By Dr. Tom Gross
Marin Independent Journal (California)
Copyright 2006 Marin Independent Journal, a MediaNews Group publication
All Rights Reserved
Editor’s Note: Dr. Tom Gross is the emergency medical services director for the Novato Fire Protection District.
The standard of medical care is always changing. What was appropriate a few years ago may quickly be surpassed by newer therapies.
Fifteen years ago, the standard of care for heart attacks was changed by the introduction of thrombolytic medications. Known as “clot busters,” the medications were able to dissolve small clots that were obstructing arteries in the heart, allowing blood to flow freely and stop the heart attack.
These medications were revolutionary. Previously, much of the care of a heart attack had centered on giving medications to relieve the pain and slow the heart to protect it from damage. Thrombolytics changed the landscape, allowing cardiologists to affect the cause of the heart attack and often to reverse its course.
Yet another revolution is occurring. For the past six months in Marin County, paramedics have had the tools and training to distinguish between certain types of heart attacks. Working under new policy developed by the Marin County EMS, patients with hearts attacks known as STEMI are not taken to the closest hospital, but are transported to a hospital with a cardiac catheterization facility, often known as a cath lab. There they undergo a procedure known as PCI, or percutaneous coronary intervention, for the placement of stents. These stents serve to open an obstructed artery and to keep it open.
The lifesaving benefit of this procedure is well documented. National standards developed by the American College of Cardiology recommend that the duration of time, after a patient enters the hospital until his artery is opened, should not exceed 90 minutes. The cardiologists will tell you, “Time is muscle.” That is, the sooner that the arteries are opened by PCI, the higher is the patient’s likelihood for positive outcome.
A few days ago, a patient called 911 complaining of chest pain. The paramedics arrived in six minutes. Within another six minutes, they had initiated treatment and had performed a 12-lead EKG, determining that the patient met criteria for transport to one of the two cath labs in Marin. The paramedics notified the hospital that they were en route with a patient who met cath-lab criteria. The catheterization team members were paged and were in the emergency department when the paramedics arrived.
Forty minutes later, the patient’s arteries were open, and the pain had eased.
Aside from the technology, which is staggering all by itself, the interagency cooperation is the real breakthrough that contributed to this patient’s outcome. The hospital built the cath labs. The EMS provider agencies, such as the fire departments, provided advanced training for their paramedics and purchased $30,000 EKG machines for each emergency vehicle that was equipped to provide advanced patient care.
The county EMS agency coordinated with all providers, including the county communications network. The result is a seamless transition, for the patient, into the ambulance, then to the ER, where the cath team is waiting, and then into the cath lab for treatment.
However, not all communities have this level of care because not all hospitals can support a cath lab. Not all communities have cardiologists and nurses who are prepared to be on-call 24 hours a day, seven days a week. Not all communities have an EMS system that is prepared to provide 12-lead EKGs in the ambulance. In many communities in California and across the United States, the standard of care for STEMI is still thrombolytics in the emergency department.
But this is slowly changing. Good ideas have a way of catching on.