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Friday, January 3, 2014

The Cardiac Save Pin

I’ll admit, I don’t understand why the stork pin is so popular. 

The mother is doing all the pushing and tearing, while the medic or EMT isn’t really doing any work besides not dropping the newborn. That’s not really an advanced medical skill, you have to admit.
"Good job holding a human off the floor!"
Our new “Cardiac Save” lapel pin, on the other hand, recognizes the judgement that medics use in identifying a STEMI, and then communicating effectively with the ED and cardiology. These skills aren’t as dramatic as, say, sinking an ET tube or needle decompression, but they are arguably far more important.
And they're made in New England! (site)
I wanted to illustrate this with a few recent STEMI cases. Basically, I just want to brag about EMS in Bridgeport!

Case #1 - Not an obvious STEMI
See what you think about the ECG. Older female, late at night, chest pain:

Kind of a tough one, since the RBBB mucks up the QRS. Unlike LBBB, however, the ST segments should be basically normal in RBBB. The paramedic, Gordon MacCalla, from VEMS, also thought this was a STEMI, despite the fact that the computer took a little longer coming to that conclusion than he had. 

Once in the ED, this ECG had the cardiology fellow scratching their chin, but the interventional cardiologist only needed about 0.25 seconds to verify the STEMI before heading to the cath lab with the patient. Since this all happened late at night, the cath team needed to be called in from home, so Gordon's prehospital activation saved plenty of time and myocardium!

Case #2 - Bypassing the ED
It’s not always possible for EMS to go directly to the cath lab, since the cardiac team may not have assembled by the time EMS gets to the hospital (as in case #1). Case #2 was the first time where the timing worked out, and paramedic Erin Smith, of Stratford EMS, got to skip the ED.

This middle-aged gentleman was actually hypotensive when EMS arrived. He complained of chest discomfort, and the first ECG showed:

Not subtle. Yeah, it was the RCA. By calling this in from the field and skipping the ED, medic Smith helped save this guy some heart muscle. The patient did well, spending less time admitted to the hospital than do most women after childbirth!

Case #3 - STEMI and cardiac arrest
Paramedic David Rodriguez of AMR had his hands full on this call! A not-old male had some chest discomfort, and called EMS instead of waiting it out. Good move.

Dave obtained the first ECG:

Nasty ST segment elevations in the anterior leads, eh?

That was bad enough, but then the patient went into VF! Fortunately, the time to first shock was minimal, since they were in the back of the ambulance at that point, with the defibrillator an arms-length away. After just one 200 joule shock* the patient was back in NSR, with a pretty brisk return to consciousness. At the hospital, he went immediately to the cath lab, where a proximal LAD lesion was opened.

This case is a good reminder - always think of STEMI with a cardiac arrest! Once you get a pulse and a blood pressure back, do an ECG if it hasn’t already been done.
Case #4 - Fantastic Door-to-Balloon times
Sorry, no ECG, but in a way that’s a good thing. Let me explain…

Paramedic Dane Johansson from Stratford EMS responded to a call for a middle-aged male with chest pain. On-scene he quickly performed an ECG, found a large anterior STEMI, and immediately called for a cath lab activation.

Despite a brief stop in the ED (again, EMS beat the cath lab team!), the door to balloon time was a stunning 36 minutes. That’s incredible - the national goal is 90 minutes, so Dane beat that by almost 2/3s!

So why is the "missing" ECG a good thing? Well, no hospital ECG exists because nobody needed one - all the cardiologist needed was the EMS ECG. The patient was discharged from the hospital before I could copy the EMS ECG, so we just have the “after” ECGs stored in our system!

The Bottom Line

Earn a Cardiac Save pin yourself! All you have to do is follow the the SHCGB guidelines for a prehospital AMI alert.

* Sorry Barry! It's just that shock has fewer syllables!


  1. Interesting outcome in #2, I would have been thinking LCx all the way (not that there's any foolproof way to tell the difference...). Congrats on having such a proactive and effective EMS system!

    1. Thanks!

      The ECG might have been more helpful if I didn't clip off the left precordial leads.

  2. PAMI Alert sounds funny to say...

    Great job Gordon, Erin, David, and Dane!