the heart of the matter a journey through the system of care

The Heart of the MatterA Journey through the system of care

Introductions

Brian RichardsonDirector of Emergency Services at BMH

Emergency RoomPreparednessEmergency Medical Services Liaison/Quality Assurance

Paramedic

George TerwilligerEmergency Department Medical DirectorMD over 25 years of experience

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

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

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.

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

En-route to the Hospital• Cardiac monitoring• Intravenous lines• Additional ECGs• Vital sign monitoring• Additional

medications• Early

communications with the hospital

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

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

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

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

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

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

QUESTIONS