A Sea Change in Treating Heart Attacks

http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html

by dankohn1 • 11 years ago

123 59 11 years ago

Cass4• 11 years ago

A month ago, a friend who'd worked as a doctor in South Africa for decades was interning with me to learn about the procedures in our German ER. I remember the first time a patient with a heart attack came in while she was there, and the speed of the proceedings just blew. her. mind.

What happens, if things go well, is this:

The EMTs transmit a picture of the electrocardiogram to us[1]. We confirm that it's a STEMI (the kind of heart attack where speed matters the most, as opposed to an NSTEMI, which isn't quite as urgent), and alert the catheter lab and the attending cardiologist. Half the ER personnel drops everything else to prepare for the patient's arrival.

The patient arrives. We transfer them to our gurney. One nurse gets the patient's clothes off (with scissors if necessary) while another nurse attaches electrocardiogram electrodes and a third shaves the puncture site for the catheter.

The ER physician puts in an iv line and draws blood while informing the patient of the treatment plan. The cardiologist takes a very quick history of the patient and confirms the STEMI with the second electrocardiogramm. We wheel the patient up to the catheter lab and get started.

Altogether, if everything goes well, it's something like five to twelve minutes from the moment the patient comes through our doors to the moment we've got the patient on the operating table.

[1]By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.

agumonkey• 11 years ago

For the curious, differences between {N}STEMI http://imgur.com/HbREzfo

JshWright14• 11 years ago

Hmm... ST depression often means there is ST elevation somehwere you can't see. ST depression is generally a 'reciprocal' change, and there will be elevation on the opposite side of the heart.

A 'standard' EKG looks at the front, bottom, and left side of the heart. If the area of the heart affected by the heart attack is on the right or back side, then you won't see elevation, but you may see the reciprocal depression.

EDIT: s/almost certainly/often/

maxerickson5• 11 years ago

It's kind of startling that what is essentially a straightforward process improvement can have such a large impact. It's fantastic that it is happening, but it raises the question of whether there are similar opportunities, or more forcefully, where the similar opportunities are lurking. I'm reminded of the famous stuff about checklists and infections.

stephengillie4• 11 years ago

By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.

Congrats on the massive process improvement on using readily-available technology. I'm no lawyer but I'm pretty certain that this violates HIPAA, which means it's a new market just screaming for PII-managing image-transfer networks and startups.

__z• 11 years ago

HIPAA doesn't apply in Germany...

PS - its HIPAA not HIPPA.

tgokh• 11 years ago

The technology exists -- see http://www.physio-control.com/ProductDetails.aspx?id=2147484... and http://www.zoll.com/medical-products/data-management/rescuen... from PhysioControl and Zoll, two of the biggest EMS EKG monitor manufacturers, but its certainly not easy to use. In my system, we used to have to upload the EKG to the computer and then "e-fax" it from he computer to the Emergency Department -- practically, this took 3-4 minutes to do, and when you're in an urban area and nearly always < 10 minutes from the hospital, its not the most productive use of time. Most of the time, if was easier to do the EKG, and in case of a STEMI, call the "code STEMI" via radio, print the EKG and spend the rest of the time doing important patient care (IV access, aspirin, etc)

That said, we were in a Paramedic system with a relatively short to-hospital drive time, and going to an academic medical center that had 24/7 in-house interventional cardiologists. If you're in a aystem with only EMT-Basics (who are trained to perform the EKG but cannot interpret the printout), or going to a hospital where the interventional cardiologists need to come in from home, or if your primary hospital doesn't even have a cath lab and will need to divert you to another bigger hospital, it makes a lot of sense to be able to send the EKG from the field and get the ball rolling early.

athenot• 11 years ago

There are already several HIPAA-compliant messaging apps that take care of that.

loco5niner• 11 years ago

HIPPA... Germany...

BjoernKW• 11 years ago

Yes, it is. HIPAA doesn't apply to Germany though, unfortunately. Despite its reputation for privacy Germany's healthcare regulations are severely lacking in that respect.

Implementing a more stable - and legal - system for exchanging medical data is next to impossible because there's a bunch of stakeholders who actively undermine what's in the interest of the patients for their own good.

So, for the time being, transmitting patient data via WhatsApp and the likes unfortunately - and quite bizarrely - probably is the only option to act in the patient's interest. Besides, the regulators won't notice anyway because for them the Internet still is some passing fad.

oh_sigh• 11 years ago

HIPAA is a set of American laws, and this is in Germany.

chasb• 11 years ago

It depends on whether the message/pic is identifiable. If it's not -- just "HEY IS THIS BAD?!" -- then it probably would not constitute protected health information, for HIPAA purposes. (Presuming this is in the US.)

