Northern California Cardiologists and Emergency Medicine Expert Provide an Update On STEMI (Severe Heart Attacks) and Sepsis Protocols

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New developments to aid in the diagnosis and timely treatment of severe heart attacks and related infectious conditions were the topics discussed recently at the Regional STEMI Program and Sepsis meeting at the John Ash Restaurant at the Vintner’s Inn Event Center.

Dr. Patrick Coleman Dr. Thomas Dunlap and Dr, Tucker Bierbaum

Without proper diagnosis, paramedics cannot know with certainty how to proceed and implement the correct treatment protocol unless a cardiologist miles away at a regional emergency department catheterization lab reviews the EKG tape,” Dr. Coleman

Dr. Thomas Dunlap and Dr. Patrick Coleman, cardiologist with Northern California Medical Associates, Inc. and Dr. Tucker Bierbaum with Emergency Medicine at St., Joseph Health System’s Santa Rosa Memorial Hospital, co-hosted the biannual dinner meeting. They observed that both STEMI and Sepsis conditions present in similar ways and require time-critical intervention to avoid large area heart damage and progressive infections that can result in mortality.

According to Drs. Coleman and Dunlap, the medical community has come a long way in implementing timely procedures to treat patients with STEMI. “Cardiologists in the late 1990’s and early 2000’s began treating heart attack patients with intravenous stents, catheterization and balloon angioplasty – as well as drug-covered stents and balloons -- for faster, more effective intervention -- as opposed to just prescribing drugs to open clogged arteries which can take longer to do their job. The heart continues to suffer damage as long as the arterial occlusion remains. This new treatment strategy yields remarkable benefits in terms of less heart damage and improved patient prognoses.”

Dr. Dunlap said, “The STEMI Program has instilled a pervasive sense of urgency in people involved in administering the heart attack response protocol, and our efforts are paying off. The new STEMI treatment approach has been so successful that it’s not uncommon for patients that get picked up by EMS personnel at referral hospitals in Petaluma or Healdsburg to have their lifesaving device implanted within the next 90 minutes. There is still plenty of work to be done to increase STEMI response efficiency even further.

Dr. Coleman addressed the necessity of adhering a standardized response protocol. “The urgency of any heart attack situation requires that all caregivers involved, including the paramedics, firemen, ED triage nurses, ED physicians, and cardiologists, perform precise tasks with efficient command and expertise.”

All of the presenters at the meeting emphasized the vital importance of education and teamwork in an era marked by new techniques, technology and procedures. “It’s our job as cardiologists to educate everyone involved about their essential roles in saving heart attack patients’ lives,” Dr. Coleman added. “We know what needs to happen for STEMI patients to be treated effectively. Only through unified countywide planning and optimal utilization of local emergency facilities can we give patients their best chance for survival.”

A key barrier to the proper diagnosis of STEMI (ST-segment elevation myocardial infarction, or a severe heart attack) is that while EMS personnel and paramedics in the field can take EKG readings on site, or as they transfer the patient in an ambulance, they do not have the expertise or authority to read the tape and determine whether a STEMI incident has occurred. Only a cardiologist seeing the tape can make this assessment.

When a suspected heart attack victim is received by EMS personnel, they immediately call ahead to the nearest regional center emergency department (ED) to alert the cardiologist on duty so cath lab team members can be assembled in advance to save time.

“Without proper diagnosis, paramedics cannot know with certainty how to proceed and implement the correct treatment protocol unless a cardiologist miles away at a regional emergency department catheterization lab reviews the EKG tape,” Dr. Coleman continued. “So the quest has been to find a way to transmit EKGs to the cardiologist for precise interpretation while the patient is still in transit.”

Most facsimile machines are only capable of transmitting relatively low-resolution images. However, today’s cell phones have high-resolution cameras that can produce detailed images fine enough for an accurate STEMI diagnosis. Now a picture can be taken of the EKG tape in the field and transmitted to a physician in seconds, cutting the time interval for obtaining a diagnosis and treatment authorization during the journey from the field to the hospital, while also enabling the EMS to start appropriate medication therapy enroute.

