Imagine this: you are
sitting on the couch watching the “Breaking Bad” finale and all of a sudden your chest
begins to close in on your lungs and you are finding it harder and harder to
breath. A sharp pain radiates down your arm and you start to have some numbness
and tingling throughout your body. You put down your 5th slice of
pizza and dial 911 frantically and within 3 minutes you have more people in your living room than
you thought you could fit, all stomping around with muddy
boots on. The paramedics attach you to a heart monitor, run a 12-lead and find that
you are having a ST-segment elevation myocardial infarction, or a STEMI. There
is good news though, you have 90 minutes to get to a cath lab and you will survive! 90 minute is a lot of time, right? Wrong. The paramedics have some work to do
to you before we head out, 15 minutes pass. You are then lifted off your feet
and taken to St. Mary’s Hospital, the local community hospital, to be stabilized
before you head to the cath lab, 30 more minutes pass. Just so we are all on
the same page, 45 minutes have passed and you still don’t have a balloon inside
of you. Finally you are whisked away from the tiny hospital and you are now
flying down the road like Dale Ernhart Jr on your way to the cath lab, you are
saved! Wrong again. You can’t forget you are in Nebraska City, 45 minutes away
from the nearest cath lab, your available time left… 0 minutes. This scenario played out with everything going as planned, but if anyone has ever been on one of these scenarios, it is often Murphy’s Law. I guess your heart just wont make
the cut and you have to say your good byes. Wrong again! Luckily those wise
guys in Nebraska City have come up with a solution. We will get to the solution
briefly, but first lets understand what a STEMI is and what treatment options
are available.
Luckily
enough, this scenario wasn’t to frequent in Nebraska City but common enough
that changes had to be made. There are multiple kinds of heart attacks,
however, the focus of the “door-to-balloon” time are STEMIs. When we refer to
the “balloon” we are talking about percutaneous coronary intervention (PCI),
the preferred treatment for any STEMI having started less 24 hours before
treatment (Comelli 2012). The
benefits of PCI over the other treatment, a thrombolytic, are that it has
greater coronary patency and a much less risk of bleeding (Keeley 2003). To
summarize a PCI we need to first understand a STEMI. A STEMI is the king of all
heart attacks and will strike fear into any paramedic, no matter how seasoned. It occurs when a coronary artery is
completely (or close to completely) occluded by a blot clot or plaque, blocking
oxygen rich blood from getting to your heart muscle. No oxygen to your muscle
means that muscle can’t be sustained, and the heart muscle slowly starts to
die. The moment this occlusion occurs, time becomes muscle and the longer your
heart isn’t given oxygen, the more muscle will die. In order to break this
clot, a physician can administer a thrombolytic and break it up or send the
patient to a catheter lab to have a PCI. Percutaneous coronary intervention is
another fancy term for a cardio-angioplasty, where a catheter with a balloon on
the end is entered into the coronary artery that is occluded. The balloon is
then inflated and in turn breaks up the buildup of whatever was causing the
blockage (CAO 2013).
A
national time standard has been established for treatment of STEMIs, it is
commonly refereed to as the “door-to-balloon” time that I mentioned earlier.
The standard is, you guessed it, 90 minutes. The “door-to-balloon” time is a
misleading name, a patient presenting with a STEMI has 90 minutes to get a
balloon inside of them from the very first medical contact, in our scenario it
is the paramedics getting mud all over your house. Prior to the realization of
the medical community that time really is muscle and the sooner the patient receives
a PCI the better, the protocol in Nebraska City was to slow. Working with the
hospital in town and the bigger hospitals that possess the catheter lab, a new
protocol was implemented. This would not have been possible without the
advancements in technology we have today. To summarize the new protocol, the on scene paramedic can beam the
12-lead of the patient to the community hospital, where the medical director
can verify the STEMI, and to the receiving catheter lab hospital. This can all
be done from the comfort of the back of the ambulance while you are speeding to
the cath lab. This is collectively referred to as a “STEMI Alert” and it allows
any off-duty personal for cath lab to come in and prepare for our arrival, in
turn saving more time. Upon arrival at the hospital, the interventional cardiologist
has already seen the patient’s 12-lead and is ready to perform a PCI and get
perfusion back to the patient’s heart, preventing any more muscle death. This
new protocol can essentially cut the “door-to-balloon” time in Nebraska City in
half. Many cities already have similar systems in place or are currently
working on implementing one. Many cities do not see the cost-to-benefit ratio
being adequate enough to fund such programs but as we found earlier, time is
muscle and the less time a patient experiencing a STEMI spends in an ambulance,
the better. Nebraska City is at the forefront of STEMI Alerts, so you can have
comfort in visiting their historic apple orchards because if your heart fails
you, their paramedics wont.
