1. The Heart of the Matter A Journey through the system of care

2. Introductions Brian Richardson Director of Emergency Services at BMH Emergency Room Preparedness Emergency Medical Services Liaison/Quality Assurance Paramedic George Terwilliger Emergency Department Medical Director MD over 25 years of experience

3. Denial, not a river in Egypt Median 2 hour delay in calling 911 (Meischke et al.) Symptoms would go away Symptoms not severe enough Did not think of calling 911 Proximity to hospital and thought 911 would delay treatment Only 65% of women said they would call 911

4. Don’t wait call 9.1.1 Call 9.1.1 at the onset of symptoms Follow the dispatcher instructions Do not drive yourself to the hospital Stay calm and try to relax

5. Emergency Medical Services In Vermont the EMS system is staffed by licensed, credentialed providers Large amounts of educational resources are directed towards training these professionals in the area of Acute Coronary Syndrome Transporting services have at a minimum, the basic tools to recognize and begin treatment for a patient experiencing a heart attack. Statewide protocols for Vermont EMS professionals provide a foundation of best practices for care of a patient with Acute Coronary Syndrome. Brattleboro Memorial Hospital works in conjunction with Rescue Inc to provide quality assurance and case review for all cases involving Acute Coronary Syndrome.

6. What to expect from EMS Pre-arrival instructions from the dispatcher First Responders An ECG History, which equals a lot of questions An exam Perhaps medications Safe but rapid transport

7. En-route to the Hospital Cardiac monitoring Intravenous lines Additional ECGs Vital sign monitoring Additional medications Early communications with the hospital

8. Once you arrive at the hospital You are taken immediately to a treatment room An ECG is done Perhaps another IV Blood samples drawn Additional questions are asked Treatment decision s are made

9. Treatment pathways Always approached from the worst case first Heart Attack Unstable Angina Low to Intermediate risk for Acute Coronary Syndrome/Chest pain pathway Risk and benefits of treatments are always discussed

10. Heart Attack (STEMI) With ECG changes, lab biomarker changes and a potential for significant damage Consultation with and arranging for transport to a catheterization lab for percutaneous coronary intervention Assessment for the appropriateness of using clot busting agents Use of those agents, if appropriate within 30 minutes of your arrival in the Emergency Department

11. Unstable Angina/non-STEMI High risk factors identified Positive ECG findings for an oxygen starved heart Positive lab results (immediately or over time) Consult with cardiology Admission or transfer to a higher level of care

12. Low to Intermediate Risk Low to Intermediate Risk factors Other potential causes eliminated or reduced No changes on serial ECGs No changes to serial lab tests May be observed in the Emergency Department (6 hours or greater) May have a consultation with cardiology May be admitted to a monitored bed in the hospital Stress test either done at discharge or scheduled shortly after follow-up with a cardiologist scheduled Factors for prevention may be discussed by the Emergency Department Physician

13. Our Goals To give you the best possible patient experience Weigh risks versus benefits in diagnosis and treatment decisions To educate and inform so that you may make the best decision for your healthcare To treat you with respect and compassion

14. QUESTIONS