Audrey Fraizer
As an EMD, you undoubtedly know that a heart attack is not the same as sudden cardiac arrest (SCA). However, you might not be aware of the differences and the corresponding Medical Priority Dispatch System™ (MPDS®) associated with heart attack, SCA, and heart disease.
The following anecdotes illustrate the experiences of a patient—an EMD—who suffered a heart attack followed by SCA and a patient who had a heart attack.
Heart attack and sudden cardiac arrest
Chris Solomons, 51, went about his routine on July 24, 2010, like he always did. He poured a cup of coffee, ate a piece of toast, and smoked his first cigarette of the day before driving to his EMD job at Yorkshire Air Ambulance Service (U.K.).
And that’s when things started to change.
While on his way to work, Solomons felt pins and needles sensation in his arms and up and down his legs. He began to sweat. A “horrendous” pain in his chest almost forced him to turn the car around but being just five minutes away from the control room, he continued driving despite worsening symptoms. His hands were shaking so hard he couldn’t call for help on his cellphone.
“I realized something was going on,” Solomons later recalled. “This was not any type of indigestion.”
Solomons parked his car and stumbled into the center, where, coincidentally, a BBC camera crew was filming an episode in the series “Helicopter Heroes.” They turned their cameras toward Solomons just as paramedics James Vine and Lee Davison were applying cardiac monitor leads to his chest. The readout was unmistakable. Solomons was having a heart attack, and within seconds he was in cardiac arrest. Vine and Davison laid Solomons on the floor and shocked him twice with a defibrillator. A Yorkshire Air Ambulance transported Solomons to the catheterization lab at Leeds General Infirmary.
He survived.
Although Solomons remembers little aside from the initial pain, he was told that everything happened within two hours of his first signs of pain.
“This is not something I would want to experience again,” he said. “This is not something I’d like anyone to experience.” He calls the paramedics whose quick action saved his life "very special friends."1
Solomons worked as an EMD with the Yorkshire Ambulance Service for 20 years before moving to the patient transport service. He travels worldwide to tell his story of survival from SCA as his way, he said, of giving thanks for the help he received. The BBC crew’s video footage is used—with Solomons’ encouragement—to educate and inspire others on the importance of early intervention.
Heart attack
When Julia Allen, 46, Charlotte, North Carolina (USA) began experiencing chest pains, she stopped at home to leave a key for her kids and make them an after-school snack. Only then did she go to the hospital.
Allen had started her day the way she normally does: groan when the alarm clock rang, get the kids ready for school, and grab a quick breakfast before leaving for work. Only when she arrived at her office did she start feeling sick or, possibly, slow down long enough to realize she was feeling sick. The heartburn she could easily confuse as gas, although it was accompanied by nausea, dizziness, shortness of breath, tightening in her jaw, and pain down her arm.
Heart attack? Of course not. That was totally off her radar. Heart disease happened to other people.
At the hospital, Allen told an ER staff member that she was having a heart attack seconds before collapsing. An angiogram showed that her left ventricle was 80 percent blocked. Surgery was immediate. She survived.
Allen had admittedly ignored the red flags: high blood pressure, increasing weight and cholesterol levels, and a family history of heart disease. She started eating healthier foods, began exercising, and let go of perfectionist standards that contributed to stress.
“If you come to my house now, I guarantee there will be crumbs on the counter and dirty laundry in the basement,” she said. “I just let it go and don’t worry about it.”2
Heart attack
A heart attack is a circulation problem.
A blocked artery prevents oxygen-rich blood from reaching a section of the heart. If the blocked artery is not reopened quickly, the part of the heart normally nourished by that artery begins to die.
Symptoms of a heart attack may be immediate and may include intense discomfort in the chest or other areas of the upper body, shortness of breath, cold sweats, and/or nausea/vomiting. More often, though, symptoms start slowly and persist for hours, days, or weeks before a heart attack. Unlike cardiac arrest, the heart usually does not stop beating during a heart attack.
Most heart attacks happen on Monday mornings. In the early morning hours, blood platelets are stickier, a person is partially dehydrated, and stress hormones (such as cortisol) are at their peak.
Heart attacks are 27 percent more likely to happen around your birthday. They are also most likely to occur on Christmas Day, the day after Christmas, and New Year’s Day.
Women have different heart attack symptoms (nausea, indigestion, and shoulder aches) compared to classic symptoms that men experience (moderate to severe chest pain, radiating pain in arms and chest, dizziness, and shortness of breath).
Cardiac arrest
Cardiac arrest is an electrical problem.
An electrical malfunction in the heart that causes an irregular heartbeat (arrhythmia) can trigger cardiac arrest. With its pumping action disrupted, the heart cannot pump blood to the brain, lungs, and other organs.
Cardiac arrest happens suddenly and dramatically. A person in cardiac arrest will be unresponsive and will usually stop breathing (or just gasp ineffectively). A cardiac arrest can be lethal within a matter of minutes if the person does not receive CPR and/or cardiac defibrillation.
Most heart attacks do not lead to cardiac arrest. But when cardiac arrest occurs, heart attack is a common cause. Other conditions may also disrupt the heart’s rhythm and lead to cardiac arrest.
Globally, cardiac arrest claims more lives than colorectal cancer, breast cancer, prostate cancer, influenza, pneumonia, auto accidents, HIV, firearms, and house fires combined.
The 2017 Heart Disease and Stroke Statistics state that among the 356,000 out-of-hospital cardiac arrests that occurred, 46 percent received bystander CPR.
A victim's chances of survival are reduced by 7 to 10 percent with every minute that passes without CPR and defibrillation.
