 Also, Danny Greg will be speaking, our PMD of both Midland and Gladwin counties, now a family physician, but still works part-time in the emergency room. So thank you very much, Danny. All right, everybody hanging in there this morning? All right. I'm going to talk about field activation mostly, and then we're going to go through some practice cases, which are always fun. We initiated the stimuli alert team, started about four years ago. It basically started with EMS's initiative. We had a couple of ED nurses involved. Right now we have 34 people involved, multi-departmental. Everyone's done a great job, and it's continuing to grow. Multiple facilities and counties. We've got Midland, Gladwin, Claire, Houghton, Bay even, anywhere else? Farwell, OK. We were the first in the state of Michigan with an approved STEMI protocol. That happened in 2011, and that was quite a struggle. Trying to get anything past the state these days requires quite a bit of an effort. We got, literally got notes back from them like the Heparin bolus. Show us data that proves that the Heparin bolus in the field is more effective than the Heparin bolus in the ER. Well, there is no such data. This is existing standard of care. I mean, there's no data that says aspirin in the field is more effective than aspirin in the ER either. It's just what we do. So finally, after a while, we've got this through, and we're proud to get it done. We have very committed cardiologist and Dr. Lauer, a bold champion who I think has dragged the other cardiologists to his way of thinking. We do immediate notification and review of all STEMI patients to any team members that were involved. We're trying to get as accurate data collection as possible. That's one of the things we're going to talk about that we do struggle with to some degree. We give immediate follow-up to all medics and all field personnel involved. We used to wait for pictures and things, but we decided we just want to get the info back to let them know what happened, how things turned out. Continuing education like we're doing today and public education. This is what's supposed to happen with the walk-in STEMI patient. And we generally do a very good job of this. This applies mostly to our outlying facilities. Patient presents to an emergency department with acute coronary syndrome, signs, and symptoms. He gets his 12 lead, hopefully within five minutes. The idea is if it shows a STEMI, we activate EMS right away for emergent transfer. If door-out time cannot be arranged in less than 30 minutes, or if the transport time to Midland is going to be greater than 60 minutes due to weather or anything else, then the patient becomes a candidate for thrombolytic therapy and still transferred to the PCI Center. At the outlying facility, they will prepare the patient for transfer, IV, aspirin, nitro, heparin bolus, all those other things. They're not going to give any plavix or effiant or berlinta or any other anti-platelet agents before the transfer. And they're going to fax the 12 lead right to us in the ER. And then they're going to call me and they're going to say, I've got a STEMI patient. EMS is here, or maybe the patient is already left. I mean, maybe EMS brought the patient in and they say, hey, this is a STEMI and they put them right on the rig. We do not delay transfer for the call. We're not giving them permission to transfer the patient. We're going over the case and deciding whether or not to activate the lab. So they faxes the 12 lead. They say it looks like an inferior MI to me. I'm sending the patient. OK, great, send the patient. We look at the fax. As long as we agree, we activate the cath lab through the midland ER. And things go as though the patient had walked through our doors or you guys had activated from the field. If we disagree with the interpretation of the 12 lead, we may call it off and have them come to the ER. If we do not get the 12 lead because of technology, because there's a lousy printout on the fax that's uninterpretable to us, we go with the read from the outline ER doc. The cath lab is still activated and you still go. And then, of course, the five minute call before you get here can't stress how critically important that is so that you know where to take the patient. Nothing's going to be worse than showing up in the cath lab without a cath team there. Nuance at left bundle branch block. We just spent a year or two years we've been talking about being able to activate on this. You guys don't activate, but we may. Your responsibilities are to get the 12 lead. You look at the patient. Patient looks like someone who's having an MI. That's one of the critical things for the left bundle. So this guy's got chest pain. He's diaphoretic. He just looks like a cardiac patient to you. You look at his EKG. He's got a left bundle branch block. So you're going to call your medical control in your community and say, I really think this guy's a cardiac patient. Can I bypass and go to Midland? They're going to say yes. The hope is that they're also going to look through old records and see if they can find an old EKG on this guy. You're also going to call us and call the ER nurse. And I'm going to look through news and see if I can find an old EKG. If we can document that this is a new left bundle, this guy will go to the cath lab with consultation cardiology. If we can't document that this is a new left bundle, it's really going to depend a lot on the situation. So if you have a 91-year-old guy who's had two bypasses and five stents, and now he's got a little bit of chest pain and looks like maybe something's going on, he's probably not going to activate on that guy. That left bundle is not likely to be new. If he's 50 years old with no past medical history and he's got crushing chest pain and a big ugly left bundle, we may just send him without any old EKG. So that's going to be a judgment call between myself, my partners, and the cardiologist on the call. This