The ability to transmit the photo image depends upon physical access to the nearest cellular signal relay tower. But even in remote areas beyond cell reception a moving vehicle often will enter an active cell zone within a few miles and be in a position to relay the picture before arriving at a hospital. HIPPA patient security and privacy considerations are avoided by asking the patient for permission to send the photo via a cell call prior to transmitting it.

In another innovative example, a Cotati-based medical transport company (ProTransport-1) has introduced ambulance technology that uses Google Glass camera-equipped spectacles worn by emergency technicians that transmit what they’re seeing to awaiting hospital staff.

The Google Glass system in the ambulances will allow EMTs, paramedics and nurses to transmit live video to receiving health care facilities during transports. In addition to mobile, visual evaluations, this versatile technology can improve the efficiency of patient care, documentation, navigation, dispatch communication and many more operational processes in the health care, ambulance and EMS industries.

“We’ve learned how to do many things well and still want to find ways to do them better, by focusing on a single process with ramifications based on how what you do will save lives, time and reduce costs,” Dr. Dunlap explained. “New communications technology is helping us expedite patient care before they arrive at the ED.”

Dr. Dunlap said the incidence of STEMI has decreased over the years, while the incidence of non-STEMI MI’s has gone up (1.6 cases per 1,000). Delays in treatment for STEMI come with a human cost per hour. Studies show that up to 40 lives can be saved for each hour medical personnel do better at identifying causes and administering proper treatment. For example, in door-to-balloon angioplasty therapy to unblock arteries, any time saved below 90 minutes makes a big difference in the 30-day mortality rate.

He said referral hospitals are good at processing patients quickly for transfer, and all regional medical centers have a reputation for rapid assessment of a patient’s condition, reducing the time required to implement treatment in receiving hospitals.

In an ideal scenario, ambulances equipped with EKGs would transmit the tape to the ED at the receiving hospital while adhering to standard protocols for drug stabilization and transfer from referral hospitals. The majority of the work will be done at the STEMI receiving hospital based on a single call from the field. This enables a classification of the case by level of evidence and severity.

The treatment ladder protocol for regional programs has been developed in consultation with Dr. David Lee at Stanford University with the goal of identifying a patient with ST elevation MI and directing the transport team to a STEMI-designated receiving hospital with a cath lab within 1.5 hours or less.

Also presenting was Dr. Tucker Bierbaum, with St., Joseph Health System’s Santa Rosa Memorial Hospital. Dr. Tucker contends that Sepsis is an issue with increase prevalence and diagnosis. From 2012-13 there was an 11% increase in Sepsis in the region affecting 122 per 10,000 of population with those in the 65+ age group most severely affected, as well as those with weakened immune systems. During this time frame, Sepsis accounted for 40% of intensive care unit (ICU) costs and involved longer hospital stays. Those with Sepsis have a high recidivism rate. When not treated in time, the condition can lead to permanent renal disease.

Sepsis is one of four pathologically similar and progressive conditions beginning with SIRS (systemic inflammatory response syndrome), Sepsis (a potentially life threatening complication of infection due to the presence of bacteria or other infectious organisms in the blood stream that can spread throughout the body), Severe Sepsis (Sepsis with organ failure) and Septic Shock (Sepsis with multiple organ dysfunction or death).

For STEMI cases, two sets of protocols were discussed, including what to do during the first three-hours utilizing the initial bundle of treatment procedures, and what to do during the next three-hour period, as well as what medications have proven to be most effective in addressing this condition.

Regular meetings such as this and the quality of information provided are the keys to continuous improvement through education, as representatives from referral and regional hospitals come together to learn about new developments that can make the health care system better and improve patient outcomes.

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John Beilharz
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Northern California Medical Associates
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