The Heart of the Matter

1. The Heart of the Matter A Journey through the system of care

2. Introductions Brian Richardson Director of Emergency Services at BMH Emergency Room Preparedness Emergency Medical Services Liaison/Quality Assurance Paramedic George Terwilliger Emergency Department Medical Director MD over 25 years of experience

3. Denial, not a river in Egypt • Median 2 hour delay in calling 911 (Meischke et al.) • Symptoms would go away • Symptoms not severe enough • Did not think of calling 911 • Proximity to hospital and thought 911 would delay treatment • Only 65% of women said they would call 911

4. Don’t wait call 9.1.1 • Call 9.1.1 at the onset of symptoms • Follow the dispatcher instructions • Do not drive yourself to the hospital • Stay calm and try to relax

5. Emergency Medical Services • In Vermont the EMS system is staffed by licensed, credentialed providers • Large amounts of educational resources are directed towards training these professionals in the area of Acute Coronary Syndrome • Transporting services have at a minimum, the basic tools to recognize and begin treatment for a patient experiencing a heart attack. • Statewide protocols for Vermont EMS professionals provide a foundation of best practices for care of a patient with Acute Coronary Syndrome. • Brattleboro Memorial Hospital works in conjunction with Rescue Inc to provide quality assurance and case review for all cases involving Acute Coronary Syndrome.

6. What to expect from EMS • Pre-arrival instructions from the dispatcher • First Responders • An ECG • History, which equals a lot of questions • An exam • Perhaps medications • Safe but rapid transport

7. En-route to the Hospital • Cardiac monitoring • Intravenous lines • Additional ECGs • Vital sign monitoring • Additional medications • Early communications with the hospital

8. Once you arrive at the hospital • You are taken immediately to a treatment room • An ECG is done • Perhaps another IV • Blood samples drawn • Additional questions are asked • Treatment decision s are made

9. Treatment pathways • Always approached from the worst case first • Heart Attack • Unstable Angina • Low to Intermediate risk for Acute Coronary Syndrome/Chest pain pathway • Risk and benefits of treatments are always discussed

10. Heart Attack (STEMI) • With ECG changes, lab biomarker changes and a potential for significant damage • Consultation with and arranging for transport to a catheterization lab for percutaneous coronary intervention • Assessment for the appropriateness of using clot busting agents • Use of those agents, if appropriate within 30 minutes of your arrival in the Emergency Department

11. Unstable Angina/non-STEMI • High risk factors identified • Positive ECG findings for an oxygen starved heart • Positive lab results (immediately or over time) • Consult with cardiology • Admission or transfer to a higher level of care

12. Low to Intermediate Risk • Low to Intermediate Risk factors • Other potential causes eliminated or reduced • No changes on serial ECGs • No changes to serial lab tests • May be observed in the Emergency Department (6 hours or greater) • May have a consultation with cardiology • May be admitted to a monitored bed in the hospital • Stress test either done at discharge or scheduled shortly after • follow-up with a cardiologist scheduled • Factors for prevention may be discussed by the Emergency Department Physician

13. Our Goals • To give you the best possible patient experience • Weigh risks versus benefits in diagnosis and treatment decisions • To educate and inform so that you may make the best decision for your healthcare • To treat you with respect and compassion

14. QUESTIONS