Out-of-Hospital STEMI Alert

The October 2006 issue of EMS Magazine featured an article on out-of-hospital 12-lead ECG programs and EMS systems that have created pathways to reduce the time interval between scene arrival and balloon inflation in the cardiac catheterization lab for patients with ST segment-elevation myocardial infarction (STEMI).¹ This issue features an article on Tampa Fire Rescue's 12-lead acquisition and transmission program (see Distant Early ECG Warning, p. 43). Entities such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and various physician professional societies are now mandating reductions in the time it takes emergency departments to obtain 12-lead ECGs for potential acute coronary syndrome patients and in door-to-balloon times for emergency cardiac catheterization.

     A landmark article published in the New England Journal of Medicine last November quantified average time savings at 365 hospitals that had implemented changes to reduce the interval from patient arrival in the ED to balloon inflation in the cardiac cath lab (see Door-to-Balloon Time-Saving Tips, page 54).² The current standard is 90 minutes, which is quite a difficult mark to achieve unless there's a focused internal marketing campaign and a large expenditure of money. Of the authors' six recommendations, EMS acquisition, interpretation and transmission of 12-lead ECGs was found to save more time (15.4 minutes) than any other intervention except requiring cath lab personnel to respond to the hospital within 20 minutes of being paged. The potential impact of this research was compared to the invention of CPR in terms of the lives that could be saved if the recommendations were acted upon.

     One of my favorite citations to point out how ridiculous it is that we still don't have widespread capability to diagnose patients with STEMIs, institute aggressive EMS care and move them toward cath labs is from the premiere episode of Emergency! This show depicted what was actually happening in the early 1970s as Los Angeles County implemented one of the first ALS systems in the country. If you listen carefully to the discussion between Gage and DeSoto during their tour of the new Squad 51 (paramedic responder/light rescue vehicle), there's distinct mention that the Datascope cardiac monitor is capable of acquiring and transmitting full 12-lead ECGs.

     This show was filmed in the fall of 1971 and aired in January 1972. It is now 35 years later, and the discussion about whether to expend money on 12-lead-capable monitors, transmission software/hardware and training so that paramedics can interpret basic emergency presentations on a cardiogram still occurs as if this topic were completely new to out-of-hospital care. In the EMS community, we take for granted the ability to identify, triage and risk-stratify patients with traumatic injuries who are candidates for immediate referral to accredited trauma centers. Statewide trauma plans, designated Level 1 and Level 2 (and sometimes Level 3) trauma centers and regional EMS system protocols for trauma care are now considered the rule rather than the exception. Ambulance crews have been calling "trauma alerts" for almost 20 years (more in some systems), and this is now considered routine practice in all metropolitan areas of the United States. Why not so for cardiac care?