 Kevin Kent, Cardiovascular Manager, under a new position. He's been promoted recently. Kevin's an active part of our STEMI team and whenever there's anything I ask him to do, it's done immediately and I appreciate that. You good to go? Yes. All right. So Charlie asked me to talk today about and review signs and symptoms of ACS and you know, we all know what they are, but it always helps to review those signs and symptoms because you know as we found that sometimes the symptoms aren't so obvious to us, but you know typical symptoms of ACS obviously are chest pain, shortness of breath, you know dyspnea, maybe arm pain. You know, I've had cases in the cath lab where that's the only thing they complained of, maybe arm heaviness, maybe not so much pain. So we have to pay attention to what is their, what is the description of their symptoms like? You know, it can be heaviness. It can be non-specific symptoms. You know, does the pain radiate anywhere? Does it go to the jaw? Does it go to the back? And I want to step back real quick and talk about chest pain for a second because people say, well, it's not pain. It's pressure. It's heaviness. It's uneasiness. It is just this atypical pain that's there. Not always chest pain. Like I said, does it radiate? Does it go anywhere? Diaphoresis. That is often a very strong clinical indicator that this is a heart problem because they had chest pain and they remember that they got acutely diaphoretic with that. And, of course, indigestion is a non-specific indicator of ACS. We know that there are certain patient populations that don't present the same way. And that's where I go with this slide, in that those not-so-obvious signs and symptoms patients. And obviously, they're diabetics in women. Diabetics have, depending on their degree of diabetes, a significant part peripheral neuropathy that may deaden their ability to perceive pain. And women as well are different patient populations that they don't present the same way. Their symptoms aren't the same. So as clinicians, we need to be able to differentiate those specific patient populations and to be able to decide, is this truly an ACS symptom or is it not? And try to guide your treatment along with that. Of course, you have a certain patient population that's going to present with a silent MI and it kind of goes along with the not-so-obvious signs and symptoms. They may have shoulder blade pain. They may have non-specific back pain. They may have non-specific chest pain. That may not give you a clue that actually they're having a silent MI. In reviewing the literature again in ACS in preparation for this, an acute onset of acute diaphoresis is often a strong clinical indicator that the patient's having an acute coronary syndrome and maybe having an MI. So if you get this acute onset of sudden diaphoresis, you know, maybe they get pale, maybe they get syncopal, you know, they may or may not pass out. But along with that is this sudden feeling, my pointer isn't working, of impending doom that goes along with that. Maybe they feel syncopal. Maybe they feel light-headed like they're going to pass out and they get sweaty and diaphoretic associated with that. So those can be very, those can be clues or indicators that the patient is actually experiencing a heart attack. So STEMI basically this is a broad statement, but any patient presenting with signs and symptoms of ACS that you suspect are suspicious for cardiac problems should have an EKG done within five minutes of patient arrival or first medical contact. First medical contact is EMS. They call EMS. They don't feel good. Maybe they have non-specific complaints or they have chest pain. Ideally, based on STEMI recommendations, we want that EKG within the first five minutes. And we track that through our data collection to see, are we meeting that goal? Because that is the STEMI team. We've decided that that is one of the goals that we want to attain. Now, does that mean that that also goes into play when you come into the emergency department? As Dr. Greger will be talking about in a little bit, we want that EKG within the five minutes of them walking in the front door. So take some rapid assessment to say, is this patient truly a STEMI or truly a patient having ACS symptoms because time is muscle. That being said, patients with symptoms and no EKG changes, so say their EKG is normal on first presentation, should have a repeat EKG within five to ten minutes afterwards. We don't want to wait an hour afterwards. And if they have persistent symptoms, we should be doing that repeat EKG at regular intervals to pick up any changes. Because we know historically that even though they have a normal EKG, that can change to an ST segment elevation MI in the matter of minutes. We're going to talk briefly about the protocol. This is the adult transport cardiac protocol for STEMI patients for Midland Gladwin for this medical control authority. And our goal is to decrease the damage to the myocardium by transporting qualified patients to the cardiac cath lab. Well, this is what the STEMI team set out a number of years ago to put in place. It has been shown as a class 1A recommendation from the American Heart Association that primary PCI or emergent angioplasty in stent places, its placement decreases death and mortality when the patient is taken directly to the lab as opposed to going to the emergency department and being admitted or whatever the case may be. So it's been well established that that is what the STEMI team was originally initiated for to develop this rapid transport to the cardiac cath lab, get the vessel open and stop their heart attack. So we have the pre-medical control protocol, which I'm sure all the paramedics, everyone a paramedic here? Or nurse? Paramedic nurse? So these are field protocols, so we're going to