Cass4• 11 years ago

We don't put the patient's name on the EKG, so it's not directly identifiable, and we get their consent before submitting (if they're in any state to consent, which often they aren't), but I'm sure it does violate all kinds of rules and guidelines, if not actual laws.

clsec• 11 years ago

Though I can't find any reference to it, I'm fairly certain that TextSecure would be HIPAA compliant. I think I'll try to point that out to Moxie and see if they can make it official.

JshWright14• 11 years ago

Interesting... I would have assumed Germany would be a bit more advanced in prehospital care.

Here in the US (in a rural/suburban area outside a smallish city in upstate New York), the flow would look more like:

A paramedic recognizes a potential MI and takes a 12-lead EKG. If it is indeed a STEMI, then we'll call the ER and transmit the EKG and other vitals (via a cell modem embedded in the monitor). If the ER doc agrees with my diagnosis, then the cath lab is activated.

I'll have a couple large bore IVs in place before we arrive at the hospital, and when we get to the hospital, the patient stays right on our stretcher as we bypass the ER entirely at take them directly to cath.

Cass4• 11 years ago

For an unstable patient, our process is much the same - the EMTs will put in the IVs, and we'll bypass the ER to proceed directly to the cath lab. For stable patients, the EMTs will prioritize getting them to the hospital as fast as possible and often won't have the time to get the IVs into place before they arrive. (This part of the county has a ridiculous density of hospitals, so the ambulance ride is frequently not even five minutes long, which doesn't give the EMTs that much time to work.)

We've found that things go little more smoothly if we do some of the prep in the ER, where there's a little more space for people to undress the patient etc. without worrying about bumping into the expense catheter equipment or compromising sterility, but even stable patients aren't supposed to spend more than five minutes there before being rushed to cath.

I do wish we had some way to directly transmit EKGs and vitals. American hospitals seem to have more money available for electronic equipment like that. (On the other hand, in Germany, the whole hospital stay including the catheter and a day in the ICU, probably won't cost you more than 10.000 Euro, and usually less than that.)

Scoundreller• 11 years ago

Is there any opportunity (or practice) of other conditions bypassing the ER? If that's the bottleneck, I hope it doesn't have to be life-or-death for someone to thing "We should re-engineer this process".

E.g. uncomplicated fractures getting brought to the fracture clinic?

sliverstorm• 11 years ago

By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.

Patient privacy laws really do put some perverse constraints on the system sometimes.

Animats• 11 years ago

But who calls an ambulance? Now that's an opportunity for a wearable device.

mindcrime4• 11 years ago

After I had my heart-attack last year[1], I was asked to participate in a clinical trial of a device called a "Life Vest". I did so briefly, although I ditched it pretty quickly because it was too uncomfortable to sleep in. But this thing was basically a wearable EKG/defibrillator. It monitored your heart rhythm and, if you went into a bad rhythm, would actually give you a shock from the defibrillator. Handy if you were asleep or had already fallen unconscious and couldn't call for help.

Of course it gave you a warning buzz first and had a "cancel" button so you could avoid being shocked if you were actually still OK. And it wouldn't shock you, AFAIK, unless you were in a "shockable rhythm"[2].

Anyway, it's still a bit big, bulky and uncomfortable and I doubt you'll see millions of people wearing something like this anytime soon, but as things get lighter and cheaper and better, it might just become mainstream.

[1] https://news.ycombinator.com/item?id=8550315

[2] https://suite.io/elizabeth-batt/4z1520d

JshWright14• 11 years ago

Other than being slightly less invasive, this seems significantly inferior to an AICD [1]

[1] https://en.wikipedia.org/wiki/Implantable_cardioverter-defib...

JshWright14• 11 years ago

It would have to be a pretty awkward device if you wanted to automatically detect a STEMI. An EKG capable of diagnosing a STEMI requires at least 9 electrodes (most use 10+), placed in very specific locations around the body.

akhilcacharya• 11 years ago

JshWright14• 11 years ago

  They included ambulance drivers’ transmitting electrocardiogram
  readings to emergency rooms, E.R. doctors’ deciding whether a
  person was likely having a heart attack, and hospital operators’
  summoning treatment teams with a single call. These hospitals
  also continually measured performance.

I know it's a really minor thing, but the term 'ambulance driver' is a little irksome... It's like calling a doctor a 'prescription writer'.

