Time is Muscle: AN EXCLUSIVE SUPPLEMENT Sponsored by: ZOLL

Case Study #1
     It's a sunny fall morning outside Wilmington, DE, when a BLS ambulance from the Elsmere Fire Company and paramedics from New Castle County (NCC) EMS are dispatched to a call for chest pain. The medics arrive to find a 54-year-old man on oxygen being loaded into the fire company's ambulance. The BLS crew reports that the patient is complaining of chest pain, rated 8 out of 10, with shortness of breath and nausea since earlier in the day. He has no medical problems and takes no medications, but says it's been several years since he's seen a doctor. His vital signs are: pulse rate 62, in a normal sinus rhythm with a first-degree AV block; respiratory rate 24, with clear breath sounds; blood pressure140/80; and pulse ox 98%. He would like to go to the VA Medical Center right down the street.

     The paramedics continue to assess the patient and perform a 12-lead ECG that shows ST elevation in leads V1-V3, with reciprocal ST depression in leads II, III and aVF (Figure 1). This ECG is diagnostic of an acute MI, and a second is then performed to rule out right-side involvement. Paramedics tell the patient he's having a heart attack and recommend he be transported to a facility with emergent cardiac catheterization capability, which the VA does not have. He then requests to be taken to Christiana Hospital in Newark, a self-designated "heart center" about 10 minutes away.

     During transport, one paramedic gives the patient 162 mg of aspirin to chew and starts an IV. His partner then calls the base physician at Christiana to request a "heart alert." The patient is given sublingual nitroglycerin, one inch of nitroglycerin paste and 5 mg of morphine sulfate under Delaware's AMI protocol. The physician on the radio agrees with the prehospital assessment and directs the crew to bypass triage and go directly to a resuscitation bay in the ED upon arrival.

     The patient reports feeling much better after receiving the medications; he rates his pain at 4 out of 10, and repeat ECGs show that the ST elevation has resolved (Figure 2). The crew is met in the ED by a heart alert team with a cardiologist, who elects to send the patient to the cath lab after viewing the initial prehospital 12-lead ECG.

Case Study #2
     It's early in the evening when a BLS ambulance from the Claymont Fire Company and New Castle County paramedics are dispatched to an unconscious diabetic at a suburban home. Paramedics arrive to find a 60-year-old male on oxygen being extricated from the residence in a stair chair by the BLS crew. They report that the patient had a syncopal episode after standing up and was unresponsive for a few minutes. The patient is pale and diaphoretic and complains of feeling weak. He reports a history of non-insulin-dependent diabetes but no other medical problems. He denies any chest or abdominal pain.

     The patient's vital signs are: pulse 114, in sinus tachycardia with no ectopy on the monitor; respiratory rate 20, with clear breath sounds; blood pressure 102/60; pulse ox 96%; and blood sugar 458 mg/dL. A 12-lead ECG shows a right bundle branch block, ST elevation greater than 5 mm in leads V2-V4 and reciprocal ST depression in leads III and aVF (Figure 3). The paramedics recommend he be transported to St. Francis Hospital in Wilmington, which is the nearest heart center.

     During transport paramedics administer aspirin, start two large-bore IVs and apply one inch of nitroglycerin paste. The base physician at St. Francis is contacted, and the hospital's heart alert team is activated. The patient continues to deny chest pain and maintains his vital signs. He is transferred to the cath lab shortly after arriving in the ED.