EMS Role in Reducing the Symptom to Reflow Interval for AMI – Closing Comments

Here are my closing comments from the NAEMSP Dialog group discussion “EMS Role in Reducing the Symptom to Reflow Interval for AMI”.

I think it’s important that we finish building regionalized STEMI systems in every state, and do our best to help ensure that our patients receive evidence based therapies, no matter where they live. Once these systems are up and running, they are fine-tuned, and we have a better understanding of where we want to be in terms of “false positives” and “false negatives” (including standardized definitions) we will be in a position to extend these systems to include select high-risk NSTEMI patients, if and when the evidence supports treating them the same as STEMI patients (immediate reperfusion as opposed to “early invasive therapy”).

The most important step for my EMS system (and many other EMS systems throughout South Carolina) was meaningful representation on the hospital’s multidisciplinary STEMI committee. We’re not perfect, and we still have many, many opportunities for improvement, but it’s very important for EMS to have a seat at the table where the concerns of the various stakeholders can be discussed, and data can be shared between the hospital(s) and EMS. Every single case is a learning opportunity! I especially enjoy collecting the prehospital 12-lead ECGs of patients who were fast-tracked to the cardiac cath lab and had no clear culprit artery. It seems to me this is our best chance at reducing “false positives” while maintaining an acceptable degree of sensitivity.

I’ve given more thought to the idea of a 12-lead ECG certification for paramedics, and I do think the idea has merit, but it seems to me this should be the same type of certification a physician, advanced practice nurse, or PA would get. The “STEMI recognition” model will never be sufficient to eliminate the need for ECG transmission due to the problem of baseline abnormalities and STE-mimics, so any type of certification should be comprehensive and include rhythm analysis, axis determination, conduction abnormalities, STE-mimics, STEMI recognition (ischemia, injury, and infarct), as well as identifying acute STEMI in the presence of baseline abnormalities. It can be done, and it should be done, if we want to transition into the clinician model.

Having said that, ECG transmission does have some stand-alone merit and I don’t personally have a problem with the technician model if it leads to good outcomes for our STEMI patients. If you can get your EMS organization to identify the candidates for a prehospital 12-lead ECG, undress the patient from the waist-up, prep the skin and place the electrodes accurately, capture a 12-lead ECG with excellent data quality with the first set of vital signs and within 5-10 minutes of arriving on scene, and act on that ECG (whether it’s calling a STEMI Alert based on some set criteria transmitting the ECG for physician interpretation or both), and you do that well, to me that is a true mark of professionalism. We need to take pride in our workmanship whether we’re the ones who “make the call” based solely on our own interpretation or not.

The only thing I can think of that wasn’t touched on (much) in our discussion is the walk-in STEMI patient at the local non-PCI hospitals. I worry about the young, otherwise healthy patient who receives failed thrombolysis (TIMI 3 flow may be achieved only 50-60% of the time according to some studies) and languishes away in a hospital bed with a dying myocardium. Regionalized STEMI systems need to consider how walk-in STEMI patients are going to be treated within the context of the system. My personal feeling is that 100% of STEMI patients should be emergently transferred to a PCI-hospital, even if they receive first-dose thrombolytics at a non-PCI hospital (the Minnesota model).

A lot of rural EMS systems are loath to take their ambulances out of the county (or even out of service for 2-3 hours) for interfacility transports but this is a situation where they should make an exception when rotor-wing EMS or private ambulances are not available, and respond with all of the urgency of a 9-1-1 call (not necessarily “lights and sirens” en route to the hospital but respond right away).

If you need assistance or guidance as to how you should take the next step, I would encourage you to find out who oversees AHA Mission: Lifeline in your state, and get involved with your chapter’s EMS Advisory Committee. There’s no reason you need to “go it alone” because I can assure you, all of the EMS systems in your state are struggling with the exact same issues. The cross-pollination can be quite beneficial when EMS systems share solutions with each other, whether it’s with regard to education, technology, buy-in from the ED docs, turf wars between hospitals, obtaining funding for 12-lead ECG machines, developing protocols, obtaining representation on multidisciplinary STEMI committees, or comparing outcome data.

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