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Original Contribution

Medical Editor`s Commentary

October 2006

     "Time is muscle" refers to the strategy of early reperfusion, an effort to get patients with acute myocardial infarctions to cardiac catheterization laboratories quickly enough to minimize or prevent permanent loss of cardiac muscle and the potential subsequent development of myriad complications, including lethal cardiac arrhythmias, congestive heart failure, cardiogenic shock, clot formation and ventricular aneurysm. The phrase and the strategy may sound like just the current rage, but it's not. It's the standard of care in emergency medicine and invasive cardiology now and for the foreseeable future!

     Sullivan and Rosenbaum have prepared a straightforward and easy-to-read article that summarizes the principles related to the early reperfusion strategy, offers several case studies and presents real ECGs of patients who sustained AMIs. As EMS medical director for the state's busiest and only contract BLS 9-1-1 system in Wilmington, DE, from 1999–2002, I was witness to and participant in the explosion of research from Christiana Care Health System and the cadre of emergency physicians who supervise the three career ALS systems in Delaware. Much of the research cited in this article made major headlines at annual emergency medicine research conferences when it was originally presented.

     Additionally, the authors work in one of the top-performing EMS systems in the United States. High-performance EMS systems don't grow themselves. They have to be developed by motivated and proactive EMS providers and aggressive and savvy EMS medical directors who collaborate within a political climate in which there is support for improvement in patient outcomes. The state of Delaware is one such environment. In future issues, EMS Magazine will highlight additional progressive EMS systems and the efforts they are undertaking to save lives, reduce morbidity and advance the science of out-of-hospital emergency medical care.

     Here are my take-home points and recommendations in regard to the content of this article:

  1. Twelve-lead ECG technology is widely available, reliable, relatively inexpensive and easy to implement in EMS systems. The acquisition and interpretation of 12-lead ECGs by paramedics in the field after proper training has been clearly proven to reduce the times to physician ECG interpretation and eventual reperfusion. Research will eventually prove that morbidity and mortality are improved in EMS systems that routinely acquire 12-lead ECGs.
  2. Paramedics will always be able to acquire a 12-lead ECG faster than the ED because in most cases they focus resources on a single patient at a time. We are still 25 years away from convincing and training the nursing staffs in our nation's EDs that the only thing that matters when a chest-pain patient arrives is 12-lead ECG acquisition within the first five minutes. Think about how long a patient can sit in the waiting room, triage and/or treatment room before this occurs. It's bad, folks, and JCAHO knows it!
  3. Call the margin wide and acquire a 12-lead ECG on any patient who possibly has cardiac ischemia (mild dyspnea, nausea/vomiting, diaphoresis, weakness, etc.). Early identification of critical illness is where point-of-care testing is heading in the U.S. Twelve-lead ECGs can be a valuable triage tool if they uncover unsuspected cardiac ischemia.

David Jaslow, MD, MPH, EMT-P, FAAEM, is chief of the Division of EMS, Operational Public Health and Disaster Medicine within the Department of Emergency Medicine at Albert Einstein Medical Center in Philadelphia. He is an active firefighter/paramedic, assistant chief for EMS and EMS medical director for the Bryn Athyn Fire Company. He serves as medical editorial consultant for EMS Magazine.

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