is the checklist that we would like the ERS to complete. Oral report given to the cath team, PCI worksheet completed. Copy of the 12-way inpatient identification given to staff, pre-hospital labs labeled and taken to the laboratory. Paramedic agency involved. Down here we talk about question nuance at left bundle. We just talked about that. Right bundle with ST elevation. I think Kevin touched on the idea that right bundles we can interpret just the same way we would someone without a bundle branch block. Initially, the rule was back in 2011, any bundle branch blocking we didn't activate. You guys have all done such a good job that we decided we'd expand the criteria. So now, as long as you can find your baseline, you can activate on right bundle branch block with ST elevation as if it was any other patient. Is the entrance still OB or do we have a new one? It's still OB. All right, so on to a few case studies. None of these are terribly difficult, but it's always a good idea to review. These are all real people, so none of these are made up. You dispatch to a, oh, and hopefully this will be interactive, which so I'd like you to tell me what you think of the EKG and what you do. Normally interactive means I pause for a minute and then give you the answer myself, but hopefully someone will take a look and say something. You're dispatched to a 240 pound, 52 year old male complaining of being awakened by mid-sternal chest pain. 10 out of 10, blood pressure's good, pulse is good, O2 sat's good, skin's a little clammy, lung sounds are clear. Within five minutes, you have the following EKG. Is that projecting okay? All right, good. Okay, all right, so what's your decision? Activate, right, so you're gonna call us and you're gonna activate, okay. Which coronary artery is involved, which region is involved? Inferior wall, which coronary artery? Good, so your job is to look at this and see ST elevation in 2, 3, and ABF. Call us and say, I've got ST elevation, I've got a patient with classic signs and symptoms, I'm activating the cath lab. If you tell us there's elevation in 2, 3, ABF, it's an inferior MI, we'll be impressed. If you tell us there's elevation in 2, 3, and ABF, I have an inferior MI and a likely acute occlusion of the right coronary artery, we'll be impressed, but we also might think you're a little bit annoying. Ha ha ha ha ha ha ha. Next case, you're dispatched to an 88 year old male complaining of chest pain while mowing his grass to push more, five out of 10. Again, good blood pressure, pulse, skin is pale and diaphoretic. Lung sounds are clear bilaterally, EKG here. Yeah, so he's got a little bit of anterior lateral, maybe a little bit of elevation inferiorly, where's the pointer? So you could maybe argue that he's up a little bit in 2, ABF, mostly out here laterally, right? Pointer's dead now, so there we go. All right, so what region is that? Anterolateral, kind of, yep, good. Which artery? The big one, right? LAD, we don't make it right. Ha ha ha ha ha. You're dispatched to a 210 pound, notice these real world cases and the body habituses in these people. It's always kind of funny when I look at the 4,000 unit maximum bolus, so you may give less than that in all of our 60 kilogram acute MI patients, but otherwise you'd probably be giving the 4,000 unit bolus almost as a standard, right? So you're dispatched to a 210 pound, 62 year old male with heaviness in his chest and left arm pain after physically exerting himself outside. Classic story, 10 out of 10, went into rest but the pain did not go away. Sounds like maybe he's had episodes of this in the past where it did go away, huh? Blood pressure 104 over 62, pulse 50, O2 sad's good, he's pale and diaphoretic, lung sounds are clear, pulse is a little weak. You get this EKG right away. Inferior, are you activating on this? Yeah. Absolutely. Vessel, you got it. Yeah, you knew this guy, yeah, yeah. Did he get a fluid bolus on the way in? Yeah, he got a lot of stuff. Yeah, yeah, so these inferior guys, this is something you gotta be careful with. You give them the nitro and blood pressure just drops out of sight and then you gotta give the fluid bolus. You gotta keep that right atria full. You're dispatched to 150 pound 88 year old male complaining of chest pain. Five out of 10, blood pressure, pulse, O2 sad, all good. Skin color's normal, lung sounds are clear. In 17 minutes you get the following EKG. Not as obvious, I hear inferior. That what everyone's seeing? Yeah, yeah. Anything about this EKG that makes you think that inferior's a little more real than he's got some reciprocal changes across the protein doesn't it? So you're gonna activate on this one? Yeah. Vessel, right, you got it. Now you're going to see a 220 pound 37 year old male. He complains of midsternal chest pain which began last night and has become worse throughout the night. Complains of nausea, headache, shortness of breath. He's also 10 out of 10, hypertensive, O2 sad, pulse good, skin is clammy. Here's your EKG. Antiroceptal, right? Gonna activate? Yeah, blood vessel. And he does have some reciprocals over in the inferior side too doesn't he? You're dispatched to a 240 pound 57 year old male sitting in a chair, sub-sternal chest pain. Right arm and jaw pain, seven out of 10. Vitals all look good. He's pale and diaphoretic as well. Here's your EKG. What'd you say? Antiroceptal? Yeah, looks real. He's up a couple of boxes. Maybe a little reciprocal stuff inferiorly. So you're gonna call us and activate or not activate? Excellent. Which artery? LAD you got it. That's the guy that goes into fibrillation and dies in front of you, yeah. You're dispatched to a 200 pound 76 year old male. He's five out of 10 chest pain. He's a little hypotensive at 84 over 53. Gratocardic, skin is pale, diaphoretic. Lungs are clear bilaterally. Yeah. Not subtle, right? I take it you're gonna send this guy? Yeah. Okay. Why, why do you think he's hyper? We'd see a left main. Yeah, could