Joining the 'winds of change': STEMI and EMS

Cooperation is key in coronary treatments

By Robert Donovan and Kate Donovan, RN, BSN

A 48-year-old man presented with crushing chest pain to an outlying hospital ER, where he was diagnosed as having an acute inferior wall myocardial infarction. The ER doctor gave thrombolytics, nitroglycerin, and morphine, but to no avail. The patient's chest pain worsened, and the ST segments began to look like tombstones.

The ER doctor called my ER, and spoke to me about the case. Her hospital did not have percutaneous cardiac interventional (PCI) capabilities. Together, we decided to send the patient via Code 3 ambulance to my facility. After I hung up the phone, I activated our "AMI Pre-Alert," which is announced over the paging system throughout the hospital. I also spoke with the interventional cardiologist via phone, and the cath team was alerted.

I was at the ambulance entrance when they arrived. The patient was sleepy, but opened his eyes when I spoke. His skin was cold and dry, and he had a good radial pulse. I decided that he was "stable enough" for me to escort him directly to the cath lab, where the cath team awaited him.

An amazingly quick 24 minutes later, the cardiologist had opened up the blocked vessel with a balloon and placed a stent. The patient was taken to the CCU, where he spent the night. He returned home four days later with minimal damage to his heart. From start to finish, each player in this chain of care has played an important part.

Explaining heart disease
Is heart disease a modern-day phenomenon resulting from our poor lifestyles?

Surprisingly, coronary artery disease (CAD) has been around for eons, so we can't blame it all on Burger King Whoppers. Recently, several Egyptian mummies underwent high resolution CAT scans on their hearts, with the majority showing significant CAD.

The most ancient Egyptian discovered so far afflicted with atherosclerosis was Lady Rai, who lived to an estimated age of 30-40 years around 1530 BC (about 200 years prior to King Tut) and had been the nursemaid to Queen Nefertiri.

When I graduated from medical school, our treatment for a patient having a heart attack was basically 'wait and watch.' Our treatment was passive: oxygen, rest, morphine, nitroglycerin, ASA, and hope for the best. We were not "treating" heart attacks; we were really just watching them evolve and then dealing with the resulting tissue damage afterward.

The winds of change have arrived, and now we can actually make a difference. Even more recently, the role of EMS and community education has jumped to the forefront of how we can make a difference and actually minimize the damage to the heart.

The key is expeditious treatment. Today's trend for treatment of a STEMI (ST Elevation MI) is to get an ECG as quickly as possible, either in the field, or within five minutes of arrival at the ER. If the ECG shows a STEMI, a pre-determined sequence of events is put into motion. The actual steps that a hospital should take depends upon its resources, ranging from stabilize and transport, all the way to giving thrombolytics or opening up the blocked artery with stents or balloons.

Inter-departmental cooperation
In our hospital, we call our action plan "AMI ALERT." This has taken inter-departmental cooperation and much thinking out of the box over the last 2-3 years. With a team effort, we have been able to achieve some remarkable outcomes, getting patients re-perfused in as little as 24 minutes after arrival in the ER.

Here's how it works: the cardiac interventionalist and cath lab team are alerted within minutes after the ER doctor reads the ECG, and the patient is whisked away as quickly as possible to the cath lab after his/her arrival in the ER. The ER usually consists of getting an IV, CXR, nitro and heparin drips,, rapid electrolytes, and clothing removal in 5-6 minutes; they are then moved to the cath lab.

Today's catch phrase is "time is tissue." The goal is to keep the "door-to-balloon" time to 90 minutes or less. No matter what else we do, it is re-perfusion of the heart muscle that is key, and the more quickly we get the patient to the balloon after onset of symptoms, the better the outcome.

The sequencing may involve different steps depending upon time of day, or how the patient arrives at the ER,- whether it's inter-facility transfer, from the field via helicopter or ambulance, or a walk-in. During "off hours" for the cath lab, it is more of a challenge, as the on-call team must be paged and get to the hospital within 30 minutes.

We have set our own benchmarks in accordance with those put out by the Society for Chest Pain Centers (, an international organization dedicated to seeing cardiac mortality decline. Studies have shown that following pre-determined pathways for treatment of the chest pain patient result in better patient outcomes and lower mortality.

What can you do as a pre-hospital health care team member?

Your intervention is key to the rapid treatment of an ACS (acute coronary syndromes) patient. Being the first point of contact for health care on a scene call, paramedics and EMTs are vital to starting the rapid sequencing to get the patient diagnosed as quickly as possible. If you have ECG capabilities, you can get the first ECG and get the IV in, following your local protocols. Many of today's newer ECG machines will interpret an ST Elevation MI and the EMS team can alert the ER physician.

If your hospital facility does not have percutaneous interventional capabilities, arrangements can be made with the nearest facility to bypass a non-PCI hospital and go directly to the STEMI receiving center. Precious time is saved in doing so.

Here are my suggestions:

• Get involved. Minimizing the door-to-balloon time is important, but really it is the onset of symptoms to balloon that is more important. EMS plays a big role in this.

• Ask the tough questions. What can our community do to improve our care of the ACS patient? How can we educate the public to access EMS appropriately?

• Bring the latest information about STEMI treatment to the attention of your health care team and see if you can't start the winds of change blowing in your community.

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