Cardiac Cath Lab - Specialty Referral?

[JPINFV]

JPINFV, we are supposed to call for morphine as well, but our medical direction understands the limits of communication based on geography for us. Not allowing medics to give ASA is ridiculous. I would hope that your dispatchers are telling these patients to take some Excedrin, or Bufferin before you get there. :shock:

I honestly don't know what, if any, prehospital instructions are given. Just going through the Regional Paramedic Advisory Committee minutes (I was bored), there was some talk in April of returning Aspirin to the field.

[JPINFV]

Oh I believed you! I just couldn't believe the people that made that decision!

Just curious. Let's say you have a 50 year old patient. She's a heavy smoker and has a history of HTN and high cholesterol. She woke up out of bed in the middle of the night with unbearable chest pain and called 911. BP is 140/90, HR is 90 and regular, RR is 22. No JVD, no edema, and lung sounds are clear, no dyspnea. You do a 12 lead and see, undeniably, ST elevations in leads 2, 3, and aVf. But she's agitated, and all the V leads are unclear. Your monitor says, "Excessive noise: Unable to interpret".

Could you (would you) call the base hospital and request to go to the cardiac center? What do you think the decision would be?

To be honest, I've never run any 911 calls yet besides the rather mellow calls I got during my orientation. I'm 99% sure [i.e. they're required, but that doesn't always mean they do] that calls like this would have to have a base hospital contact [only 1 city is currently operation under comprehensive standing orders]. I'm sure that they could request it, but it would still be up to the base hospital physician.

[ccmedoc]

All 12 leads interpreted in the field, no thrombolytics or anti-platelet drugs, only asa, NTG, and morphine for pain. We need a 12 lead before NTG, then every 10 min for ST evaluation (improvement or degredation). We have 3 cath labs, only 2 are interventional and are opposite ends of the county. All they need is 10 min heads up, 12 lead correlated in ED, and away they go. I was told avg door to cath is <30min. The average HERN to cath was <45min..Pretty good if the medic is on the ball..the ball gets dropped from time to time..

Oh, and the 12 lead diagnostic is supposed to be turned off as not to distract the interpretation. STEMI only at the cath labs, I think this is pretty standard..

[OVeractiveBrain]

we recently conducted a study of 100 paramedics to see if (A) they can properly identify an STEMI and ( whether they make the correct judgement call to activate a cath lab. There are 4 major hospitals in connecticut with the option for percutaneous coronary intervention, and transport (via helicopter or ground ambulance is not far off from any satelite/cumminty hospital). While there are horror stories of doctors "sitting" on an ACS patient waiting for labs / etc, most hospital courses are discharge to a PCI suite within an hour (usually with Integrilin and Heparin).

The problem is that too seldomly is there a patient having "the big one." And not the big one as any medic would see it, but the pale cool diaphoretic patient with a pressure of 70/P with STsegment elevation of 5mm in II III and aVFwith reciprocal chanes in the anterior leads. So most of the time the care is routine, medics administer ASA NItro and Morphine (or fix the cause), hospital grabs labs, starts clot-buster cocktails if there is no PCI available, or sends them up to the cath lab if the suite is present in house.

While the need for PCI is present in our system, it is not recommended to divert to a PCI hospital 30 minutes away, especially if they are a clot-buster (and i use that to refer to any of the medications allowable for the job) candidate, an uncertain MI (new/old LBBB?) or stable to take the ride.

So yes, we recognize the need to go to a hospital with PCI, but it is recommended to go to the nearest hospital for initiation of care and transport out.

[Dustdevil]

we recently conducted a study of 100 paramedics to see if (A) they can properly identify an STEMI and ( whether they make the correct judgement call to activate a cath lab.

So... since you bring this up, but then fail to give us the results of the study, am I correct to assume they have not yet been published?

Or are you just keeping us in suspense for some other reason?

[flight-lp]

we recently conducted a study of 100 paramedics to see if (A) they can properly identify an STEMI and ( whether they make the correct judgement call to activate a cath lab. There are 4 major hospitals in connecticut with the option for percutaneous coronary intervention, and transport (via helicopter or ground ambulance is not far off from any satelite/cumminty hospital). While there are horror stories of doctors "sitting" on an ACS patient waiting for labs / etc, most hospital courses are discharge to a PCI suite within an hour (usually with Integrilin and Heparin).

