• Scenario #1: Emergency medical services (EMS) personnel are summoned to a college graduation event after the presenter suddenly faints during her presentation. Upon their arrival, the presenter, a 78-year-old minister, complains of weakness and dizziness. An electrocardiogram (ECG) performed on-site by EMS personnel reveals prominent anterior ST-segment elevation. EMS immediately contacts the local emergency department. The emergency physician on duty discusses the patient and ECG findings with the EMS personnel, and the decision is made to bypass the local ED (a non-percutaneous coronary intervention) facility and drive directly to the closest PCI facility, 20 minutes down the road. Having been activated prior to arrival, the catheterization lab at the PCI facility is waiting for the patient, who undergoes emergency PCI despite the event’s occurrence on a busy Sunday afternoon.
• Scenario #2: A 48-year old man, manager of a local auto parts store in a rural Kansas town, develops severe “heartburn” while stacking bales of hay on his farm. Despite his protests, his son rushes him to the local hospital, which is 42 miles away. The emergency physician working in the nine-bed ED that day correctly diagnoses the patient with an acute inferior wall myocardial infarction. Knowing that the closest PCI hospital is 82 miles away, the emergency physician quickly administers a fibrinolytic agent to the patient while at the same time arranging ground EMS transport to the nearest PCI hospital.

An estimated 400,000 adults in the United States annually experience prehospital and inhospital STEMI (ST-segment elevation myocardial infarction).¹ As illustrated, it often occurs without warning and can present with a variety of symptoms. The benefits of reperfusion therapy are time dependent, and the appropriate reperfusion strategy varies from location to location. In those systems that utilize interfacility transfers for STEMI patients, topography, weather conditions, and variable EMS availability further complicate the picture.

Among the vast population of patients transported by EMS, STEMI is an uncommon event, rarely encountered by most EMS providers. This infrequency impairs prompt recognition of the STEMI patient and is an impediment to the goal of rapid reperfusion. Each participant in the “STEMI continuum of care,” including the patient (by activating EMS), is integral to the process. During an acute STEMI, all members of the team must know their role, and each segment of the process must flow smoothly.

Emergency physicians are at the center of a vital intersection in the STEMI process of care. In nearly all systems, the ED functions as the connection point, serving to integrate and connect EMS with processes and personnel within hospital walls. The ED is the gateway into most hospitals. The tight relationships formed between EMS and ED staff (fostered by working closely together, day after day) are important in developing sustainable systems of STEMI care. Regardless of the reperfusion strategy selected (fibrinolysis, on-site PCI, or transfer for PCI), it is likely that an emergency physician is involved, either as direct participant or in the construction and development of that particular STEMI system of care.