New STEMI protocol in Riverside County, CA

[jgmedic]

So I just wanted a few opinions from people who work in better EMS systems than mine. We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field. Doesn't matter if there are elevations or depression, unless the monitor readout states Acute MI and the pt is having chest pain, it goes to the closest. I think this is absolutely ridiculous, the last 3 STEMI's I've had have been pain-free, Anyone else run into a similar protocol?

 

[JPINFV]

Well... there goes Riverside LEMSA as being my favorite counter example to the fire based systems in LA and Orange Counties...

 

[ah2388]

id be very reluctant to follow such a protocol.

 

[Veneficus]

So I just wanted a few opinions from people who work in better EMS systems than mine. We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field. Doesn't matter if there are elevations or depression, unless the monitor readout states Acute MI and the pt is having chest pain, it goes to the closest. I think this is absolutely ridiculous, the last 3 STEMI's I've had have been pain-free, Anyone else run into a similar protocol?

While I think it is sad, it is not ridiculous.

If providers have been grossly overtriaging patients, then they are not performing well enough to make the determination. Apparently the powers that be feel the machine is doing a better job than the providers, do they have numbers to back it up? I am guessing ""yes."

I have no idea about this service, but generally if you are going to start pressing alarm buttons, you have to have an acceptable level of accuracy. The old school idea of "just in case" is no longer valid. Like all of healthcare, cost/benefit is coming under scrutiny.

I keep telling people, it is better to play a system than slip through a crack. If you think your patient maybe falling through a crack, it is very easy to convince them they are having chest pain. However, if you are wrong, you made the call, responsibility falls to you, not the BS "I was just following protocol" defense.

I like to ask "why" and go right to the top. I am sure the medical director has some reason to back up his decision. Ask.

 

[TransportJockey]

Instead of making this protocol, I'd start teaching the medics how to read a 12 lead. They obviously need the extra practice

 

[Shishkabob]

We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field.

Wait wait wait... they are afraid of misdiagnosed EKGs, so they rely on a computer diagnosis that is often wrong itself?


Anyone else think that's odd?

 

[Veneficus]

Wait wait wait... they are afraid of misdiagnosed EKGs, so they rely on a computer diagnosis that is often wrong itself?


Anyone else think that's odd?

the question is which is wrong more often?

 

[Shishkabob]

The fact that either / or is wrong often is sad in and of itself.

 

[firecoins]

I am sorry but that is ridiculous. The medics need to be retrained on 12 leads but calling a Stemi when it isn't is much better than the reverse.

 

[dmiracco]

WOW, thats pretty sad and ridiculous. Sounds like maybe that service should just have Intermediates on the trucks if all they want you to do is read what the machine prints out.
SO either most of the medics there cant read a 12 lead and need more training or the Administration,Training officer needs a wake up call into the current world of EMS or perhaps they need training themselves.
I know nothing about his service but based on what was written that is one of the most ignorent things I have heard of in EMS in a long time.
Hopefully that will be changed for the benefits of the patients that are served in that county.
What you are going to see is A LOT of false positives from the machine.

 

[MrBrown]

Dude seriously that is pretty sad.

Rather than rely on machine interpretation and if the Firefighters aren't up to the task of being trained in how to interpret a 12 lead, at least transmit the bloody thing and have a doctor look at it, or a nurse, or you know, a janitor who happens to be wandering by coz I bet he can be taught to interpret a 12 lead!

 

[trevor1189]

Regardless of this protocol, if the medics think stemi, the should be transmitting and allowing the doc to make the call if this protocol restricts them from doing so.

 

[Veneficus]

because perspectie is my thing

Reading over the responses here, There is considerable focus on STEMI, not on the nature of the ACS as a whole.

If you need "chest pain" and a machine that can see ST elevation in multiple leads, it rules out any "abnormal" presentation. Even if you were to base treatment on the 12 lead readout alone, I am sure we are all very much aware the reason we have a classification called "NSTMI."

If a written protocol states you need a high degree of certainty it is a STEMI to transport to a cardiac facility, that seems like it purposefully excludes a significant number of patients who very well could be in need of specialty care.

I would be interested in hearing the med directors logic. Is he just following the primary practice in the area or is there more to it?

 

[reaper]

Since over 50% of AMI's are NSTEMI, there are going to be a lot of heart muscle dieing out there. Hell, over 40% have no chest pain, so they are really screwed!

 

[MrBrown]

Since over 50% of AMI's are NSTEMI, there are going to be a lot of heart muscle dieing out there. Hell, over 40% have no chest pain, so they are really screwed!

But they lived in SoCal, they were alreayd partly screwed anyway

 

[jgmedic]

Reading over the responses here, There is considerable focus on STEMI, not on the nature of the ACS as a whole.

If you need "chest pain" and a machine that can see ST elevation in multiple leads, it rules out any "abnormal" presentation. Even if you were to base treatment on the 12 lead readout alone, I am sure we are all very much aware the reason we have a classification called "NSTMI."

