Cardiac Cath Lab - Specialty Referral?

[HellsBells]

We have a STEMI, LBB block protocol where we transmit the ECG via landline to the ER doc, if he agrees with our assessment we go straight to the cath lab.

Just as a side note, Our protocols have really moved away from the use of Morphine in the case of acute MI. We only administer it if weve given 2.0mg of nitro with no pain relief. What our your peoples thoughts/protocols on using morphine?

[Redcell19512]

All the hospitals we transport to offer full service cardiac care (I feel like I'm talking about a car). We started transmitting 12 leads this year. We do the 12 lead. If we have a STEMI or if the medic isn't sure we transmit the EKG and call in to speak with a doctor. The doctor will then decide whether or not to call an MI alert. Either way it has no effect on the hospital destination.

Case in point: Two weeks ago we had a woman pull into the shopping mall parking lot with chest pain. She called 911 after waiting 15 minutes for the symptoms to subside. The medic arrived, did a 12 lead, transmitted the 12 lead, hospital called an MI Alert. Call dispatched at 1255. Patient at the hospital, through the ER, to the Cath Lab, and into the OR for bypass by 1400.

Case in point (not so good): EMS crew responds to the same address for the second time in one day. Elderly, female, diabetic, laying in the bathroom screaming that she's going to die. When asked to clarify that statement all she can say is that "something's wrong!" The medic calms her down and encourages her to slow her breathing. She is transported to the hospital, BLS. Several hours after she arrived in the ER a 12 lead was finally done and revealed that she was having an MI. She died in the hospital a week later. (Medical director is doing a case review on this, I'll post more when he's finished).

Regionally we've just adopted a protocol that allows the use of a helicopter to fly STEMIs to cardiac centers and CVAs to stroke centers when the time of onset (for strokes) is known. This doesn't effect my service but it applies to plenty of services along the outer rim that don't have access to specialty centers.

I still have more than a few medics who don't bother doing 12 leads on ANY patients because "duh...it won't change my treatment none....duh". Frustrating but ever the optimist I'm still trying to help them see the light.

[JPINFV]

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?

It was removed prior to me starting work as an EMT-B, so I can't really answer that one either.

[RedZone]

Well, it's good to see that many regions don't have this same problem we do. Even the case of one region requiring a machine interpretation is still more than our regional council recognizes.

[AnthonyM83]

Ugh! I do a lot of transfers from ER directly to the cath table. Lots of times the patient is freaking out and one of the things I say to help calm them is, "They try not to crack chests anymore if at all possible." Where did you hear about that bypass thing?

An intstructor at the paramedic prep course I'm in told us that. He's pretty on top of the prehospital medicine trends and journal studies. Studies are preliminary at this time, though.

[Spock]

We give NTG, ASA and morphine to our STEMI patients prior to command contact and transport these patients to hospitals with cath labs. The few community hospitals without cath labs will divert us to the cath lab centers. The only time we would go to the community hospitals is if the patient absolutely refused to go anywhere else even after we explain the community hospital can't treat them and will transfer them. The region is looking into establishing a cardiac divert policy similar to the trauma divert policy so we can go to the cath lab hospitals even if the patient objects. It really is in their best interest.

Don't forget that the use of stents is under fire and we may see a return to primary CABG as the best treatment for the STEMI patient. When the questions concerning stents came up a few months ago we saw an increase in CABG's at the patient request. I admit my bias because I specialize in cardiac anesthesia. Time will tell how this plays out.

Didn't the new AHA guidelines recommend that 911 dispatchers tell patients to take ASA if having chest pain before EMS arrival?

Live long and prosper.

Spock

[RedZone]

Well, I came across an answer to my question. It appears in May 2007 issue of JEMS in an article titled "Specialty Center Boom: Is transport to the closest ED a thing of the past?"

Quoted from Marc Eckstein, MD, FACEP:

Cardiac center designation is currently in vogue. Good science supports treating ST elevation myocardial infarction (STEMI) patients with emergent percutaneous coronary intervention (PCI) instead of fibrinolytic therapy, as long as the door-to- balloon time is less than 90 minutes. However, the American Heart Association has not yet formally supported EMS diversion of STEMI patients to cardiac centers. Rather, it recommends having an internal process to get the door-to-balloon time under 90 minutes if PCI is available, or else have a formal process in place to rapidly transfer STEMI patients to PCI-capable facilities.

I guess my system is actually in compliance with recommended guidelines. As I realized myself, hospitals are making internal changes as recommended. The article does explain that many EMS systems have begun adjusting their own procedures despite AHA's lack of formal support. Definitely an article that answered a lot of my questions!

[Richard B the EMT]

Both my local hospitals are now "stroke centers", and one is getting a cath lab within the next few months.

Perhaps all hospitals will be going the direction of being both stroke and cath centers, while there will still be Trauma, Burn, and the one Snakebite, centers, due to the expected expenditures.

[brentoli]

Both my local hospitals are now "stroke centers", and one is getting a cath lab within the next few months.

Perhaps all hospitals will be going the direction of being both stroke and cath centers, while there will still be Trauma, Burn, and the one Snakebite, centers, due to the expected expenditures.

What kind of snakes does NYC have?

[Richard B the EMT]

Whatever poisonous reptiles we have on display at the Bronx Zoological Park. Due to location, closest ED is Bronx Municipal Hospital/Jacobi Medical Center, which is also the snakebite center.

One never knows what an individual might have in their home, brought in illegally from somewhere else. Remember, a few years ago, we had some guy in the Harlem section of Manhattan, had both a Lion and an alligator in his apartment, and the city only found out after the lion took a bite out of the guy! So, who is to say what types of exotic snakes are here? Certainly, not this reporter, your humble (?) servant.