The Complete Idiots Guide to...STEMIs?

When I was a kid, a family friend gave us a wooden chess set and a book titled "The Complete Idiot's Guide to Chess." While we definitely aren't complete idiots, that book broke down a complex game into concepts we could understand.  We had so much fun learning to play chess... After awhile, it becomes easy to play the game and you can start focusing on more important things: like strategy. I find that doing the same thing for complex medical conditions or trying to learn how to cultivate bonsai (Bone-Sigh) plants helps. If I can explain it so a layperson can understand, then I generally have a good grasp of the subject.

Minerva watching it rain while trying to ignore a bonsai tree I was trying (and failed) to keep alive.

So the last couple weeks, I put in a decent amount of time as the Region A medic. I missed the lunar eclipse (which was also a full blood moon) because well, as folklore says, wild things happen on the night of the full moon. I was so busy running calls and writing my reports that when the clouds cleared I still didn't get a chance to see it. The theme of my last couple weeks seems to be responding for complaints of "chest pain."

Current medical practice in response to chest pain is very different from what it was 50 years ago. Fifty years ago, if you started having chest pain and you picked up the phone to call someone to take you to the hospital, you probably would have dialed your neighbor's house instead of 911.

I think that comparing the chest pain protocol suggested by the American Heart Association with common practice in 1965 might be enlightening. Please note that different jurisdictions have different protocols and may prefer to use different medications. This is normal, but the goal is the same. (And to anyone in the medical field who reads this, feel free to message me if I get something wrong. I'm happy to make corrections).

Let's start with some terminology: the medical term for a heart attack is an Myocardial (My-O-Car-Deal) Infarction (In-Fark-Shun) which is abbreviated to MI. When someone has a major medical event of any kind, we typically monitor their heart activity with an Electrocardiograph (Electro-Cardio-Graf) machine which is abbreviated either as EKG or ECG. There are two kinds of MI: ST-segment Elevation MI called a STEMI (I pronounce it Stem-Ee) and Non-ST-segment Elevation MI, or NSTEMI. I'll discuss the meaning of the ST-segment later.

And no, I don't expect you to remember all this. I also don't expect others to be as fascinated with cardiology (the study of the heart) as I am. 

Diagram of a myocardial infarction (2) of the tip of the anterior [front] wall of the heart (an apical infarct) after occlusion [blockage] (1) of a branch of the Left Coronary Artery or LCA. In the diagram, RCA is the Right Coronary Artery. [Diagram found on Wikipedia.][1]

My protocol dictates that when the patient I've been dispatched to help complains of chest pain, that patient is instructed to take 4 baby Aspirin if available. When I arrive, several things should happen quickly: somebody gets a set of vitals, and I get a 12-Lead EKG reading. Vitals consist of blood pressure, pulse, oxygen saturation, respiratory rate, listen to the lungs and check skin condition (because if the patient is pale, cool and sweaty, it tells me a lot about how sick they are). The 12-Lead is kind of like an electrical picture of the heart taken from 12 different angles. If the patient's blood pressure is above a certain number (and the 12-Lead isn't showing lack of oxygen to the right side of the heart), I will administer the first of up to 3 doses of nitroglycerin and transmit the 12-Lead to the ED for the doctor to look at. If the patient's oxygen saturation is below 94%, I'll have someone put the patient on a little bit of oxygen. At this point I typically like to move everyone to the back of the ambulance because I can do everything else in the ambulance on the way to the ED.

An MI is truly an emergency. The longer that area of heart muscle goes without oxygen (take a look at that diagram above again), the more permanent damage to the heart there will be. So this is one of the cases where I try to keep my time on scene short and sweet. Once in the ambulance with an emergency like this, I have to get vitals every 5 minutes (that's my EMT's job if I have one in the back with me), start an IV, radio the hospital to let them know that they're getting a STEMI, get a follow-up 12-Lead if possible, administer the other 2 doses of nitroglycerin if appropriate, and if that does not help the patient's pain, give morphine. And meanwhile, I'll be talking to the patient and my crew, asking for this or that, and trying to keep everyone calm and as comfortable as possible. If it's a long transport or something important changes en-route, I'll call the ED again to give them an update or to ask the doctor for orders. Oh, and did I mention the paperwork? I have to get patient information for my report and so I have it to give to the hospital so they can register the patient when we arrive.

If you're wondering how I know if the patient is having an MI, it's a combination of the patient's symptoms and my lovely little 12-Lead EKG. There's a whole science to reading and performing those 12-Leads too. First, not all MIs will show up on the 12-Lead EKG. However, most will show up on the EKG, and most of those that don't initially show up on the EKG will show up in the lab test the doctor will run once we get to the ED. And there will always be some that are never discovered--because that's just the way life is, right? The ones that show up on the EKG in the field are typically the ones that I'll be the most worried about. Especially if the patient looks really sick.

If you're curious, here's an example of a 12-Lead done on patient's having active MI's.

Check Anesthesia UK's website for full article "Ischemic Heart Disease"
http://www.frca.co.uk/article.aspx?articleid=100690 

Check Anesthesia UK's website for full article "Ischemic Heart Disease" 
http://www.frca.co.uk/article.aspx?articleid=100690 

Each segment of the heart beat tracing has a letter name.

