Diagnosis: STEMI

Info for the Community

My Roots (North of the Homestead)

Devils Lake = Home

Devils Lake = Home

FYI: ND has 4 PCI centers…

2 1

4 3

North Dakota – The Four “F’s”

F1) Freezing…

Coldest temp inDevils Lake last year?

-32 degrees (below zero)

North Dakota – The Four “F’s”

F2) Farming…

Life in the “Vast Lane”

North Dakota – The Four “F’s”

Snow plow on Devils Lake…

Ice House

Ice = 3.5’

F3) Fishing (ice)

North Dakota – The Four “F’s”

F4) And Flooding…

1997 Red River of the North flooding Grand Forks, ND

Photo: “Come Hell or High Water” (left) won Pulitzer Prize

ST-Segment Elevation Myocardial ST-Segment Elevation Myocardial Infarction (STEMI) =BAD!Infarction (STEMI) =BAD!

What is a STEMI?

A suddenly clogged artery to the heart May happen without warning High risk of death or permanent injury Symptoms are not always chest pain Treatment is opening of the artery

Drano (thrombolytics)

Roto-Rooter (angioplasty)

Lesson: Avoid “Fred Sanford Syndrome”

Not everyone with a heart attack has “chest pain!”

How do you diagnose STEMI?

Its very simple: Do an ECG

ST elevation on the ECG defines the disease

ST elevation is an acute emergency trigger for something…….

STEMI: A Needle in the Haystack

STEMI cases are few and far between

Without Recognition there can be no Reperfusion

So, you have to do a lot of ECG’s!

!

…Its a cost of doing business!

Another Bad ECG!Another Bad ECG!

No Recognition = No Reperfusion!

STEMI 2010: “60 is the New 90”

Gersh BJ, et al. Gersh BJ, et al. JAMAJAMA. 2005;293:979-986.. 2005;293:979-986.

00

2020

4040

6060

8080

100100

1212 2424Time From Symptom Onset to Reperfusion TherapyTime From Symptom Onset to Reperfusion Therapy

(hours)(hours)

Mort

ality

Red

ucti

on

, (%

)M

ort

ality

Red

ucti

on

, (%

)

Mortality Mortality Reduction (%) (%)

Extent of Salvage(% of area at risk)

D-B – Harm

A-B – No Benefit

Shifts in Potential

Outcomes

A-C – BenefitB-C – Benefit

D-C – Harm

00 44

DD

CC

BBAA

88 1616 2020

i.e. 44 is better than 66!!!

The “STEMI Care Continuum”The “STEMI Care Continuum” Cemented by Relationships! Cemented by Relationships!

THE PATIENTTHE PATIENT EMS personnelEMS personnel ED triage personnelED triage personnel Medical CommandMedical Command ED nursing staffED nursing staff ED physician ED physician EMS transfer staffEMS transfer staff Paging system personnelPaging system personnel Cath lab staffCath lab staff CardiologistCardiologist Quality Improvement staffQuality Improvement staff

Reperfusion!

Recognition!

Relationships

The Cardinal Rule: Once STEMI is identified it must trigger a clear response downstream!

ECG Acquisition

Communication

EMS Evaluation

Decision!

I. Remember…Most of the Time

…the easy ones are easy!

So, make more of them easy!

II. STEMI Fact: If it Can Go Wrong, it Will (sooner or later)

Leave nothing to chance!

Approach STEMI systems building like a system’s engineer…

Don’t try to error-proof your providers. Error-proof your system!

III. STEMI 2010: There is NO New Frontier!

Every STEMI case has the same fixed endpoints (R2R)

Model success, but don’t copy it! (???)

Adapt principles to the situations not vice versa!

Recognition to Reperfusion

TRUTH: Without early recognition there can be no progress towards early reperfusion

The focus must be on the earliest possible recognition followed by fast and precise reperfusion

Again, it all begins with Recognition!

However, it is as it is….

Several reasons why pre-hospital STEMI

care will always remain a challenge…

Rokos et al. J Am Coll Cardiol Intv, 2009; 2:339-346

All Americans are Not Distributed Equally!

All Americans are Not Distributed Equally!

STEMI Systems of Care

PCIPCIcapable

Non-PCINon-PCIcapable

SYSTEMSYSTEM OF CARE OF CARE

CENTER OF CENTER OF CARECARE

CENTER OF CENTER OF CARECARE

Patient &Community

EMSED

STEMI Referral

STEMI Receiving

Awareness

Activate EMS

Avoid delay

12-lead ECG

9-1-1 inter-hospital transport

Activate team

No diversion

Treatment protocols and clinical pathways

Jacobs. Circulation 2007;116:217-230.

“STEMI Vision” –Just Say No!

95%+ of EMS calls are NOT STEMI!

Ab PainMVA

Weak/dizzy

???Altered

Need rideEtoh

STEMI

Chest Pain

The “STEMI/Sick Patient” Paradox…

Sick EMS patients (usually) look sick(trauma, VFIB, hypoxia, asystole)

Motto: Keep ‘em alive, & diagnose ‘em after arrival!

…Not so with STEMI!

Think Globally, Act Locally EMS STEMI

solutions must be locally driven based on national suggestions

Change items that really matter.

So, Where Do We Start?

4 a.m. Sunday night, Raining… Grandma’s house …44 miles out…

Got STEMI? –Call the ED!

EMS/ED communication on every potential STEMI is a must

Either with OR without ECG transmission

I think I got one!

D: Logging, Bad Burgers & “Angels”

34 year-old male is logging trees in remote area Increased heartburn after “gut bomb” lunch Later, his boss starts driving him to the hospital Pain worsens; His boss calls rural EMS, who

arrange to meet them at a local “KwikMart”. EMS does ECG in parking lot: it looks “bad” Idea: fax ECG to MedCom before departure

DX: Acute Inferior Wall MI! EMS departs for PCI center “Joe” at KwikMart faxes the ECG In route patient goes into VFIB arrest Defibrillated once with good results… EMS contacts PCI center in route;

discusses ECG with the ED physician (…NO TRANSMISSION) Cath lab activated, ED on Standby…

Post Cath

Madison County, VA “EMS Angels”