Ask the STEMI Expert

Re: STEMI: Challenges, Opportunities, and the SINCERE Database (Cath Lab Digest December 2009)

Sameer Mehta, MD, FACC, MBA Voluntary Associate Professor of Medicine, University of Miami Miami, FL Course Director, LUMEN http://www.lumenami.com
Sameer Mehta, MD, FACC, MBA Voluntary Associate Professor of Medicine, University of Miami Miami, FL Course Director, LUMEN http://www.lumenami.com
Dear Dr. Mehta, I enjoyed your STEMI article in the December Cath Lab Digest. I found the ten commandments to improve the STEMI process very interesting. I would like to ask you to elaborate on #7 - Make that critical second call to the nurse in the CVL. Thank you, Kristine McMurtrie, RN, MSN, Director, Invasive Cardiology Lehigh Valley Hospital - Cedar Crest Allentown, PA kristine.mcmurtrie@lvh.com [Editor's note: Read the December 2009 interview with Dr. Mehta at http://tinyurl.com/CLDSINCERE] Dear Kristine, Thank you for your kind note and for your feedback. I am glad that you found the ST-elevation myocardial infarction (STEMI) process ten commandments interesting. As you requested, let me elaborate more on # 7 - Make the critical second call to the nurse in the CVL. I routinely make two calls to the team during the STEMI process and more, if needed, between the STEMI alert and beginning the procedure. The first communication is with the emergency department and it has two main purposes — the identification of the culprit lesion by EKG and to review pertinent clinical details and provide standard orders: oral 325 aspirin, 300 mg clopidogrel and 5,000 units bolus of heparin. The second call that I make is en route to the hospital to the nurse in the cath lab — I update them as to my ETA, get a feedback on the clinical status and the hemodynamics, and request preliminary equipment to be pulled out — some opened and placed on the table, other items simply kept out. For the culprit right coronary artery (RCA) lesion, this includes opening a JL4 diagnostic, a JR4 guide and a Choice PT Extra Support guide wire and placing on the table; for the left coronary artery (LCA) lesion, it is a JR4 diagnostic and a JL4 guide that are opened, as well as the same guide wire. I always take angiograms [2 pictures for the left and a single left anterior oblique (LAO) for the right] of the non-culprit lesion prior to proceeding with percutaneous coronary intervention of the culprit lesion with the guiding catheter. From the SINCERE database, I know that in 92% of the procedures, I was able to use this pre-determined equipment. In addition, the thrombectomy catheter is kept out but not opened, as well as a 2.5/12 mm balloon catheter. Finally, for all STEMI lesions, the AngioJet and intra-aortic balloon pump (IABP) are ready to go. For patients with cardiogenic shock, I am using the left ventricular assist device, the Impella, although this decision is requires more thought and is made after angiography. The second call to the nurse also requests for surgical standby, sedation and other critical medications. Over the years, I have found that this additional communication improves outcomes and door-to-balloon times. Regards, Sameer Mehta, MD, FACC, MBA Voluntary Associate Professor of Medicine, University of Miami Miami, FL Course Director, LUMEN http://www.lumenami.com Send your STEMI question to Dr. Mehta at mehtas@bellsouth.net
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