So when you look back at those 12-Leads, do you see that little portion between the S-wave and the T-wave? In a normal EKG, that little line is parallel with the baseline. But wait, it's NOT on the baseline in some of those tracings. It's either above or below. When it's above the baseline, we call it ST-elevation. When it's above the baseline in several leads that are from neighboring parts of the heart it indicates lack of oxygen to that part of the heart due to a blockage of one (or more) of the arteries (in one or more places) supplying oxygen and nutrients to the heart muscle. And that's why we call it a STEMI.

An NSTEMI is simply where the patient is having an MI but there is no ST elevation in their EKG. NSTEMIs are typically diagnosed by labs run at the ED.

Ever wonder what happens after your local paramedic brings a STEMI patient to the ED? They usually get a couple more medications in the ED that help with preventing more blood clots and then are taken to the Cardiac Catheterization Lab (Cath Lab). In the cath lab, the doctor will place a stent in the clogged artery to allow blood to circulate to that part of the heart again. If that fails, it's open heart surgery and a coronary artery bypass graft. There are an awful lot of people out there running around and living their lives with one or more stents or coronary artery bypass grafts!

Back when the first paramedics hit the streets of America in the 1960's things were different. Medicine has come a very long way in the last 50 years allowing people who would otherwise die the chance for a second lease on life.

As fall hits full swing, the plants in my garden are hanging on. Several of them have new growth. I love seeing the new leaves mixed in with the colorful ones that are falling from the trees. My front porch doesn't look as pretty as some of the back roads around here.

So take a few minutes to step outside and enjoy the weather and thank God for the weather and the beauty of the world.

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[1] https://en.wikipedia.org/wiki/Myocardial_infarction#/media/File:AMI_scheme.png [Accessed 10/5/15].

Taking A Break From The Garden: Puppy Time!

Last August I took a break from gardening for a little while after moving. Why? Because I acquired a small fuzzy ball of trouble, mayhem, energy, messes, fun and total cuteness: also known as my Border Collie puppy Fiona Grace or "Fi" (pronounced "fee") for short.

NOTICE: This is your warning that there will be a LOT of puppy pictures in this post.

Last July, I stopped by southern Virginia on my way to North Carolina for some R&R after paramedic class to meet the litter of puppies and decided I wanted the only girl in the litter of four. She was about the size of a Guinea Pig and really cuddly. I spent the next four hours I was driving talking to my car about puppy names. Half the list I'd picked out earlier just didn't seem to fit this little girl's temperament. Finally settled on calling the little princess Fiona because not only is it a traditional Border Collie Name, she was spunky and stood up to all three of her bigger brothers kind of like the character in the TV show Burn Notice. And before you ask, I was completely unaware of the movie Shrek. Never seen it.

Hello world, meet Fiona!

My friend (and fellow volunteer paramedic) ended up getting one of her brothers, so we carpooled down to pick up the puppies in August and my roommate came along for the ride.

Fiona and her brother decided to cuddle with my roommate on the way home.

The next few weeks were a blur. Figuring out puppy-sitting arrangements on the days my roommate and I were both working, vet appointments, starting initial training, socializing her and getting her used to strange loud noises and large objects. With such a busy schedule, she took frequent naps to keep up her incessant energy.

So tired and so small!

She loved to chew. One of her favorite toys was (and still is) this Kong binkie. Especially if it's filled with chunky peanut butter.

Two Months old with Binkie

Four months and the ever-present binkie.

Six Months with Binkie. She's lost the puppy fuzz now.

Taught her to enjoy strange things--like drinking out of a syringe, and normal things like sit, down & stay. Oh, and look at me to so I can take yet another picture with you looking this time.

Two months and drinking water out of a syringe during a visit to the Rescue Squad station.

Three months and I FINALLY have her full attention for a few seconds.

I had her attention in the last picture because I was holding her new favorite toy: a Frisbee. We've gone through about five of these now. She's truly obsessed with the game. She's eight months in this picture.

We've been hiking, pumpkin picking, and visited the fire station I volunteer at. The bells going off or the tones dropping don't even bother her. She's working on getting comfortable around crowds since she's a little shy with new people.

Hiking to Bear's Den at 4 months.

Pumpkin picking at 4 months

Posing on the front of the engine during a visit to the fire station. Almost five months old.

Posing in one of the chase vehicles for National Puppy Day. Seven Months old.

She's now reached the fine age of 10 months. She's all of about 35 lbs, fast, smart, and totally obsessed with balls, frisbees, and cats. Good old Border Collie instinct kicking in because she wants to round up all kinds of things. Chickens, cats, me... We're getting pretty good at the basic obedience commands. She's a good traveler and I take her everywhere I possibly can. So much fun now that she's patient enough to focus and obey commands!

All a girl needs when going hiking: backpack and faithful canine companion. Fiona is nine months in this photo taken at Bear's Den. 

As you can see, I've had my hands full with this one. She's finally reached an age where her body has grown enough that I can start agility and sheep herding training with her. Going to try obedience competition first though. And then maybe we should try something that involves swimming...

Fiona at nine months. She's on a nice "down-stay" in the middle of a patch of bluebells we found next to the Bear's Den lodge on the Appalachian Trail. Isn't she gorgeous?

At ten months, she's staying cool while playing fetch with a stick in a lake and giving her best "drowned rat" impression.  

Fun and exciting times coming up this summer! Her new thing is to have me throw the frisbee from the patio and leap over my pots to go fetch it. As long as she doesn't tip over all my plants in her pursuit of the frisbee, ball and cat, we'll be fine.

Until next time then...