambulance service in longer…

  • Herbie says:

    Strong work!! It’s amazing to watch the MI evolve over the 12-Lead EKG!

  • Rogue Medic says:

    I agree with TOTWTYTR that you did nice work, but the hospital can do better – at least, if they intend to take MI care seriously. Joe,What drug are they using?Medic Three,It is a shame that you have a medical director with a no-show job. There are too many medical directors like this. It is nice to see that you strive for excellence in spite of the lack of medical oversight. I’m reading this on my phone and V4 clearly makes some dramatic changes. Nice ECGs.

  • PC says:

    Thanks for all the comments.In defense of the hospital, while I am not all that up to speed on everything it takes to do the cath, the door to balloon time is not time into the cathlab, but time when the balloon is actually inflated inside the artery. They were on the table in 16 minutes. I do think that a better way which will hopefully be coming if the current program proves successful is for medics to bypass the ED entirely and go right into the cath lab. In this particular hospital, given the cath lab location, a patient could be on the table in 5 minutes.

  • Rogue Medic says:

    I just read the JEMS article. How can a doctor claim that it is obviously impossible to train 2700(?) medics to read 12 leads? There are plenty of things that medics can be trained to do. Whether they can be trained does not depend on the number of medics. Tom B. tell me Dr. Rokos doesn’t believe this. Using this logic, they probably could not train physicians to do this, either. Claiming that you have too many medics to be able to train them to be competent at something that is in the paramedic scope of practice is scary. Why believe that you are able to train them to be competent at anything? I’m sure the National Registry could come up with some sort of ECG liturgy as a test of competence in this.

  • UKEMT says:

    What a load of rubbish from that doctor. I work in the UK for the London Ambulance Service. About 3 or 4 years ago all our staff were trained to diagnose stemis and transport to a cath lab direct.Whenever I take a patient in, our 12-lead is accepted by the cardiologists and the patient transfers from our trolley onto the cath lab table. LAS has somewhere in the region of 3500 frontline staff who were all trained to diagnose STEMIs. It is possible, we have proved it. For those patients whose MIs are missed or difficult to diagnose (LBBB or similar) we are able to head to the ER and get a doc to look at the strip before redirecting to the cath lab if necessary.

  • Joe says:

    Rogue the drug used in the trial is a mixture of glucose insulin and potassium.

  • Tom Reynolds says:

    We do this in London, on my particular patch we bypass the A&E departments and head for the specialist heart hospital (which has no A&E).It's one of the few things that I think we do right and is a real model of how we should be dealing with people's health.

  • brendan says:

    I just read the JEMS article. How can a doctor claim that it is obviously impossible to train 2700(?) medics to read 12 leads? What’s even more pathetic is that, from that statement, we can only assume that 2700 paramedics weren’t taught to read 12-leads in paramedic school.Which, come to think of it, I believe, considering the system in question is LA if memory serves.

  • VA FireMedic says:

    awesome case, and it shows great communication and team work. its always great to see when this happens nearly perfectly.the only problem here is that some agencies still dont have 12 lead, and those of us that do have it cant transmit (which shouldnt be a problem). case in point, had a pt that showed marked ST-elevation, called it in, but couldnt transmit. even called a “STEMI ALERT” on the radio. the hospital didnt activate the cath team until the dr saw the 12 lead at the hospital (the cath team isnt even in house…they had to come from home). apparently medics cant see elevation and cant even read the printout when it says **ACUTE MI SUSPECTED**oh well.

  • Tom B says:

    I understand where you guys are coming from, and I feel your pain, but Dr. Rokos does have a point. He’s also a huge advocate for EMS and prehospital 12 lead ECGs, and it’s hard to dispute the success of the program they’ve got running in Southern California.In the paper I co-authored with Dr. Rokos (The emergency medical services-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance – Issue 2 of STEMI Systems available at stemisystems.org) we point out there is no “one size fits all” solution for regionalized STEMI care.”[T]hree strategies exist for prehospital diagnosis of STEMI: direct, on-site interpretation of the PH-ECG by appropriately trained paramedics, direct, on-site interpretation by PH-ECG machines using computerized interpretive algorithms, or off-site interpretation, with PH-ECG transmission to a physician for immediate interpretation. Each of these options has benefits and drawbacks, but potentially the most timely and accurate system involves a combination of all three strategies. Research in this area is ongoing.”While I agree that paramedics can be trained to do almost anything, I also concede that it would be extremely difficult to train all of the paramedics in the 4-county region of Southern California to interpret 12 lead ECGs to a high enough level to activate the cath lab at 0300 Sunday morning based strictly on the paramedic interpretation (and maintain an acceptable over-triage rate).That’s just reality, not a slam against anyone. Please see my post at the PH12ECG blog entitled “The problem of ST segment elevation” dated Oct 26, 2008. It’s not helpful that we’ve been told 12 lead ECG interpretation is so easy that a janitor can do it. That’s only true for the slam dunk cases (like this one). I’d like to point out that the GE/Marquette 12SL interpretive algorithm gave the ***ACUTE MI SUSPECTED*** message for this case. I don’t like relying on a machine either, but it’s been proven that the message has a high specificity, especially when the chief complaint is chest pain. Like it or not, it’s specificity that matters with STEMI care. which makes it a little different from trauma.It’s debatable as to whether or not 12 lead ECGs are in the paramedic scope of practice (according to my reading of the DOT curriculum they are) but I am acutely aware of the level of education most paramedics receive.Should it be the goal we all strive for? Certainly! But first we have to change the way paramedics are educated!Tom B.

