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Diagnosis: STEMI

Diagnosis: STEMI. Info for the Community. My Roots (North of the Homestead). Devils Lake = Home. 2. 1. 4. 3. FYI: ND has 4 PCI centers…. North Dakota – The Four “F’s”. F1) Freezing… Coldest temp in Devils Lake last year? -32 degrees (below zero). North Dakota – The Four “F’s”.

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Diagnosis: STEMI

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  1. Diagnosis: STEMI Info for the Community

  2. My Roots (North of the Homestead) Devils Lake = Home 2 1 4 3 FYI: ND has 4 PCI centers…

  3. North Dakota – The Four “F’s” F1) Freezing… Coldest temp in Devils Lake last year? -32 degrees(below zero)

  4. North Dakota – The Four “F’s” F2) Farming… Life in the “Vast Lane”

  5. North Dakota – The Four “F’s” Snow plow on Devils Lake… F3) Fishing (ice) Ice House Ice = 3.5’

  6. 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

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

  8. 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)

  9. Lesson: Avoid “Fred Sanford Syndrome” Not everyone with a heart attack has “chest pain!”

  10. 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…….

  11. 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!

  12. Another Bad ECG! No Recognition = No Reperfusion!

  13. STEMI 2010: “60 is the New 90” Mortality Reduction (%) 100 Shifts in Potential Outcomes i.e. 44 is better than 66!!! D 80 A-B – No Benefit 60 A-C – Benefit Mortality Reduction, (%) C B-C – Benefit D-B – Harm 40 D-C – Harm 20 B A Extent of Salvage(% of area at risk) 0 0 4 8 12 16 20 24 Time From Symptom Onset to Reperfusion Therapy(hours) Gersh BJ, et al. JAMA. 2005;293:979-986.

  14. The “STEMI Care Continuum”Cemented by Relationships! THE PATIENT EMS personnel ED triage personnel Medical Command ED nursing staff ED physician EMS transfer staff Paging system personnel Cath lab staff Cardiologist Quality Improvement staff Recognition! Relationships Reperfusion!

  15. The Cardinal Rule: Once STEMI is identified  it must trigger a clear response downstream! ECG Acquisition EMS Evaluation Communication Decision!

  16. I. Remember…Most of the Time …the easy ones are easy! So, make more of them easy!

  17. 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!

  18. 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!

  19. 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!

  20. However, it is as it is…. Several reasons why pre-hospital STEMI care will always remain a challenge…

  21. All Americans are Not Distributed Equally! Rokos et al. J Am Coll Cardiol Intv, 2009; 2:339-346

  22. Non-PCI capable PCI capable STEMI Systems of Care Awareness Activate EMS Avoid delay Patient & Community 12-lead ECG 9-1-1 inter-hospital transport EMSED Activate team No diversion STEMI Referral SYSTEM OF CARE CENTER OF CARE Treatment protocols and clinical pathways STEMI Receiving CENTER OF CARE Jacobs. Circulation 2007;116:217-230.

  23. “STEMI Vision” –Just Say No! 95%+ of EMS calls are NOT STEMI! Etoh Chest Pain Need ride Ab Pain MVA Altered STEMI ??? Weak/dizzy

  24. 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!

  25. Think Globally, Act Locally • EMS STEMI solutions must be locally driven based on national suggestions • Change items that really matter.

  26. So, Where Do We Start?

  27. 4 a.m. Sunday night, Raining… Grandma’s house …44 miles out…

  28. Got STEMI? –Call the ED! I think I got one! • EMS/ED communication on every potential STEMI is a must • Either with OR without ECG transmission

  29. 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

  30. 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…

  31. Post Cath

  32. Madison County, VA “EMS Angels”

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