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When Time Is Not On Your Side
Written by Keith Darcey   
Wednesday, May 19, 2010 09:23 AM

"The last thing I remember is feeling a burning sensation, and then the whole room went gray," says Judith Rehase Provenzano. "Next thing I know, I am waking up with my physician at my bedside. He just said that I was one lucky lady."

What Judith doesn't remember, however, is her medical team's 37-minute race against the clock to save her life. In fact, the burning sensation she felt was the electricity from the paddles reviving her heart, a revival that needed to take place three different times. It wasn't until Dr. Stanley Bleich, her interventional cardiologist, inserted a balloon into her blocked artery to restore normal blood flow that her vital signs stabilized, and she survived the most serious and deadly type of heart attack – a STEMI.

"She basically died three times," says Dr. Bleich. "Judith had no blood pressure, and the lack of blood flow to the brain is lethal. Everyone had to work quickly, and fortunately, she survived without any heart damage." That morning seemed to be a normal one for Judith. She had breakfast and was getting ready to go into work. She decided to take a little something for the heartburn she thought she was feeling. By the time she arrived at work, the burning worsened, and she decided that she couldn't stay. Her arm began to hurt, and she began experiencing sudden nausea and vomiting that now required medical attention. As the seriousness of her condition became apparent, an ambulance was immediately dispatched, and she was rushed to East Jefferson after an EKG was done in the field.

Upon arrival, the Emergency Department staff was already alerted to her condition by the paramedics and was ready. The Cath Lab team began their preparations so they would be in place as soon as Judith was rolled in. The goal set forth by the American Heart Association and the American College of Cardiology is to have a STEMI patient in the Cath Lab with blood flow restored to the coronary artery in under 90 minutes from the time they arrive at the hospital, commonly know as door-to-balloon time. For Judith, it was done in 37 minutes. Too much longer and the event may have proved fatal.

"Saving the life is not enough," says Dr. Bleich. "We know the longer someone goes without blood flow and oxygen, the greater the risk of dying or suffering permanent heart muscle or organ damage. We want that blood flow restored and to have the heart returned to normal function as quickly as possible. We say time is muscle, and in Judith's case, she was very fortunate that everything came back normally."

STEMI is the most severe type of heart attack

According to the American Heart Association, almost 400,000 people suffer a STEMI each year, while they estimate that only 25 percent of hospitals in the country are equipped to most effectively treat STEMI patients. STEMI, short for ST-elevation myocardial infarction, is the most serious type of heart attack because it means that a major artery is totally blocked. Less severe heart attacks can occur when the artery is only partially blocked.

The STEMI is recorded by an electrocardiogram (EKG) test. The results of the EKG are used by physicians to determine if there is blood flow to the heart. When no flow is present, it signals that the heart muscle is now in the process of dying and that action must be immediately taken to restore blood flow. Permanent damage to the heart muscle can lead to congestive heart failure or death. In most cases, the best treatment option is for a balloon to be inserted into the occluded, or blocked, artery to reopen it. The balloon could then be followed with a wire stent into the blocked area of the artery to help keep it open.

"The key to treating STEMI patients is the EKG," says cardiologist Dr. David Snyder. "Being able to quickly assess and identify that a person is having a STEMI event sets all the other pieces in motion so that everyone on the medical team can act rapidly. Taking care of that patient involves multiple departments all working on the same page."

Dr. Snyder says that the multidisciplinary hospital team critically looks at East Jefferson's STEMI Program and continually looks at all processes to decrease the door-to-balloon time. Communication links between the departments are examined, and the technology to better coordinate the departments is evaluated. Shaving crucial minutes at every point in the process gives the patient the best chance of survival with minimal or no damage occurring to the heart.

"We are extremely proud of the advances we have made in our STEMI Program," says Dr. Snyder. "The goal throughout the nation is a door-to-balloon time of under 90 minutes. We are exceeding that goal as our average time for STEMI patients is under 60 minutes. We challenge ourselves everyday to bring these times down even further."

New EKG Technology Leads the Way

East Jefferson's Emergency Medical Services (EMS) led the way in our area by introducing 12-lead EKG capabilities to our ambulances almost a decade ago. The latest version of this technology is now installed in all East Jefferson ambulances and allows EMS workers responding to an emergency to perform a 12-lead EKG in the field and instantly send a diagnostic quality test result to the hospital.

At the hospital, these test results are simultaneously received by the emergency department, cath lab and attending cardiologist even before the patient arrives. The medical team is then standing by at the ready, prepared to take the patient either into the Emergency Department to administer appropriate care or possibly straight to the cath lab to begin a life-saving interventional procedure.

"This 12-lead EKG transmission technology is up and running and saving lives in our community," says Mike Guillot, EJGH Director of Emergency Medical Services. "What we stress to everyone is that if you believe you are having a cardiac event, don't drive yourself to the hospital. Call 9-1-1 and let us evaluate you at home, or wherever you are, so that we can instantly alert the medical team back at the hospital."

The addition of the 12-lead EKG transmission technology in the ambulances significantly enhances a medical team's ability to exceed the door-to-ballon guidelines and positions EJGH to meet the challenges of future guideline changes. In fact, as a participating member of the American Heart Association's Mission Lifeline program, an initiative also designed to achieve a more timely treatment for STEMI patients, East Jefferson is ready for guideline changes. The American Heart Association will change door-to-balloon in 90 minutes or less to time from first medical contact to balloon in the same timeframe.

"The bar keeps being set higher and higher, and we believe that translates to better outcomes for our patients," says Guillot. "We recognize that as technology progresses so does our ability to save lives. We are prepared to meet the new standards before they are even in place."

Enhanced Communication saves time and lives

When the patient arrives at the hospital from the ambulance, the Emergency Department and the Cath Lab teams are already alerted to the patient's condition and are readying for treatment. The task force guiding the hospital's STEMI Program also changed lines of communication in case a patient presents to the Emergency Department on their own.

The goal is to administer an EKG within 10 minutes of arrival for any walk-in patient who displays symptoms of a heart attack. Either the physician or, now, nursing staff, has the ability to call a STEMI alert to prepare the Cath Lab team as soon as a STEMI is suspected. This early identification and alert has proven to be successful in driving down door-to-balloon times.

"We are ready should the patient arrive by ambulance or on their own," says Cheryl Carter, RN, Emergency Department Director. "If they come by ambulance and we know they are a STEMI patient, we can bring them here for basic safety checks and get the patient to the Cath Lab. If they arrive on their own, our physicians trust our nursing staff to call the STEMI alert. Either way, our goal is to rapidly open the vessel to restore blood flow."

As soon as the STEMI alert has been called, the beeper notification system is immediately sent to the entire care team. The Cath Lab team and interventional cardiologist are assembled and the procedure room is prepared. When the patient arrives, final checks are made, images of the heart are taken for placement and the balloon procedure can quickly begin. Once the balloon is inserted into the occluded artery, in less than one minute, blood flow can be restored and the patient's vital signs can begin to normalize.

"It is so gratifying to the team to get the artery unblocked and stop the STEMI," says Robbie Roussel, RN, member of the EJGH Cath Lab team. "The communication systems have helped us to respond even faster. We want to be alerted, and now, with a click of the computer mouse, we are notified. We are ready 24 hours a day, seven days a week."

 

 

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