be a left main or it's gonna be a high LAD. So why is he hypotensive? His pump's not pumping, right? His left ventricle just ain't working, right? Do you know how this guy did? Did he do okay? All were success stories, okay. That is amazing. This guy 10 years ago would have been a cardiac cripple when he left the hospital. If he left the hospital, right? You're dispatched to 175 pound 62 year old male. Complains of pain in the center of my chest. Eight out of 10, hypotensive, pulse and sat are good. Skin colors normal, lung sounds are clear. So what do you think? Inferior, okay. Activate, don't activate. Activate. Yeah, looks real to me. He's up in up in two, three ABF. He's got a little reciprocal V1, V2. If it says that, make sure you take, at least take a close look at it before you ignore it. Okay, which coronary artery? Which area of the heart? Right, and it's inferior. Now we've got 135 pound. This might be a person who gets less than the 4,000 units. 135 pound, 85 year old male, not feeling good. Pain is zero out of 10, blood pressure, pulse are good. He's a little tachypneic, O2 sat is marginal. Skin is clammy. He does have rails in both lungs. What do you see? What leaps out at you on the CKG? Bunch of PVCs, right? Okay, ignore the PVCs. Look at his native bees. Activate, don't activate. Don't activate. If you ignore the PVCs, his STs are flat, right? There's not any acute abnormality there. This one was activated. So this is one of the misses that we have. And it was activated because this bee has ST elevation. This bee has ST elevation. But those are PVCs. So the ear here was not looking at the native bees, but calling ST elevation on a PVC. 220 pound, 37 year old male. He's got crushing chest pain, shortness of breath, nausea and headache. His pain is seven out of 10, he's quite hypertensive. Lungs are clear, skin colors normal. I think you can see that, okay, good. Someone said anterior. Everyone agree with that? Yeah, okay. He's got an anterior MI. He's got some reciprocal changes in the inferior leave, maybe even a little depression. That's the T-wave inversion over here laterally. So he's an, he's a septal anterior MI. Hardery, L-A-D, got it. 100 pound, 47 year old female dialysis patient. This should always raise a red flag with him. Complains of chest pain, eight out of 10, 165 over 91 pressure, pulse is a little high, breathing is labored, 83% of two sat on a non-regreener. What do you see? QRS is a little wide, right? Probably doesn't meet the criteria for true bundle branch block, but QRS is a little wide. What else loops out at you? Yeah, you know, I think Dr. Selick is gonna go, has she spoken yet? She's gonna go over more detail on LVH and rule a 35 and count in your boxes. But really the format and his way to look at it is if the QRS complexes are touching each other across the corium, you probably got LVH. Be very careful about activating on LVH. I think that's one of the things we're gonna tell you not to activate on. So this one was activated and you certainly can argue that yeah, if I find a baseline, I'm up in two and three here. I may be up a little bit in four. I've got some T-wave inversion out here in five and six, but the marked LVH is what should say, tell you maybe I shouldn't activate the lab on this. You're dispatched to 150 pound, 51 year old male, sitting upright in his chair, pressure in the center of my chest going down, my left arm, it's about two out of 10, vitals all look good, skin's a little clammy, lungs are clear. What do you make of this? He's got peak T-waves, right? And he's got, what's he got inferiorly? So is this guy suspicious for a coronary syndrome? Yeah, would you activate the cath lab? No, right. He doesn't have ST elevation. He's got peak T-waves. For extra credit, anyone know what those peak T-waves are sometimes referred to as? You can call them hyper acute T-waves. So this is a guy who addressing Chris McKellar's question, probably ought to have a repeat EKG in five to 10 minutes. These hyper acute T's are the first change in the evolution of an MI. So there's a fair chance that this guy looks the part that you're gonna repeat his EKG in five or 10 minutes and now he's gonna have obvious ST elevation across the recording. And if he develops that, then you're gonna activate. If he doesn't develop that, you're gonna call us and say, I got a guy who I think is a real cardiac patient. I've done all my interventions I need to do, but he's come to the ER because he doesn't meet cath lab criteria. This one was activated then? This is one of the ones that was activated, yeah. Yeah, usually, you know, this one was within what, the first 30 minutes. Oh yeah, the hyper acute's are very early. So this guy, do you know what the outcome was? This guy, have an LED lesion? Do we even? You know, I don't remember. I suspect he did. I suspect this was real. I suspect those, why we've expanded our program into Q-A to say I'm also the right bongo brain to this and maybe a little bit of why we've given the heparin and how that helps Dr. Lauer because he's not gonna have a chance to talk about how the heparin will soften your client. So that's exactly, it's an anti-coagument. It'll inhibit the platelets. It'll stop the clot forming that's going on, you know, all the thrombin, all the laying down clots and that'll make it easier for him to get out. Easier for him to suck out of the artery. We're not giving the anti-platelet agents, I understand, because they can give the immediate acting once in the cath lab and then they're just as effective. And if the patient turns out to not be repairable by cath and needs a cabbage, you don't want him to have anti-platelets on board. The main reason we've expanded to Q-A's and right bongo and even left bongo is because everyone's done such an excellent job with the regular stuff. You guys have shown that you're capable and the more people we can help with this, the better. Thank you. You bet. Thank you.