In the case of a heart attack patient, a paramedic recognizes the possible indications, takes an interprets an EKG, considers the possible differential diagnosis, makes the appropriate hospital notifications, and provides advanced level care to speed things along at the hospital (obtaining IV access, administering various medications, etc). We do a bit more than just drive the ambulance...

mindcrime4• 11 years ago

To be fair to the author, not every ambulance crew is paramedic level. And the term "ambulance attendant" was, at one time, in widespread use - to the point that the first level of EMS certification was actually called "Ambulance Attendant", if memory serves correctly.

I know it's annoying when non-domain-specialists misuse terminology, even slightly, but I could see giving them a pass on this one.

JshWright14• 11 years ago

Yeah, hence my being 'irked' not 'really offended'.

I suspect most folks here consider themselves more than just "typists".

benburwell• 11 years ago

As an EMT, I too found this rather disturbing. Throughout the article, prehospital interventions were repeatedly not acknowledged. From the reference to "ambulance drivers" that you mentioned to things as subtle as saying that the clock starts when the patient rolls into the ER rather than when the ambulance arrives on scene, the article completely misses (or does not fully acknowledge) a hugely important factor in improving outcomes for STEMI: the prehospital care involved.

ajmurmann• 11 years ago

Nice, this makes it even more likely I will die a slow death from cancer instead.

mindcrime4• 11 years ago

Yeah, this jibes with my experience. I was rushed to UNC Hospital in Chapel Hill last Nov. with a STEMI, and I was amazed at how fast things progressed. Granted, time seems to compress in highly stressful situations, and I wasn't exactly timing with a stopwatch, but subjectively, I feel like I was in the ER maybe 15-20 minutes top, before they had me on my way to the cath lab. And the catheterization procedure took somewhere around an hour (maybe more, maybe less, hard to recall exactly). I never asked for the exact time until they had the catheter in my artery, but I'm pretty sure it was well less than 90 minutes.

At any rate, it was enough that I survived and the amount of heart damage I suffered was minimal enough that I was able to resume a completely normal life afterwards. By 3 months after the MI, I was biking 20+ miles at a time, and by 4 months had worked up to 75 miles a week, and then I raced in a 6 hour MTB endurance race about 5 months afterwards.

So yeah, speed is definitely of the essence. Luckily for me, and I am fortunate enough to live near a good hospital, in a community with top notch 911 and EMS providers.

eplanit• 11 years ago

I'm grateful to be in the same club. My Myocardial Infarction was in 2005: blockages in coronary arteries of 100%, 98%, 95%, and 80%. From the time I arrived at the E/R to the time the acted on me in the Catheterization lab was < 15 minutes. One hour and three stents later I was in recovery. My cardiologist explained that people with my symptoms, had they come to the E/R 3 years earlier, usually would die. I try to never forget to be grateful to all those who acted so quickly.

noir_lord• 11 years ago

Few weeks ago I woke up with massive chest pain, struggling to breathe and pouring with sweat, rang ambulance and went to open door by time I'd limped to unlock it one of the fast response cars not ambulance was at my home total time was <5 mins and they had 12 leads on me.

Turned out to be an awful gallstone attack blnot heart attack but damn was I impressed with speed of response for early hours of Sunday morning - traditionally their busiest time.

Still ended up in hospital as they recommended that since I was projectile vomiting I should get checked out.

shirro• 11 years ago

Reading articles like this you suddenly realise that living in a sparsely populated rural area you sacrifice a hell of a lot in health care as as well as the more obvious career, education and entertainment benefits.

Having some risk factors like age and weight and living hundreds of km from a cardiologist is a bit of a worry. Are there cheap, effective ways of screening people with no history of heart problems so perhaps they could be more closely monitored or something?

fragmede• 11 years ago

Probably the biggest two that we have are mentioned in the article. Blood pressure and cholesterol. Hopefully you are getting your yearly checkups including blood work done.

sebouh00• 11 years ago

It's like an F1 pit stop.

kzhahou• 11 years ago

If only.

http://img.pandawhale.com/post-41481-ferrari-f1-pit-stop-per...

But you know, maybe someday it will be like this. You suspect heart attack, ambulance pulls up, does procedure on the spot, and you're back in business in 60 minutes. If they detect major tissue damage, then a quick stem cell injection plus you have to call in sick for a week.

All of today's medicine would have been impossible to believe even a century ago.

BJBBB• 11 years ago

Perhaps too cynical after seeing medicos botch treatment for two family members. The main reason is the bottom line. If the allow people of marginal health to die too early, then their maximum utility diminishes unless the victim/patient can be kept alive for another 5 to 10 years.

This is a similar monetary basis for the cancer model - to extend the treatment period. Prolonging life has little to do with quality and meaning of life. The medical community is fundamentally corrupt.

A Sea Change in Treating Heart Attacks

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