Protocols
In the United States, chest pain is the second most common reason for emergency department visits. A patient's primary complaint of “chest pain” may reflect a broad range of underlying causes; therefore, it is important that emergency medical services (EMS) agencies gain a thorough understanding of these cases, beginning with the initial management of chest pain in the 911 center. The caller's answer to "Okay, tell me exactly what happened" drives the Chief Complaint. An EMD cannot assume a diagnosis. Three Chief Complaints in the MPDS address conditions of the heart.
- Protocol 9: Cardiac or Respiratory Arrest/Death
- Protocol 10: Chest Pain/Chest Discomfort (Non-Traumatic)
- Protocol 19: Heart Problems/A.I.C.D.
For a patient with chest pain, additional dispatcher interactions with the caller are recommended to overcome caller or patient denial or to validate that the caller's descriptions of symptoms and signs may represent the presentation of a heart attack. Specifically, in Key Question 3 of Protocol 10 the EMD asks, “Is s/he changing color?” and in Key Question 4 of Protocol 10, the EMD asks, “Is s/he clammy or having cold sweats?”
Protocol 9: Cardiac or Respiratory Arrest/Death
Cardiac arrest and respiratory arrest are time-critical events, and Protocol 9 serves as a buffer between Case Entry Protocol and Pre-Arrival Instructions. The patient is not breathing and unresponsive. When someone stops breathing, the heart soon stops as the blood oxygen levels decrease and can no longer sustain the heart.
In cases where the caller describes an SCA that just happened, Protocol 9 does not have any required Key Questions, since generally the SCA is identified in Case Entry and getting to Pre-Arrival Instructions for arrest is time critical. The ECHO Determinant Codes provide EMDs with a way to get a response moving quickly for the patient who is unresponsive and not breathing.
In cases where the caller describes a possible death, the EMD begins Protocol 9 Key Questions. After completing Key Questions, the EMD initiates an appropriate response and then provides PDIs that best address the situation. For either OBVIOUS DEATH or EXPECTED DEATH situations, the instructions similarly reassure the caller “I’m sending someone to assist you” (the EMD will notify proper authorities) and ask whether the EMD can do anything else for the caller.
Protocol 10: Chest Pain/Chest Discomfort (Non-Traumatic)
The Chest Pain Protocol is to be selected by EMDs whenever the caller reports a conscious person with a primary complaint of chest pain (not caused by trauma) or one or more of a defined set of heart attack symptoms, including any of the following: aching pain; chest pain/discomfort (now gone); constricting band; crushing discomfort (heaviness, numbness, pressure, tightness); or (similar) pain present in the arm, jaw, neck, or upper back.4
According to Rule 6 in Protocol 10, “Chest pain due to trauma (current or non-recent) should be handled on Protocol 30.”
Primarily due to the risk of acute acute coronary syndrome (ACS), the Emergency Medical Dispatcher must consider a complaint of non-traumatic chest pain in conscious adults of cardiac-risk age to be an unstable condition until serious causes can be ruled out, either through on-scene ALS paramedic assessment or further assessment in the hospital emergency department. For this reason, the MPDS places all chest pain patients age 35 and over in the DELTA or CHARLIE priority levels.5
The EMD need not give CPR PAIs unless the heart attack victim goes into cardiac arrest, which means the patient is unconscious and has stopped breathing. If this happens, CPR will keep the blood circulating while the EMD waits for the ambulance or for someone to get a defibrillator.
Protocol 19: Heart Problems/A.I.C.D.
Heart problems are considered specific diagnosis (and may range from old rheumatic fever through benign forms of congestive heart failure), and Protocol 19 was designed to help the EMD gain more serviceable information. Protocol 19 also covers the group of heart and blood vessel disorders (cardiovascular diseases or CVDs). CVDs are the No. 1 cause of death globally: More people die annually from CVDs than from any other cause. An estimated 17.9 million people died from CVDs in 2016, representing 31 percent of all global death.6
An Automated Implanted Cardiac Defibrillator (A.I.C.D.) is a device designed to administer an electric shock to control rapid heart rate and restore a normal heartbeat. Multiple firings or firings associated with priority symptoms may indicate a prehospital emergency. ALS evaluation for these patients is recommended.
Sources
1 “Yorkshire Ambulance Saves One Of Its Own.” Sudden Cardiac Arrest Foundation. 2011; Feb. 24. http://www.sca-aware.org/survivor-stories/yorkshire-air-ambulance-saves-one-of-their-own (accessed Nov. 12, 2018).
2 Gurnon E. “How Five Women Discovered They Had Heart Disease.” Next Avenue. 2015; Feb. 12. https://www.nextavenue.org/how-5-women-discovered-they-had-heart-disease/ (accessed Nov. 12, 2018).
3 Lenfant C. “Emergency Medical Dispatching: Rapid Identification and Treatment of Acute Myocardial Infarction.” International Academies of Emergency Dispatch. https://www.emergencydispatch.org/articles/acutemyocardialinfarction.htm (accessed Nov. 19, 2018).
4 Scott G, Clawson J, Gardett I, Broadbent M, Williams W, Fivaz C, Marshall G, Barron T, Olola C. “9-1-1 Triage of Non-Traumatic Chest Pain: Association with Hospital Diagnosis.” Prehospital Emergency Care. 2017; April 25. http://dx.doi.org/10.1080/10903127.2017.1302530 (accessed Nov. 19, 2018).
5 See note 4.
6 “Cardiovascular diseases (CVDs).” World Health Organization. 2017; May 17. http://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) (accessed Nov. 19, 2018).
