The call is for a “heart attack.”
We get dispatched to “heart attacks” fairly often. “Heart attack” is a layman’s way of describing chest pain or stroke or cardiac arrest. It could be anything really. We sometimes even get called for heart attacks in doctors’ offices and it turns out not to be a true heart attack, but some just version of chest pain.
But there is a difference this time. The location of the call is a cardiologist’s office.
“This is going to be a STEMI,” I tell my partner as he hits on the lights. “And I bet they are going to want us to go right to the cath lab.”
I wrote about a similar experience with this office a number of years ago in cath lab, when I lamented that a golfing buddy of a cardiologist could go right from the field to the cath lab, but any regular Joe had to go to the ED where I would have to persuade a doctor to look at my ECG, and then he would have to call a cardiologist to convince him to open the cath lab.
But as my last post STEMI Alert shows, there has been progress in recent years. We can now activate the cath lab from the field. We are still required to go to the ED where the patient gets registered, a hospital 12-lead is done, any appropriate care we haven’t already done is started (such as giving Plavix or starting heparin), and the patient signs the consent form for the procedure.
Sure enough, when we arrive we are led down the hall to the last room where a 12-lead machine is spitting out an ECG. I can see the ST elevation from the doorway. The doctor tells me the patient – a 65-year-old female is having an acute anterior MI. When I ask what medicine she has already gotten, he tells me they have given her aspirin and NTG.
“Are we going to the ED or…?” I ask.
“Right to the cath lab. Dr. Blank is waiting for him in cath lab # 2.”
And it is off to the races. While we transfer her over to our stretcher, the doctor gives her some plavix. Then we are out the door, back in the ambulance and on our way.
Our normal procedure is to call the ED with a STEMI alert. This time I just call and say I am en route from (I name the cardiologist’s office) with an acute STEMI going directly to the cath lab. Can they have someone from the ED meet us at the door and escort us up? I know where the cath lab is, but there are some locked doors that you need an ID swipe to enter.
I manage to put the patient on oxygen, get a set of vitals, do a 12-lead of my own, and put in an IV and start to run fluid (Her BP is in the 90’s, which she says is low for her), while getting a cursory history (none, she says) on the way in. We talk about what is happening to her – she has a blocked artery in her heart and what they are going to do to open it up – insert a balloon. She is intelligent and has some medical background. When I start to explain why I am putting on the defib pads, she shakes her head and says, “I don’t even want to know.”
She tells me she started feeling badly about an hour earlier so she called her cardiologist (she had to have some history, but I didn’t have time to get into it) and made an emergency appointment. While I wish she had called 911 instead of the cardiologist, at least they recognized what was going on right away and they have the pull to get her right into the cath lab. No need for my interpretation or a stop in the ED.
Our guide from the ED meets us at the door and clears our way up to the cath lab, where we transfer her to their table as the cardiologist holds out a clipboard with the consent form on it.
Instead of staying to watch the procedure this time, I go back downstairs and write up my run form. When I return to the cath lab, while the patient is still on the table, I learn the balloon has been inflated. The blockage is now clear. The stent is in. And the patient is doing well. The patient had a 100% occlusion of the Left Anterior Descending Artery (the LAD) — also know as the Widow Maker, or in the case of female patients, the Widower Maker.
Door-to-balloon time is 28 minutes and 911 call-to-balloon is 60.
Using the STEMI I did the other day as a comparison, bypassing the ED saved 7 minutes.
While these were special circumstances (the patient coming from the cardiologist’s office), I am hopeful that we can build on calls like this one to the next logical step for our area – joining some other progressive areas in the country in making field to the cath lab the routine rather than the exception.