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].

Patio Garden Therapy

Late last summer, the garden and I moved…to a bigger patio about 8 miles down the road. There’s no space for an actual garden bed here and the management is really particular about what is on your patio. So I’m making do with a few more pots. I also had to get a storage bench to hold my gardening stuff. Not that there’s anything wrong with more pots, beautiful flowers, or a nice reading spot in the middle of them…

Rocking chair and patio tomatoes...and the lovely Fiona with her frisbee.

Back in March, my “black cloud” showed up again, and I ran a series of tough calls. It didn’t seem to matter if I was riding backwards in the bucket seat on the engine, covering as the Region A medic, helping a friend with driver training in preparation for EVOC or having another insanely busy day working at the ambulance transport company. It all began with a code that went out a couple miles from the station Wednesday night.

Every new medic needs at least one confidence-building critical call, where given all the variables everything goes pretty much like clockwork. I’d come down to the station to take one of the new members out in the second out (unstaffed) ambulance for pre-EVOC driver training. Just as we were about to head out, the station tones dropped for a cardiac arrest and an EMT/driver walked in and asked if I wanted to take the call. A quick check showed that we were much closer to the scene than either of the two medics initially dispatched and the first out unit wasn’t at the station. So I grabbed my drug keys, we squirreled it and arrived on scene just after the engine and before all the other EMS units. I grabbed the drug bag, walked in and handed out work assignments to the crew to facilitate the “pit crew method” I heard about at the EMS Today Conference earlier this year. From there it went like clockwork. The patient started in asystole and when we reached the ED 10mg of Epi and 50mEQ Sodium Bicarb later the patient was still in asystole and the doc called the code. Unfortunately, asystole (aka flatline or no heart rhythm at all) is the stablest rhythm of them all.

The next day I was at work, and it was one of those really busy days. One of my patients that shift was a tiny premature baby who had developed necrotizing enterocolitis. Necrotizing enterocolitis is the death of tissue in the intestine and occurs most often in premature or sick babies with a 25% mortality rate according to the National Institute of Health.[i] I checked with the doc in the Peds ED the next week and he confirmed that thankfully this little one was treated in time and survived.

A dressed up patio storage bench turns this corner of the patio into an inviting place to relax outside.
Mama ducky is admiring that orange Gerbera daisy too. 

The next night, after a busy day acquiring the patio storage bench, I had fire duty. Riding backwards on the engine can be fun and a nice break from bossing a medic unit... until you get dispatched on that 2:50am stabbing three doors down from the firehouse, are the only medic on the engine and are first on scene after the police. We did everything we could. This patient's wounds were too severe and he practically bled out in front of us and in the end did not survive. The calls where a patient starts out talking to you and ends up dead are the worst. This one was particularly difficult due to the circumstances.

Needing some version of therapy after those calls, and now that spring had arrived, I started working on the garden again. I still have a few pots I haven’t planted yet. Between turning an old bookshelf into a potting bench and acquiring a storage bench/seat per request from the management company, the patio has become a lovely place to read and work.

New job for an old bookshelf: potting shelf.

The rest of the garden is still in the works, but I have squash, beans, cucumbers and a variety of herbs and flowers growing.

Planter of Basil varieties and the lonely Zucchini plant.

When you spend a significant portion of your time caring for ill, injured and dying people, it's nice to be able to come home and care for something healthy and alive.

Green Beans.

Cucumbers and trellis.

I like to daydream about God being the supreme gardener. He has more plant varieties than I could ever dream of...and He's got the whole universe to grow them in. But you can also think of gardening as an analogy for life. Any gardener knows that caring for a garden requires weeding, thinning, pruning and re-potting. God does the same for our lives. We may not know the master plan for the garden, but He does. And in the end, He works everything together for our good and His glory-- even though we may not see it at the time. In the end, God is the one who gives and takes life. I've gotten to see a decent share of both recently. It's a good reminder that it is a privilege to be alive. Use your time wisely and don't take it for granted. We never know when our time on earth is up. Don't waste your life.

Citronella, Violas and Oxalis (shamrocks) decorating a corner of the patio.