If a written protocol states you need a high degree of certainty it is a STEMI to transport to a cardiac facility, that seems like it purposefully excludes a significant number of patients who very well could be in need of specialty care.

I would be interested in hearing the med directors logic. Is he just following the primary practice in the area or is there more to it?

I would love to ask him, maybe I'll try next time I go to his ED. The problem stated in the memo is the overtriaging of "possible STEMI", stating that too much is coming from poor ECG tracings with baseline wandering and poor interpretation, sadly, the most training our medics get outside of school is the initial 12L class given during county accreditation and that's just for AMR, I don't know how the ALS fire agencies do it. This med director recently pulled pediatric intubation due to a series of esophageal tubes, I heard something like 5 in a week, and has recently threatened to pull adult tubes if we don't get our act together. Our division has a pretty good reputation for our clinical skill but it seems like the director is on the warpath, putting us in-line to be another SoCal Mother May-I system.

 

[dmiracco]

Sounds like there needs to be a FORMAL 12 lead course put on at that service and it probably would be best if it was someone completely outside of the service that teaches the class.

 

[TomB]

So fashionable to beat up on Southern California, even though the STEMI system is thriving and the patients are doing wonderfully. The flaw in your argument is the fact that NSTEMI patients are not treated the same as STEMI patients. Early invasive strategy is not the same as an urgent cath where minutes count. Select NSTEMI patients may one day be fast-tracked to the lab like STEMI patients (perhaps with point-of-care biomarkers and some type of field risk assessment) but that's a ways off in the future, and it will be an add-on to a STEMI system. It's a rare EMS system indeed that makes the decision based 100% from paramedic interpretation (no interpretive statement and no ECG transmission). 99% of the time when I challenge someone who ridicules Southern California, if turns out their own municipality, region, or state cannot compete with Southern California's stats.

 

[Veneficus]

So I just wanted a few opinions from people who work in better EMS systems than mine. We were just given a memo that we are not to transport to the STEMI center, unless the monitor states Acute MI suspected due to misdiagnosed STEMIs in the field. Doesn't matter if there are elevations or depression, unless the monitor readout states Acute MI and the pt is having chest pain, it goes to the closest. I think this is absolutely ridiculous, the last 3 STEMI's I've had have been pain-free, Anyone else run into a similar protocol?

I think this was the key phrase I was focusing in on. It doesn't seem prudent to require chest pain with ST elevation in order to be transported to a specialty center.

This is one of the articles I have seen recently on early invasive treatment of NSTEMI.

http://www.aafp.org/afp/2007/0101/p47.html

So fashionable to beat up on Southern California, even though the STEMI system is thriving and the patients are doing wonderfully. The flaw in your argument is the fact that NSTEMI patients are not treated the same as STEMI patients. Early invasive strategy is not the same as an urgent cath where minutes count..

But if the goal is early invasive therapy, it seems like it would help more to drop the patient off at the facilty that could schedule it faster than a work up at one hospital, the arrangement of transfer, followed by the process the specialty center would ultimately start there.

Select NSTEMI patients may one day be fast-tracked to the lab like STEMI patients (perhaps with point-of-care biomarkers and some type of field risk assessment) but that's a ways off in the future, and it will be an add-on to a STEMI system.

You have to start somewhere. As I said above, transporting the patient to the STEMI center seems like it would naturally reduce the time to whatever care is rendered as the STEMI center in all likelyhood has a C/T surgeon on staff who could render additional invasive therapy in addition to interventional cardiology/radiology. By your own logic it would seem that since fast tracking will be built on top of a STEMI center, taking your ACS patient to that ceter to begin with would be a prudent step?

It's a rare EMS system indeed that makes the decision based 100% from paramedic interpretation (no interpretive statement and no ECG transmission)..

I wasn't suggesting activation of a cath lab or any other treatment course should be one by EMS. I was insinuating That if EMS suspects some form of ACS with an acceptable level of accuracy, then it would be more prudent to transport to a specialty center thn the closest hosptial which may not be able to render the most effective care called for.

99% of the time when I challenge someone who ridicules Southern California, if turns out their own municipality, region, or state cannot compete with Southern California's stats.

I twice suggested finding out directly from the medical director first hand the reasons for his new directive in this thread.

It is my opinion if a machine is better at reading an EKG than a medic, that medic is faulty regardless of system design. Might as well just teach a basic how to hook up a 12 lead and save the whole system a lot of money by reducing medics.

 

[irish_handgrenade]

My service spends a lot of time practicing ekg and 12-lead interpretations. We have had part time medics in the past who had trouble with reading them and they were takin off the truck until they could show the medical director otherwise. This sounds like a lack of education to me and a loss of confidence from your medical director. As for our full time medics most of us are as good if not better at reading a 12-lead than the staff doctors at the local ER.