  • TOTWTYTR says:

    Maybe the problem in Southern California is that there are too many paramedics. It’s not a matter of training, it’s a matter of educating and training. My system has been doing 12 lead interpretation in the field without the computer based algorhithms since the mid 1990s. We’ve done several studies, which show we have 98% agreement with cardiologists when our 12 leads are over read. There is no reason to transmit EKGs to hospitals for interpretation either. Systems that think those are good strategies need to rethink the standards they expect their paramedics to meet.

  • MedicThree says:

    The issue of having a no-show medical director is just part of the foundation of about a million problems I am encountering with my current job. Posts will follow about my attempts to fix such things, as well as my plan if they aren’t fixed. Honestly, in Paramedic school we had ONE day of 12 lead interpretation. If it wasn’t for the desire to know more I would be clueless.If paramedic schools don’t HAVE to teach something they are not going to do it.

  • Tom B says:

    Are you in Toronto, TOTWTYTR? Or was it Ontario? I’m trying to remember the city in Canada that has its computerized interpretation turned off. If you have studies that show paramedics are that good at 12 lead ECG interpretation, then by all means publish them so we can study what your system is doing right. I’d like to see the methodology. ED physicians don’t generally do that well when compared to cardiologists. I respectfully disagree with the idea that there’s no reason to transmit an ECG to the hospital. When it’s a borderline case, I don’t want to be the one to make the call, especially considering the overtriage rates reported in JAMA last year.Tom B.

  • TOTWTYTR says:

    No TomB, I’m right here in the US. Interestingly, the studies have been published, but I’m not sure if the system is named in them. Naming the system would tell a number of people who I am, and I don’t desire to do that for reasons I won’t bore you with. Our data has been published and even presented at Eagles. As to borderline cases, there is no reason to think that ED doctors are going to be better at figuring that out than medics are. That’s why we have three choices, STEMI, Possible STEMI, Non STEMI. Neither transmitting 12 leads nor using computer interpretation algorithms will eliminate the borderline cases. Medicthree, not to sound like the cranky old guy I am, but back when I was in paramedic school the LP10 was just being introduced, the LP11 was being designed and the LP12 wasn’t even a concept. When we first started doing 12 leads a few years later, we were using LP10s with the single channel 12 Lead adapter. All of which is to say that no one was teaching 12 leads back then. It’s about an eight hour course to get the basics of 12 leads down. After that, it’s practice, practice, practice.

  • MedicThree says:

    TOTWTYTR–I’m not blaming my school, but was pointing out that my program sees it as optional, as do most. If I didn’t dig into it more I wouldn’t have a CLUE what I’m doing.Our big step towards progress here was that we got the LP12 modem for sending in 12 leads… not that I can get my coworkers/supervisor to actually run a 12 lead and send it in, let alone interpret it themselves.My battle is more about fighting a system of complacent medics who have it way to good. The way things are going here I don’t plan on staying much more than a few more months. I’m honestly considering moving to one of the “career ender” services over this one–this one is far worse, they have just not pissed off enough people in the EMS community for word to spread.

  • Anonymous says:

    G’day Peter,Im a student paramedic in Aus and I would love if it if the different discrepancies and arrhythmias on your ECG’s could be in some way described and pointed out. I’ve been having a look and been trying to work some of them out myself but there are a few that I struggle withCheers mate!

  • Walt Trachim says:

    Great post, Peter – as always, you always put up such good quality stuff.The whole issue of training vs. education and standardization seems to be an ongoing headache for so many organizations. The DOT does indeed have a standard in the curriculum for each level of practice – we all know that. Why does it seem like it is so hard for said standards to be met in some areas? I know that this might be a rhetorical question, but it is an important one, at least in my view.$0.02

  • DrWes says:

    Shortest door-to-balloon times always occur when the “acute” arrives just before the routinely-scheuduled AM cath lab case is about to be placed on the table… Still, nice case.

  • PC says:

    Thanks for all the great comments. I’ve learned a lot from them. STEMIs are my “favorite” calls in that you have a lot to do, the patient is usually always working with you, and you can make a difference. While clearly from the comments some systems are way more advanced than others, the trend is moving toward these patients getting to the cath lab quicker and quicker and EMS is playing a key role in that. I plan on writing a follow up post sometime in the next month looking at this from a system issues and incorporating some of the comments you all have made.Thansk again,Peter C

  • Tom B says:

    By the way, it’s Ottawa, Canada that has the computerized interpretation turned off! 🙂 They’re doing quite well with it turned off, too! Tom

  • WelshMedic says:

    Currently here in the Netherlands all ALS EMS providers (usually CCRN’s) are trained to interpret an ECG and diagnose a STEMI. The patient is then given heparin, clopidrogel and aspirine enroute and then directly admitted to the cath-lab. There is, as far as I’m aware, an extremely low incidence of false-alerts. So, if a whole country of providers can be trained, why isn’t that the case in California?WM

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