3. STEMI Care

My # 3 greatest treatment change in the last twenty years is STEMI care.

When I started in EMS we had Life Pack 5s, which showed only one lead at a time in a tiny window. When I went to paramedic school, no one taught us about 12-leads. Paramedics didn’t do them. Early on, we did an experimental project where we had a giant 12-lead machine in our ambulance, but it was so big and we were so uncertain about how to do a read a 12-lead that we never used it (or at least I didn’t) and the project soon died.

Later, another medic taught me how to do a modified 9-lead ECG. This involved putting the machine in lead III and moving the left leg electrode across the chest in the V1-V6 positions, while being certain to print in the diagnostic mode. We then had to cut and paste the strips onto a sheet of paper. We labeled the newly aquired views as MCL1-MCL6.

The first time I did one (the day after I had been taught how to do it), I had a healthy young man with crushing chest pain. His skin was warm and dry. His vitals were BP 120/80, HR-64, RR-16, SAT-100% on room air. As a lark, I tried the 9 lead ecg. When I put it in MCL4, it showed tombstone elevation. Curious, I thought. I showed it to the triage nurse, who was dismissive, but at least instead of putting the patient in the waiting room, she put him in a regular room, where the room’s nurse found him in cardiac arrest when she went in to assess him. He was defibrillated successfully, taken to the cath lab and found to have a 100% blockage of his LAD.

I can remember many times when I walked through the ED waving my 9-leads, and then even later after we got 12-leads, waving those, trying to get a doctor to look at one. The regular procedure was put the patient in the room, have the nurse come over, assess, do a 12-lead and have the nurse show it to the doctor. We all soon learned to be aggressive with our 12-leads, calling in saying the 12-lead showed an MI (sure, sure, they thought), and then using the 12-lead as a ticket to the head of the triage line. Excuse me, see my 12-lead, mind if I cut ahead. Take a look at this. Where’s the doctor?

Nowadays, of course, it is so much different. We see a STEMI in the field, we call the hospital from the patient’s bedroom, talk directly to a doctor and activate the cath lab from the field. We often bring the patient right up to the cath lab on our stretcher. Progress.

Here’s a post I wrote on STEMIs.

STEMIs

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.

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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.”

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16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

4. CPAP5. Capnography
6. Termination of Rescusitation Guidelines
7. Decreased Use of Lights and Sirens
8. Selective Spinal Immobilization Guidelines
9. Alternative Airways
10. Chemical Restraint
11. No More Lasix
12. EZ-IO
13. Permissive Hypotension
14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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Peter Canning

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