follow our general pre-hospital care protocol in treating chest pain and acute coronary syndrome. Like I said, the goal is to decrease our damage to the myocardium. We do not delay transport. We want to transport to the PCI center within 90 minutes of onset of symptoms. If there's an estimate to be greater than 90 minutes, then that's where it alters a little bit. You need to transport to the nearest emergency department. And actually some of those guidelines have actually been changed out to 120 minutes for respect of transport to our facility. But basically we're trying to meet a door to balloon of 90 minutes. Door to balloon of 90 minutes. Of course we're going to start an IV. We're going to give nitro. We're going to do all those things that we do for the ACS patient. We're going to administer sublingual nitro knowing that we have to keep an eye on the blood pressure. And all this is in your protocol. We can start a nitro drip as well. So we should be very burst on this protocol and also administering morphine and titrated to pain. Where we differ a little bit is down here after we have talked to the emergency department or gotten bypass protocol or whatever bypass permission. But we need to administer 60 units per kilogram bolus of heparin to a maximum dose of 4,000 units. And that is something do you give that order, Dr. Gregg, from the emergency department? Or is that are they okay to do that? They're doing it. So that's what I thought the process was. They call, they say you have a stemmy. We're going to give the heparin bolus. Keep in mind the max dose is 4,000 units. Of course we're going to continue to give morphine as indicated for the pain. Tight trade or nitro drip up. Obviously we're going to increase their drip to pain and don't be afraid if their blood pressure can take it. Don't be afraid to go up to those higher levels because sometimes it takes more nitro than is typical for the patient who maybe has unstable angina. We don't want to delay transport. Obviously we want to get the patient to the PCI center within 90 minutes. Any questions on your protocol? Pretty straightforward protocol. This is the EMS radio report sheet that the ER takes from EMS. So we need to be calling when we activate the stemmy team so we know that the operator activates or the emergency department calls the operator activate the stemmy team. And then EMS calls five minutes out to find out if the lab is ready to accept the patient. At night time is usually when that's an issue. It can be an issue during the day if we have two cases going on. At the same time we have two cardiac cath labs. So if there are two in process on occasion the patient has to go to the emergency department briefly as well as at night there's a 30 minute response time. So those two times that's why that five minute call is important for direction for EMS and where to go. Once they get that call the ER nurse calls the lab says is the lab open. We say yes bring the patient directly to us. If we say no either we have a situation where we can't accept the patient at the time they need to go to the ER briefly and that's what this report kind of indicates. So I can't underestimate the importance of the five minute phone call. On occasion I know the city cars are close. Sometimes it is we'll be there in five minutes. So on occasion you may have to walk through the emergency department especially at night knowing that we're 30 minutes away. You know you're five minutes away from the hospital and you've just activated we are not going to be there ready for you once you arrive at the hospital. And then of course the PCI worksheet. This is something that's in all the PCI packets. We need to you need to be familiar with this form. What's important information especially to give the emergency department is name date of birth height and weight. Those are four bare minimum criteria that we need to get the patient registered through admitting because now with the advent of electronic medical records it's a little bit harder to do it after the fact or ad hoc. The accurate name we need an accurate name you know spelling there's a lot of people that go by a different name than what their given name is. And then the height and weight that that is the data that we need to get started the rest of the data we can get later. But the best we can fill out this PCI worksheet and it may it may be after the case but we also get a lot of data from this form. And specifically is what time did they get to the cath lab. We can look from the time of the call to the time they arrive at the cath lab. Are we in we use that data to see did we meet the door to balloon. Did we meet the criteria for getting their them here within 60 minutes from our outline areas. Did they get TPA you know did they stop briefly at Claire. All those things going to play what kind of history did they have you know the other important thing is the allergies you know these patients are usually alert and can tell us some of that stuff. But you know from a data collections perspective the top part the patient name those identifiers symptom duration when it started. We know that patients don't call right away. It started three hours ago that can kind of give us some treatment you know ideas that hey this isn't something that started you know right away. What do we have to be worried about. So that's the PCI worksheet that stays as the permanent or should stay as the permanent medical record so there is a place for a sticker on it to be scanned into the medical record. Any questions about the PCI worksheet. There's been a lot of you know tweaking of this form so to speak and I think we've got it down to what Dr. Lauer and Dr. Greg feel is the bare minimum data for our PCI worksheet. We do this form is utilized quite a bit. And that's what I have for mine.