Cao G, Ko GY, Sung KB, Yoon
HK, Gwon D, Kim JH. 2013 April. Treatment of postoperative main portal vein and
superios mesenteric vein thrombosis with balloon angioplasty and/or stent placement.
Acta Radiologica. 54: 526-532
Comelli I, Vignali L, Rolli
A, Lippi G, Cervellin G. 2011 February. Achievement of a median door-to-balloon
time of less than 90 minutes by implementation of organization changed in
‘Emergency Department to Cath Lab’ pathway: a 5-year analysis. Journal of
Evaluation in Clinical Practice. 18: 788-792
Keeeley EC, Boura JA, Grines
CL. 2003. Primary angioplasty versus intravenous thrombolytic therapy for acute
myocardial infarction: a quantitative review of 23 randomized trials. Lancet.
13-20
Ian,
ReplyDeleteThat's some intense role-playing. I can't imagine being in that situation as a paramedic and having that uncomfortable thought of losing that person because there wasn't enough time to get the individual treatment. Although it may be a slightly cynical way to view the world, that may be a reality that many people in rural areas must face and accept given the lifestyle that they live. Don’t get me wrong, everyone deserves the right to be treated and have access to treatment, no matter if they live in the middle of the city or out in the boondocks. However, life isn’t always so simple and I would imagine that those who reside in areas that are not as easily accessed should expect a slower response time from medical personnel and, as such, an increased risk of death for those conditions that are time sensitive. It’s a tragic way to view the situation and it could be part of the reason there are significant drops in those who want to practice medicine in such areas. Anyone have any thoughts on this?
Garrett
Ian and Garrett,
ReplyDeleteFirst of all, Ian, nicely done. Your blog was captivating and entertaining. I could envision this scenario perfectly. Also, as a friend of many EMTs and paramedics, I can only imagine your frustration and the importance that must be placed on STEMI Alert. Would you happen to know if, depending on the distance of the patient from the hospital, would STEMIs be considered for retrieval using LifeNet or any sort of airlift service?
Garrett, I definitely agree with you in all aspects of your comment. I have spent my entire life living in areas that are less than 10 minutes away from a large hospital. However, I have friends that live almost an hour from any hospital, let alone an adequately equipped hospital. A particular friend that lives in Montana has a driveway that is 9 miles long, unpaved, that is 20 minutes from the main road. On this main road, it then takes 45 minutes just to reach the nearest decently large town with a hospital. As you can see, in this situation, chances of survival would be minimal. I have heard many stories of people that have lost their lives, because they are simply not close enough to a hospital, and even further from a hospital with adequate equipment.
Many times, patients coming from far distances will not receive the treatment outcomes as other patients coming from closer distances would, because of such a large delay in medical care. Also, many of the hospitals in rural areas are not, as I have mentioned, adequately equipped with medial personnel or equipment. The patient then needs to be transferred to larger hospital, thus decreasing chances of survival even more. As a physician or medical personnel, I would definitely be frustrated with such a lag in medical response time and inadequate equipment to help. After all, having gone to school and completed residency for many years in order to help heal people's physical ailments, only to have a patient in which there is little you can do would be defeating. This is obviously a reality all physicians must face, however rural physicians probably face this more frequently than others. Therefore, I could definitely see why this could be a cause in the decreased number of rural medicine physicians.
Further, I have spent a lot of time with people living in rural areas, and as you have mentioned, this is a reality they face. Rural residents know they deserve treatment, but they accept that death is a large possibility if anything were to go wrong. However, I think rural mentality is very different from urban mentality. From past experience, the rural people I am friends with do not worry or place such an emphasis on death. They know that what they do and where they live puts them at risk, but it is how they want to live their life. As with all things in life, there are pros and cons to everything.
Jamie,
DeleteThe only time I see LifeNet being plausible for a STEMI would be in a super rural area with around a 3+ hour ground travel, like in Alaska or similar to your friend in Montana. This is due to the time it takes for the helicopter to start up and head to the scene. I saw your last paragraph very often in Nebraska City. It is hard to persuade a 60 year old farmer that he has to leave his land and go to the hospital, even if his life depends on it. Unfortunately, the small community hospitals that are in these communities have limited capability, as you and Garret have stated. It is a price you pay for solitude and the small town way of life!