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A month ago, a friend who'd worked as a doctor in South Africa for decades was interning with me to learn about the procedures in our German ER. I remember the
by Cass 11y ago
A month ago, a friend who'd worked as a doctor in South Africa for decades was interning with me to learn about the procedures in our German ER. I remember the first time a patient with a heart attack came in while she was there, and the speed of the proceedings just blew. her. mind.
What happens, if things go well, is this:
The EMTs transmit a picture of the electrocardiogram to us[1]. We confirm that it's a STEMI (the kind of heart attack where speed matters the most, as opposed to an NSTEMI, which isn't quite as urgent), and alert the catheter lab and the attending cardiologist. Half the ER personnel drops everything else to prepare for the patient's arrival.
The patient arrives. We transfer them to our gurney. One nurse gets the patient's clothes off (with scissors if necessary) while another nurse attaches electrocardiogram electrodes and a third shaves the puncture site for the catheter.
The ER physician puts in an iv line and draws blood while informing the patient of the treatment plan. The cardiologist takes a very quick history of the patient and confirms the STEMI with the second electrocardiogramm. We wheel the patient up to the catheter lab and get started.
Altogether, if everything goes well, it's something like five to twelve minutes from the moment the patient comes through our doors to the moment we've got the patient on the operating table.
[1]By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.
- agumonkey 11y agoFor the curious, differences between {N}STEMI http://imgur.com/HbREzfo http://imgur.com/HbREzfo
- JshWright 11y agoHmm... ST depression often means there is ST elevation somehwere you can't see. ST depression is generally a 'reciprocal' change, and there will be elevation on the opposite side of the heart. A 'standard' EKG looks at the front, bottom, and left side of the heart. If the area of the heart affected by the heart attack is on the right or back side, then you won't see elevation, but you may see the reciprocal depression. EDIT: s/almost certainly/often/
- Herodotus38 11y agoI wouldn't say certainly, but sometimes. There are a lot of more common causes of ST depressions than STEMIs. For example, left ventricular hypertrophy with tachycardia.
- JshWright 11y agoFair point. I meant that if you see ST depression in an MI, then it's probably not _actually_ an NSTEMI, you just probably don't have the leads you need.
- maxerickson 11y agoIt's kind of startling that what is essentially a straightforward process improvement can have such a large impact. It's fantastic that it is happening, but it raises the question of whether there are similar opportunities, or more forcefully, where the similar opportunities are lurking. I'm reminded of the famous stuff about checklists and infections.
- stephengillie 11y ago> By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done. Congrats on the massive process improvement on using readily-available technology. I'm no lawyer but I'm pretty certain that this violates HIPAA, which means it's a new market just screaming for PII-managing image-transfer networks and startups.
- __z 11y agoHIPAA doesn't apply in Germany... PS - its HIPAA not HIPPA.
- stephengillie 11y agoNo redaction necessary!
- deleted 11y ago[deleted]
- tgokh 11y agoThe technology exists -- see http://www.physio-control.com/ProductDetails.aspx?id=2147484983 http://www.physio-control.com/ProductDetails.aspx?id=2147484... and http://www.zoll.com/medical-products/data-management/rescuenet-12-lead/ http://www.zoll.com/medical-products/data-management/rescuen... from PhysioControl and Zoll, two of the biggest EMS EKG monitor manufacturers, but its certainly not easy to use. In my system, we used to have to upload the EKG to the computer and then "e-fax" it from he computer to the Emergency Department -- practically, this took 3-4 minutes to do, and when you're in an urban area and nearly always < 10 minutes from the hospital, its not the most productive use of time. Most of the time, if was easier to do the EKG, and in case of a STEMI, call the "code STEMI" via radio, print the EKG and spend the rest of the time doing important patient care (IV access, aspirin, etc) That said, we were in a Paramedic system with a relatively short to-hospital drive time, and going to an academic medical center that had 24/7 in-house interventional cardiologists. If you're in a aystem with only EMT-Basics (who are trained to perform the EKG but cannot interpret the printout), or going to a hospital where the interventional cardiologists need to come in from home, or if your primary hospital doesn't even have a cath lab and will need to divert you to another bigger hospital, it makes a lot of sense to be able to send the EKG from the field and get the ball rolling early.
- JshWright 11y agoInteresting... I would have assumed Germany would be a bit more advanced in prehospital care. Here in the US (in a rural/suburban area outside a smallish city in upstate New York), the flow would look more like: A paramedic recognizes a potential MI and takes a 12-lead EKG. If it is indeed a STEMI, then we'll call the ER and transmit the EKG and other vitals (via a cell modem embedded in the monitor). If the ER doc agrees with my diagnosis, then the cath lab is activated. I'll have a couple large bore IVs in place before we arrive at the hospital, and when we get to the hospital, the patient stays right on our stretcher as we bypass the ER entirely at take them directly to cath.
- Cass 11y agoFor an unstable patient, our process is much the same - the EMTs will put in the IVs, and we'll bypass the ER to proceed directly to the cath lab. For stable patients, the EMTs will prioritize getting them to the hospital as fast as possible and often won't have the time to get the IVs into place before they arrive. (This part of the county has a ridiculous density of hospitals, so the ambulance ride is frequently not even five minutes long, which doesn't give the EMTs that much time to work.) We've found that things go little more smoothly if we do some of the prep in the ER, where there's a little more space for people to undress the patient etc. without worrying about bumping into the expense catheter equipment or compromising sterility, but even stable patients aren't supposed to spend more than five minutes there before being rushed to cath. I do wish we had some way to directly transmit EKGs and vitals. American hospitals seem to have more money available for electronic equipment like that. (On the other hand, in Germany, the whole hospital stay including the catheter and a day in the ICU, probably won't cost you more than 10.000 Euro, and usually less than that.)
- Scoundreller 11y agoIs there any opportunity (or practice) of other conditions bypassing the ER? If that's the bottleneck, I hope it doesn't have to be life-or-death for someone to thing "We should re-engineer this process". E.g. uncomplicated fractures getting brought to the fracture clinic?
- 11y ago
- sliverstorm 11y agoBy taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done. Patient privacy laws really do put some perverse constraints on the system sometimes.