1. Optimising STEMi Care- Role of Nurses and Paramedics
Dr. Ganesh Veerasekar, MBBS, MPH (UK), FRSPH (UK)
Epidemiologist, Kovai Medical Center and Hospital
Coimbatore, Tamilnadu, India

2. Burden of heart disease
In 2008 the leading cause of mortality across the
globe is due to Cardio Vascular Disorder, which
accounted for about 17 million or 48% of over all
Non communicable disease (NCD) deaths.
(Courtesy- Global status report on non communicableDisease-who-2010)

3. WHAT is STEMI? St Elevation Myocardial Infarction
A deadly disease caused by sudden shut down of blood supply to a part of the heart
But can be readily addressed if reperfusion to the damaged area is established through proper reperfusion techniques- Thrombolysis +/- Angioplasty
Time is a crucial factor

4. Nurses and paramedics? Ambulance staff Emergency Department nurses
Emergency department support staff
Critical care nurses
First Medical Contact- in most of the scenarios
Frequent Contact with patients

5. Pharmaco-invasive - 3-24 hours
Factors and timelines
Pharmaco-invasive hours

6. Factors and timelines Beneficial Time frames:-
Door to Needle time- Less than 30 minutes
Door to balloon time-Less than 90 minutes
Pharmaco Invasive (Thrombolysis + PCI) hrs

7. Must have qualities Objective skill sets:- Subjective skill sets:-
Early analysis of the clinical symptom
Excessive Sweating, chest discomfort, nausea, radiating pain to left arm or jaw, epigastric pain, syncope
early identification of st Elevation
Should be well qualified to identify ST elevation in ECG
Subjective skill sets:-
Readiness to work in a team
Active and vibrant nature

8. ECG:- Tips New ST elevation at the J-point in two contiguous
leads with the cut-off points: ≥0.2 mV in men or
≥ 0.15 mV in women in leads V2–V3 and/or ≥ 0.1 mV
in other leads.
On standard ECG paper 0.1 mV is represented by a deflection of 1 mm
Or one small block in vertical axis

9. ECG:- Tips

10. Example from our Experience Tamilnadu STEMI Project: EMRI Pick Up
A 51 year old male smoker.
Chest pain at 4.00 AM on 19th July.
108-ambulance called at 5.00 AM.
Ambulance (Karur) arrived at scene at 5.20 AM.
1st ECG taken at 5.29 AM.
STEMI confirmed at 5.34 AM.
Patent shifted to Amaravathi Hospital,
Karur (Spoke Hospital) at 6.10 AM.

11. Tamilnadu STEMI Project: EMRI Pick Up
ECG Taken in the Ambulance at 05:29 AM.

12. Tamilnadu STEMI Project: EMRI Pick Up
Thrombolysis initiated at 06:15 AM and completed at 07:15 AM
Post lysis ECG at 9:54 AM showed Failed thrombolysis
Ambulance called and IFT Transport start at AM 
Hub hospital (KMCH, Coimbatore) arrival at PM

13. Tamilnadu STEMI Project: EMRI Pick Up
PCI started at  03.10 PM
Femoral access

14. Tamilnadu STEMI Project: EMRI Pick Up
Right coronary artery stented with Bare Metal Stent (BMS)
PCI completed at PM

15. Tamilnadu STEMI Project: EMRI Pick Up
Patient was doing well and got discharged on 22nd July.
This is a great case that illustrates the immense benefit of this program.

16. Pharmaco-invasive - 3-24 hours
Factors and timelines
Pharmaco-invasive hours

17. Our experience Patient symptom onset to fmc time- 1 hour 20 mins
Fmc to ecg identification-14 mins
Fmc to thrombolysis time- 55 mins
Hospitalisation to thrombolysis (D to N) time- 5 mins
Total ischemia time- 2 hours 15 mins
Hub hospital door to balloon time- 55 mins
Total time onset to complete treatment- 11 hours 34 mins

18. How was this possible? Efficient Ambulance staff
Coordination between Ambulance staff and hub hospital cardiologist
Coordination between ambulance staff and spoke hospital nurses
Efficient spoke hospital nurses-thrombolysis on arrival
Well coordinated transfer from spoke to hub hospital by ambulance staff and excellent monitoring during transit
Coordinated effort of emergency and cath lab nurses at hub hospital

19. THANK YOU