1. Diagnosis: STEMI Info for the Community

2. My Roots (North of the Homestead) Devils Lake = Home Devils Lake = Home FYI: ND has 4 PCI centers… 2 1 4 3

3. North Dakota – The Four “F’s” F1) Freezing… Coldest temp in Devils Lake last year? -32 degrees (below zero)

4. North Dakota – The Four “F’s” F2) Farming… Life in the “Vast Lane”

5. North Dakota – The Four “F’s” Snow plow on Devils Lake… Ice House Ice = 3.5’ F3) Fishing (ice)

6. North Dakota – The Four “F’s” F4) And Flooding… 1997 Red River of the North flooding Grand Forks, ND Photo: “Come Hell or High Water” (left) won Pulitzer Prize

7. ST-Segment Elevation Myocardial Infarction (STEMI) =BAD!

8. What is a STEMI? A suddenly clogged artery to the heart May happen without warning High risk of death or permanent injury Symptoms are not always chest pain Treatment is opening of the artery Drano (thrombolytics) Roto-Rooter (angioplasty)

9. Lesson: Avoid “Fred Sanford Syndrome” Not everyone with a heart attack has “chest pain!”

10. How do you diagnose STEMI? Its very simple: Do an ECG ST elevation on the ECG defines the disease ST elevation is an acute emergency trigger for something…….

11. STEMI: A Needle in the Haystack STEMI cases are few and far between Without Recognition there can be no Reperfusion So, you have to do a lot of ECG’s! ! …Its a cost of doing business!

12. Another Bad ECG! No Recognition = No Reperfusion!

13. STEMI 2010: “60 is the New 90” Gersh BJ, et al. JAMA. 2005;293:979-986. 0 20 40 60 80 100 12 24 Time From Symptom Onset to Reperfusion Therapy (hours) Mortality Reduction, (%) Mortality (%) Mortality Reduction (%) Extent of Salvage (% of area at risk) D-B – Harm A-B – No Benefit Shifts in Potential Outcomes A-C – Benefit B-C – Benefit D-C – Harm 04 D C B A 81620 i.e. 44 is better than 66!!!

14. The “STEMI Care Continuum” Cemented by Relationships! THE PATIENT THE PATIENT EMS personnel EMS personnel ED triage personnel ED triage personnel Medical Command Medical Command ED nursing staff ED nursing staff ED physician ED physician EMS transfer staff EMS transfer staff Paging system personnel Paging system personnel Cath lab staff Cath lab staff Cardiologist Cardiologist Quality Improvement staff Quality Improvement staff Reperfusion! Recognition! Relationships

15. The Cardinal Rule: Once STEMI is identified  it must trigger a clear response downstream! ECG Acquisition Communication EMS Evaluation Decision!

16. I. Remember…Most of the Time …the easy ones are easy! So, make more of them easy!

17. II. STEMI Fact: If it Can Go Wrong, it Will (sooner or later) Leave nothing to chance! Approach STEMI systems building like a system’s engineer… Don’t try to error- proof your providers. Error-proof your system!

18. III. STEMI 2010: There is NO New Frontier! Every STEMI case has the same fixed endpoints (R2R) Model success, but don’t copy it! (???) Adapt principles to the situations not vice versa!

19. Recognition to Reperfusion TRUTH: Without early recognition there can be no progress towards early reperfusion The focus must be on the earliest possible recognition followed by fast and precise reperfusion Again, it all begins with Recognition!

20. However, it is as it is…. Several reasons why pre-hospital STEMI care will always remain a challenge…

21. Rokos et al. J Am Coll Cardiol Intv, 2009; 2:339-346 All Americans are Not Distributed Equally!

22. PCI within 60 minutes?

23. STEMI Systems of Care PCI capable Non-PCI SYSTEM OF CARE CENTER OF CARE Patient & Community EMS ED STEMI Referral STEMI Receiving Awareness Activate EMS Avoid delay 12-lead ECG 9-1-1 inter- hospital transport Activate team No diversion Treatment protocols and clinical pathways Jacobs. Circulation 2007;116:217-230.

24. “STEMI Vision” –Just Say No! 95%+ of EMS calls are NOT STEMI! Ab Pain MVA Weak/dizzy ??? Altered Need ride Etoh STEMI Chest Pain

25. The “STEMI/Sick Patient” Paradox… Sick EMS patients (usually) look sick (trauma, VFIB, hypoxia, asystole) Motto: Keep ‘em alive, & diagnose ‘em after arrival! …Not so with STEMI!

26. Think Globally, Act Locally EMS STEMI solutions must be locally driven based on national suggestions Change items that really matter.

27. So, Where Do We Start?

28. 4 a.m. Sunday night, Raining… Grandma’s house …44 miles out…

29. Got STEMI? –Call the ED! EMS/ED communication on every potential STEMI is a must Either with OR without ECG transmission I think I got one!

30. D: Logging, Bad Burgers & “Angels” 34 year-old male is logging trees in remote area Increased heartburn after “gut bomb” lunch Later, his boss starts driving him to the hospital Pain worsens; His boss calls rural EMS, who arrange to meet them at a local “KwikMart”. EMS does ECG in parking lot: it looks “bad” Idea: fax ECG to MedCom before departure

32. DX: Acute Inferior Wall MI! EMS departs for PCI center “Joe” at KwikMart faxes the ECG In route patient goes into VFIB arrest Defibrillated once with good results… EMS contacts PCI center in route; discusses ECG with the ED physician (…NO TRANSMISSION) Cath lab activated, ED on Standby…

33. Post Cath

34. Madison County, VA “EMS Angels”