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FirstHealth of the Carolinas
STEMI alert

In many parts of the country, particularly in rural areas, the system in place for responding to heart attacks sometimes involves many minutes or even several hours of wasted time.

Here’s how it works:

You feel severe pressure and pain in your chest and call 911. Paramedics come to your home, check your condition and put you in an ambulance. They rush you to the nearest hospital, where the emergency department staff does an electrocardiogram (EKG) and determines that you are, indeed, having a severe heart attack, most likely due to one or more blocked coronary arteries.

But the hospital is small and doesn’t have a cardiac catheterization lab where your clogged arteries can be opened. So you are put back in the ambulance and taken to a larger hospital in the next town. There, you get another EKG, which confirms the findings of the first one.

Finally, you are ready to go to the cath lab. But if all the cath lab rooms are full, with procedures on other patients already in progress, there might be even more delay. Meanwhile, as the minutes go by, part of your heart muscle is dying from lack of blood.

That is not the scenario for heart attack victims in the four North Carolina counties served by the FirstHealth Regional EMS System. Starting in January 2006, the EMS system and the various hospitals in the region adopted a new heart attack response protocol designed to eliminate the inefficiencies and redundancies that used to cost precious time.

“The goal was to streamline the process and slingshot the patient into the cath lab,” says David Carter, R.N., director of the FirstHealth Regional EMS System. Carter spearheaded the development of the heart attack protocol.

Now, if FirstHealth EMS paramedics pick up someone who is having a heart attack, they will bypass the nearest hospital if it doesn’t have cardiac catheterization capabilities and instead take the patient directly to FirstHealth Moore Regional Hospital in Pinehurst or, if it is closer, to UNC Hospitals in Chapel Hill.

Those patients don’t have to wait to get to the hospital before having an EKG. For the past several years, FirstHealth EMS paramedics have been doing 12-lead EKGs (the most complex and definitive), sometimes even before they put the patient into the ambulance. Now the paramedics also read the EKG, calling in the results to the hospital.

Emergency Department physicians trust them when they say they have a STEMI (ST Elevation Myocardial Infarction, the EKG pattern that indicates an acute heart attack).

“A STEMI means there is enough blockage in a coronary artery to cause tissue death,” says Matthew Harmody, M.D., an Emergency Department physician and medical director of FirstHealth EMS. “It means cells are dying and will continue dying until the blockage is opened up.”

Carter says the FirstHealth EMS staff has proved to be extremely competent at reading 12-lead EKGs in the field. “So far, they have not

called a STEMI alert that didn’t need to be called,” he says. Carter serves on the board of the national Society of Chest Pain Centers and is leading that group’s effort to develop a standard protocol for Emergency Department and EMS cooperation nationwide.

After the STEMI alert
An ambulance carrying a heart attack victim might be 30 or 45 minutes away from the hospital when the paramedics call in the STEMI alert. That gives the emergency department and cath lab staffs time to get ready and for an interventional cardiologist to be standing by to start working on the patient as soon as he or she arrives.

“Our stretchers hardly even stop in the emergency department anymore,” Carter says. “They go to the cath lab almost immediately. We have had some cases in which we have saved more than an hour, during which time the patient’s heart would have been dying. In all of my EMS career, this has been the most significant advancement in out-ofhospital care.”

Dr. Harmody, who is one of a group of physicians who cover all three FirstHealth emergency departments, agrees that the new heart attack response protocol has made a big difference.

“We have dramatically decreased the time it takes to get the patients where they need to be, which is in the cath lab getting their blockage open,” he says.

American Heart Association guidelines for STEMI alert patients say the blockage should be cleared within 90 minutes of the time that the patient enters the hospital. Moore Regional averages about 60 minutes for STEMI alert patients.

“We shorten the time as much as possible once patients get to the hospital, but it’s also critical for them to call 911 as soon as they start having symptoms,” says Keith Davis, M.D., an interventional cardiologist with Pinehurst Medical Clinic.

“We can do the most good for a patient within the first six hours, and if they can get here and get their artery opened in the first hour, there may not be any heart attack damage at all.”

A STEMI alert patient

Willie Leviner had come home from work and was doing some chores when her heart attack began.

Suddenly, she couldn’t catch her breath, she felt nauseated, and her face was burning hot. Sensing that something was seriously wrong, she called 911.

“In what seemed like a matter of moments, two of the nicest men entered my life and my heart forever,” Leviner recalls. “Their names were James (Barringer) and Robbie (Barber), and they were responding to the 911 call.”

The FirstHealth EMS paramedics checked her vital signs, gave her oxygen and started an electrocardiogram (EKG). Because the EKG indicated Leviner was having an acute heart attack, they took her to Moore Regional Hospital in Pinehurst even though Richmond Memorial Hospital is only about 10 minutes from her home between Rockingham and Hamlet. (See why in the related story.)

On the way, they called in the EKG results so the Emergency Department and cath lab staffs could be ready and waiting.

hortly after Leviner’s arrival at the hospital, interventional cardiologist Allen Strunk, D.O., of Pinehurst Cardiology Consultants, performed a catheterization procedure, opening five blocked coronary arteries and inserting stents to keep them open.

“After a few days, the doctor told me it was the excellent care I had received immediately after the attack and the quickness with which I had reached the hospital that allowed the stents to be placed and prevent a second heart attack,” Leviner says.

“James and Robbie’s experience and compassion made it possible for me to be here, in better health than ever, to see my granddaughter, to care for my mother and to return to work and church.”

Leviner still sees her local cardiologist, Robert Parris, M.D., of Sandhills Cardiology in Rockingham, to make sure her heart is doing well. She was one of the first patients to benefit from the streamlined heart attack response protocol adopted by FirstHealth EMS and the hospitals in the region. Since her experience on Jan. 31, 2006, the protocol has been used for more than two dozen other heart attack patients.

The FirstHealth Regional EMS System is one of only a handful of EMS services across the country that have equipped and trained their staff to read 12-lead EKGs for a serious cardiac emergency referred to as a STEMI (ST Elevation Myocardial Infarction). Studies indicate that patients with STEMI conditions can best be treated in a hospital, such as Moore Regional, that can perform a balloon angioplasty.