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Thoughts From A Clinician

Thoughts from a Clinician: How do You STEMI?

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A big part of many EMS system’s medical guidelines is their STEMI protocol. This may be common place in today’s culture, but this was not always the case.  STEMI protocols have been around for a long time, but in the early 2000’s the emergency and critical care medical communities saw their role dramatically increase in popularity – meaning they became a more integral part of EMS and critical care systems all over the United States.  The inspiration behind my selection of this topic is a recent podcast by Taming the SRU (1).  The gentlemen at University of Cincinnati Air Care covered their STEMI protocol.  Their practices are intriguing, so allow me to elaborate.

Patient’s experiencing a STEMI call for us to be quick on scene and to package the patient for transport to the closest PCI center.  Most standard procedures call for a goal door to balloon window of at least 90 minutes.  The 90-minute window is set forth by the American Heart Association (2) as well as supported by the American College of Cardiology.  The American Heart Association guidelines have been the same for the last two revisions regarding acute coronary syndromes and STEMI’s.  Most systems in the United States follow those same guidelines when they are caring for a STEMI patient. 

This brings up a very important operational question; do you know where your closest PCI center is located?  Do you know the protocol for scene STEMI’s regarding accepting physician?  For some areas of the country and the world there may not be something in place and that is a significant need which should be addressed.  The operations of every service will be a bit different depending on the latest research and evidence based practice.  However, the goal is typically always the same - to address morbidity and mortality in STEMI cases and to mitigate unfavorable outcomes.  To continue our life-saving mission and stay current with best practice, we need to be willing to ask the tough questions within your service.  Do we have the most up-to-date STEMI protocol in place?  What are we doing that puts us that far ahead for our STEMI patients?

If there is NOT something written in your protocols or guidelines at your own service, then please be willing to have these tough and sensitive conversations with your medical directors and local cardiologists.  Find out if there are policies and procedures that can be put into place to align yourself with current recommendations.  The goal is to work as a well-oiled machine.  When teams function well, they can provide the best care possible, regardless of geography or personnel on shift.

Another common question that presents itself is this - what can we do to be faster at the bedside, when caring for a STEMI patient?  There are a number of things which can take up valuable time at the bedside.  Some of these are switching infusions, adding or subtracting infusions, and gathering report.  If we look at infusions typically started on STEMI patients, we know that many of them can be either discontinued or titrated downward.  There is no right or wrong way, but the process in your system should be analyzed to see where it can be improved.  The following are guidelines recommended by the Journal of the American College of Cardiology regarding STEMI patients (3).  Three ways in order to decrease time spent at bedside are to establish a well-designed plan, rehearse it, and gather report simultaneously. Within a well-designed plan there should be ways to decrease the number of infusions.  Have a serious sit down with your local cardiologists and ask what they would like to see.  Then sit down with your medical direction and make changes that are reflected in your practices.  Once the plan has been agreed upon, rehearse it.  Make certain that all of the crew members are on the same page so that the transfer goes smoothly at the facility.  Finally, we need to write, listen, and work at the same time.  I will be the first to admit I am not the strongest at this and I have to work to improve in this area.  However, if we are able to work as a team to package the patient and gather report at the same time, our patient will benefit from the expedited transfer.

The American College of Cardiology has developed guidelines that help to streamline the process and facilitate continued improvements to future STEMI protocols and practices for the future.  These are:

  1. Prehospital ECG to diagnose STEMI is used to activate the PCI team while the patient is en route to the hospital.
  2. Emergency physicians activate the PCI team.
  3. A single call to a central page operator activates the PCI team.
  4. Goal is set for the PCI team to arrive in the catheterization laboratory within 20 minutes after being paged.
  5. Timely data feedback and analysis are provided to members of the STEMI care team.

The American College of Cardiology also voiced support for further research regarding the use of prehospital fibrinolytic (3).  The body of evidence at the time of publication was not big enough to support one way or another.  Another argument is that the use of prehospital fibrinolytic is not widespread.  Some areas of the United States are very aggressive with the use of fibrinolytic in the field, while others are not.  More education and evidence should be performed to give us a good idea as to whether or not they should be used in transport.

STEMI patients are a unique patient population.  If we are to give these patients the best care, we need to be on the cutting edge of evidence based practice.  Let us know what you are doing in your shop and get the discussion started on STEMI management.  Until next time, remember to always THINK…like a clinician, take care!

Sources:

  1. http://www.tamingthesru.com/blog/flights/code-stemi
  2. http://www.heart.org/HEARTORG/HealthcareResearch/MissionLifeli  neHomePage/EMS/Recommendations-for-Criteria-for-STEMI-Systems-of-Care_UCM_312070_Article.jsp#.Vzdcrb6WlSA
  3. J Am Coll Cardiol. 2013;61(4):e78-e140. doi:10.1016/j.jacc.2012.11.019

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Klint is a Flight Paramedic in Nebraska, USA.  He is a critical care educator for Distance CME LLC, blog writer for FlightBridgeED, and is very active in FOAMed. You can follow Klint on Twitter @NoDesat.    

Klint W. Kloepping, FP-C, NRP, C-NPT, AAS

FlightBridgeED, LLC

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