For me, that means doing my job at work or as a volunteer to the best of my ability and then coming home and taking care of my garden... and spending time playing with and training my dog Fiona.

Fiona at 9 months

Besides, who knew Border Collies loved to swim?

Yep...she's out there swimming after a stick.

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[i] http://www.nlm.nih.gov/medlineplus/ency/article/001148.htm

Allergic reactions...that turn into Codes.

You can call me a coward, but there are some situations I hope I never have to face as your friendly neighborhood paramedic. I'll train for them so I'll be prepared if they come, but I pray they don't happen when I'm on duty. Firefighters, EMS personnel and law enforcement officers come across extremely sad and often gruesome situations as a regular part of the job. So often, you show up and even with all of your training and expertise there are situations where you don't know what to do and sometimes there is absolutely nothing you can do. These kinds of situations take an emotional toll on those entrusted with handling them. 

Wildflowers

Running cardiac arrests is a fact of life as an EMS provider. We call them codes. Usually, if they are dead when we get there, they tend to stay dead. We do our best, but few un-witnessed codes actually end in a "save." In my five years with the Rescue Squad, I've been on at least 6 codes, not counting the one described below. Only one of them made it to the ER alive, but he died in the ICU a couple days later. The one that died in front of us...well, he had a massive Pulmonary Embolism (blood clot in the lungs) and never had a chance. I've never truly had a cardiac arrest "save" who made it home from the hospital...until this week.

This past week, I was on duty as the regional medic in the west end of Loudoun County--Region A. Think of this as being the EMS equivalent of a K-9 unit. In the 1/4 of the county that I cover, there are a lot of ambulances with EMTs, but I'm the only medic--or ALS provider. If I need a medic for backup, they are about 15 minutes away. To continue the story...I'd gone out to dinner with the ambulance crew from my station. It was a hot, muggy day and a large storm center had just hit the town we were in. Thunder, lightning (lots of ground strikes) and a huge downpour. 

In the middle of this, our food had just arrived when the tones were dropped at 19:28 for a 15 year-old-female having and allergic reaction w/trouble breathing at another restaurant in town about 1/2 mile away. I had a bad feeling about this one, and beat the ambulance to the scene by about a minute. As I pulled into the parking lot, the mom came running out into the storm to tell me the girl was barely breathing. I unlocked the drug cabinet on my chase vehicle, grabbed my drug bag and went into the restaurant. The girl was lying there on the floor next to the bench near the entrance breathing like a fish out of water. I didn't have enough time to give her anything before she stopped breathing. Praise God the ambulance crew came in just then, because respiratory arrest very quickly turned into cardiac arrest. We did CPR for about 2.5 minutes before we got her back, and went through the allergic reaction protocol. 

Another medic just happened to be at the restaurant and jumped in to help. I was incredibly glad to have him there helping because the next closest medic was coming from 12 miles away and I needed help yesterday. We got her to the hospital alive (she was complaining that her chest was sore), although three minutes out from the hospital the medications wore off and in less than a minute she breathing like a fish out of water again. We were assisting her breathing with a BVM again by the time we arrived. She was quickly sedated, intubated and placed on an Epinephrine drip by the ER doc before being transferred to a children's hospital. She was extubated about 11:30 that night, was discharged from the hospital later the next day. For me, this allergic reaction code was a big deal. Not only was it the first severe allergic reaction I have run since getting released as a medic, not to mention the first code, but the patient was the same age as my youngest sister. Very scary. All things considered, the call went well. Praise God this one ended so well!

I've found several ways to de-stress after a significant call like this one. Usually after a call like this, I end up reviewing and criticizing the actions performed on scene to see what can be done better the next time. But when that's over, it's time to deal with the stress. Some form of exercise usually works, running, swimming, hiking, taking a ballet class. I also like to make a trip to the library for a new book and will spend hours working on my garden while listening to music. This time around, I picked up a book on the science behind the Sherlock Holmes stories. As for music, I'm currently into a CD of harp concertos I picked up from a thrift store and the soundtrack for Captain America: The Winter Soldier that I found on YouTube. The garden looks lovely now after a bit of cleaning up.