2Patient Scenario 14:00 PM: You are visiting a friend when she gets a call from her mother that her father has been having chest pain, nausea and weakness on and off all day. She knows you are a doctor and asks you to go over to see him. What would you do?
3Patient Scenario 14:30 PM: You go immediately to his home by motor bike. You arrive at 4:30 because of traffic. 4:45 PM: While you are getting a better history of his symptoms, you note that he is cool and sweaty. You tell him that he might be having a heart attack and needs to go to the hospital.
4Patient Scenario 15:00 PM: Your friend’s father is too weak to sit up on a motorbike. At the insistence of your friend’s mother, you call a neighbor and borrow a car to take him to the hospital
5Patient Scenario 15:20 PM: You begin driving across town – in heavy traffic – to the cardiac hospital. Suddenly your friend screams that her father is unresponsive. You are passing a medical clinic.
6Patient Scenario 15:30 PM: You and your friend carry her father into the medical clinic. Minutes go by before someone finds him a bed. 5:45 PM: You discover that he has no pulse, so you start CPR. One of the doctors finds an old defibrillator in a closet.
7Patient Scenario 15:50 PM: Now what?Your diagnosis and treatment?
8Patient Scenario 16:00 PM: You diagnose ventricular fibrillation and want the doctors to defibrillate your friend’s father. They tell you that they are just a small clinic and the defibrillator is old, broken and they have never used it. You now see this rhythm…..
9Patient Scenario 16:05:The clinic has no ACLS medicationsYou are still 30 minutes from hospitalYou agree with the other doctors to stop CPRYou tell your friend her father is dead
10Patient Scenario 1Could the outcome have been different with a trained pre-hospital team transporting this patient?
11In VietnamAccording to a 2008 study from Hanoi, cardiovascular disease – both stroke and ischemic heart disease – is the leading cause of death for both men and woman in VietnamNguyen Thi Trang Nhung, et al. Vietnam Burden of Disease and Injury Study Hanoi School of Public Health and Univ. of Queensland, Medical Publishing House 2011.
12Timing of “Sudden Death” Up to 65% of deaths related to myocardial infarction occur in the 1st hour ventricular fibrillation1 of 300 patients with chest pain transported by car will go into cardiac arrest en route!
13Timing of “Sudden Death” Many deaths preventable with simple, rapid defibrillation – available on ambulances…not in cars or taxis!
14Time to Thrombolytic and PCA PCA – Percutaneous Coronary AngioplastyAmerican Heart Association: treat ST Elevation Myocardial Infarction (STEMI) with a thrombolytic or PCA within 12 hours of symptom onsetPCA preferred over thrombolyticSaif R, et al. Association of door-to-balloon time and mortality in patients admitted to the hospital with ST elevation myocardial infarction: national cohort study, BMJ.2009;338:b1807.
15Time to Thrombolytic and PCA The sooner a patient with an acute MI reaches the hospital for definitive therapy, the lower the mortality rate.Saif R, et al. Association of door-to-balloon time and mortality in patients admitted to the hospital with ST elevation myocardial infarction: national cohort study, BMJ.2009;338:b1807.
16The Pre-Hospital GoalThe goal of prehospital transfer… minimize the time it takes to get a cardiac patient to an appropriate hospital … in a safe manner
17For EMS System to WorkPatients must be knowledgeablePatients must recognize symptoms for which EMS transport is appropriate and beneficialPatients must know how to access the pre-hospital system
18Local Population Education Can the patient or family recognize the symptoms of heart attack?Do they know the importance of quickly bringing him to a hospital capable of caring for a cardiac patient?
19Local Population Education Is there a phone number to call to get help and an ambulance?Do people know that number?
20The 911 Emergency Phone Call In US: call 911 immediately connected to a trained operatorThe operator activates the prehospital system by sending an appropriate level ambulance to the site of the call
21The 911 Emergency Phone Call The operator advises the caller on basic life saving techniquesDirect pressure to stop bleedingStart basic CPR
22American Heart Association Since the 1980’s the American Heart Association (AHA) has publicized the importance of early recognition of heart attack symptoms… …and the importance of rapid transport to an appropriate cardiac center by trained pre-hospital personnel
23Signs of a Heart AttackChest discomfort: sometimes comes and goes, may be mild, feels like pressure, squeezing or fullness painDiscomfort in arms, shoulder, back, neck, jaw or stomachShortness of breath – with or without chest discomfortCold sweat, nausea, lightheaded
24Signs of a Heart Attack“Minutes matter! Fast action can save lives… Don’t wait more than 5 minutes to call 911.”
25Benefit from EMS transport? Acute myocardial infarction/ischemiaCardiac Dysrhythmias: both tachycardias and bradycardiasCardiac ArrestAcute Pulmonary EdemaCardiovascular conditions associated with hypotension
26Equipment on ALS Vehicles May contain:Telemetry monitoring with rhythm strip or EKG transmissionIntubation and ventilation equipment, including CPAPOxygen tank, tubing and masks
27Equipment on ALS Vehicles May contain:IV tubing and needlesCardiac monitor / defibrillator / pacemaker or AEDCommunication equipment
28Medications on ALS Vehicles New York City paramedics carry:Cardiac arrest medicine: adrenalineAcute MI medicines: aspirin, nitroglycerin, morphineDysrhythmia medicines: atropine, adenosine, diltiazem, amiodarone, magnesiumPrehospital Advanced Life Support protocols July 2012
29Medications on ALS Vehicles New York City paramedics carry:Pulmonary edema medicines: nitroglycerin, furosemideHypotensive treatments: normal saline, dopaminePrehospital Advanced Life Support protocols July 2012
30EMS Standing Protocols In the U.S., “standing protocols” are used by medics for basic conditions without the need to call a doctorNew York City Heart Attack protocol allows paramedics to start an IV, give oxygen, aspirin and nitroglcerin to anyone with suspected MI
31EMS Standing Protocols If the medical condition is not clear or there are questions, medics call “Medical Control” to consult
32EMS Medical ControlWhen a medic has a critical patient whose management is difficult, “Medical Control” is contacted.“Medical Control” is frequently a senior paramedic with an emergency doctor available as back up for advise
33Telemetry Transmission Before medics cardiovert a patient with an unstable rhythm, they will call medical control.They electronically transmit either an EKG or rhythm strip for review by the emergency doctor
34Scenario 250 year old man with a history of 2 episodes of syncope and a probable MI is being transfer from a rural town by ambulance.He suddenly develops severe shortness of breath, chest pain, confusion and becomes lethargic
35Scenario 2The medics are an hour away from the hospitalThe patient’s vital signs: BP=75/50 mmHg; heart rate = 240 beats per minute; respiratory rate = 32 per minute; pulse oximetry = 83% on 100% facemask
36Scenario 2The medics transmit this rhythm strip to you, the medical control doctorWhat do you recommend?
37You tells the prehospital people to cardiovert the patient Scenario 2The rhythm strip shows rapid regular rhythm and the patient is unstableYou tells the prehospital people to cardiovert the patientHe is unlikely to survive the long trip without this life-saving procedure
38Scenario 2New York City paramedics have a protocol for thisThey would cardiovert the patient after medical control confirmation
39Why Prehospital for Cardiac? Faster transportation to appropriate cardiac centerAble to monitor and treat patients with life-threatening dysrhythmias at the scene and during transportAble to manage critical patients with pulmonary edema, myocardial infarction and hypotension