STEMIs (ST-Elevation Myocardial Infarctions) are my favorite EMS call. I like them as a paramedic and I like them as an EMS coordinator. They are a great test of your both your ability as a medic and the ability of your EMS/hospital system to function well. They require clinical acumen, speed, skill, and coordination of resources.
If done well, you can save a patient’s life, if done poorly, a life could be lost (although sometimes lives are lost even when everything is done right). And the lives we are talking about here are usually people in the prime of their life. These aren’t asystole codes of 95-year-old ladies whose ribs break at the first push of CPR. And these aren’t trauma patients whose bones can’t be unbroken, whose head injuries can’t be easliy unbled.
It is simple. Recognize a possible STEMI, do a 12-lead, interpret it, notify the hospital/and hopefully get the people in the cath lab ready. Think of yourself as the 911 dispatcher for the cath lab. As important as all the skills you will do is getting the cath lab team sliding down their bat poles and getting their superhero suits on and having them there ready to work their miracles when you come through the door with your patient.
Transmit the 12-lead as soon as you identify it. If you can’t transmit, call it in, as soon as you can (not after you have done your two IVs and given ASA and 3 NTGs) — as soon as you see it is a STEMI.
Give 02 if the patient is hypoxic (AHA says no longer does every STEMI get the nonrebreather).
ASA if there are no contraindications.
IV – two is best, the bigger the better.
Nitro — unless it is a inferior STEMI with right ventricle involvement or any MI with low BP.
Morphine — if pain is not controlled by NTG.
Zofran — if the patient is nauseous.
Take their clothes off if feasible. Hospital gown on top, sheet over the pants (this will save time at the ED).
Get your registration info so they can get him into the system.
Switch O2 to the stretcher tank and mount the monitor on the stretcher so there is no delay packaging once you arrive.
Hit the curb and out you pop.
Oh, yeah, and have defib pads ready in case your patient codes. The natural progression of a STEMI is to VF and cardiac arrest. We are talking high risk here!
The hospitals have been practicing their pit crew techniques on STEMIs as well. Hospitals are being rated now on Door-to-Balloon (D2B) times meaning time from when the patient hits triage to when the balloon crosses the blockage/lesion in the cath lab.
The three big hospitals in our area have been battling with each other for STEMI patients and all of them are recording both excellent door-to-balloon times and great patient outcomes. Most of these patients who may be withinin minutes of cardiac arrest walk out of the hospital in a matter of a few days with clar stented arteries, on some new meds and told to eat heart healthy diets. Years ago they would have planted in the ground. Much of the improvemt is due the medical system recognizing and encouraging the important role EMS plays. Years ago I used to have to walk through the ED waving a modified 9-lead strip trying to get a doctor’s attention that my patient was having an MI. Now the MD knows and the ED and cath lab are already readying even before I leave the patient’s house.
A new study in the American Journal of Emergency Medicine published in April of this year, Hospital-based strategies contributing to percutaneous coronary intervention time reduction in the patient with ST-segment elevation myocardiaI infarction: a review of the “system-of-care” approach, concluded among 8 primary strategies for reducing hospoital door-to-balloon times, “2 have substantial evidence to support their implementation in the attempt to reduce door-to-balloon time in ST-segment elevation myocardial infarction (STEMI), including emergency physician activation of the cardiac catheterization laboratory and prehospital activation of the STEMI alert process.”