The problem is that too seldomly is there a patient having "the big one." And not the big one as any medic would see it, but the pale cool diaphoretic patient with a pressure of 70/P with STsegment elevation of 5mm in II III and aVFwith reciprocal chanes in the anterior leads. So most of the time the care is routine, medics administer ASA NItro and Morphine (or fix the cause), hospital grabs labs, starts clot-buster cocktails if there is no PCI available, or sends them up to the cath lab if the suite is present in house.

While the need for PCI is present in our system, it is not recommended to divert to a PCI hospital 30 minutes away, especially if they are a clot-buster (and i use that to refer to any of the medications allowable for the job) candidate, an uncertain MI (new/old LBBB?) or stable to take the ride.

So yes, we recognize the need to go to a hospital with PCI, but it is recommended to go to the nearest hospital for initiation of care and transport out.

Thrombolytics are a temporary solution to a permanent problem. These pts. need a cath lab if one is reasonably available. An additional 10, 15, hell even twenty minutes to another hospital is of greater benefit to a patient than to go to the nearest ER that may or may not give lytics. Even if they do, you are lengthening the time to appropriate DEFINITIVE care. Sorry, but there is no reason in an urban environment to not go to a cath lab.......

And to help add numbers to your study, our cath alert program has had only 2 "false activations" and they were both resulting from Brugada type syndrome and both were cathed anyway...........

[RedZone]

we recently conducted a study of 100 paramedics to see if (A) they can properly identify an STEMI and ( whether they make the correct judgement call to activate a cath lab. There are 4 major hospitals in connecticut with the option for percutaneous coronary intervention, and transport (via helicopter or ground ambulance is not far off from any satelite/cumminty hospital). While there are horror stories of doctors "sitting" on an ACS patient waiting for labs / etc, most hospital courses are discharge to a PCI suite within an hour (usually with Integrilin and Heparin).

The problem is that too seldomly is there a patient having "the big one." And not the big one as any medic would see it, but the pale cool diaphoretic patient with a pressure of 70/P with STsegment elevation of 5mm in II III and aVFwith reciprocal chanes in the anterior leads. So most of the time the care is routine, medics administer ASA NItro and Morphine (or fix the cause), hospital grabs labs, starts clot-buster cocktails if there is no PCI available, or sends them up to the cath lab if the suite is present in house.

While the need for PCI is present in our system, it is not recommended to divert to a PCI hospital 30 minutes away, especially if they are a clot-buster (and i use that to refer to any of the medications allowable for the job) candidate, an uncertain MI (new/old LBBB?) or stable to take the ride.

So yes, we recognize the need to go to a hospital with PCI, but it is recommended to go to the nearest hospital for initiation of care and transport out.

You say this is a recent study, but just curious as to how recent. It sounds as if those recommendations are how we have done things here as well. From what I understand though, AHA now considers this to be an outdated philosophy.

No longer is it "the big one" that requires immediate cath, but virtually ALL acute MIs (ST elevations + clinical presentation = cath ASAP).

Several hospitals here that are NOT capable of PCI still have cath labs used for diagnostic purposes only. So, if a pt is diagnosed with an MI at 3AM on a Sunday and considered "stable", they would have been given lytics, placed on Heparin (maybe Tridil prn), admitted to CCU, and have a cath scheduled for Monday or Tuesday. Too often on Monday or Tuesday, I would respond to that cath lab to take that patient from their table to a PCI capable cath lab when it was discovered that one or two arteries were 75 to 100% occluded (assuming they weren't CABG candidates). Sometimes, it was suspected that these patients were still infarcting. So, yes my opinion is biased, but I agree with the new AHA guidelines.

[kevkei]

.... Sorry, but there is no reason in an urban environment to not go to a cath lab.......

Sure there is. We assume that each and every patient will get into the cath lab in an expeditious manner, but the reality is this isn't the case 100% of the time. You can never ensure there is always an open and available cath suite.

[RedZone]

Sure there is. We assume that each and every patient will get into the cath lab in an expeditious manner, but the reality is this isn't the case 100% of the time. You can never ensure there is always an open and available cath suite.

Recently, the cath labs I'm familiar with are available, and patients do get expedited in 24/7, virtually 100% of the time. If our EMS system recognized a cardiac specialty referral and the lab had to be closed (say, for equipment failure), the hospital would have to report it and be placed on cardiac diversion.

[whit72]

JPINFV wrote:

honestly don't know what, if any, prehospital instructions are given. Just going through the Regional Paramedic Advisory Committee minutes (I was bored), there was some talk in April of returning Aspirin to the field.

Why was it removed?