City ambulances finally equipped to detect severe heart attacks
Thanks to NATO summit, people suffering 'widow-makers' can now be rushed to the right hospital in time
Brian Thies' "widow-maker" heart attack was diagnosed in the ambulance, which took him to the appropriate hospital. Thies, a 32-year-old graduate student, has recovered and is already back in class. (Terrence Antonio James, Chicago Tribune)
The ambulance took him directly to Rush University Medical Center, where a specialized team was expecting him in the catheter lab. Just 40 minutes after the call to 911, Dr. Cliff Kavinsky opened Thies' right coronary artery, which was 100 percent blocked.
Every minute counts during a widow-maker, when blood flow is cut off in a major artery leading to the heart.
Until recently, Chicago ambulances lacked a key piece of equipment used to diagnose the most severe heart attacks, technically known as STEMIs. But thanks to creative funding and dogged health officials, most of Chicago's 75 ambulances now carry the devices, called 12-lead electrocardiograms or EKGs.
Diagnosing a widow-maker in the field — rather than at the hospital — can speed up treatment and dramatically improve a patient's chances of survival. Not all hospitals have specialized teams that can treat STEMIs around the clock, so it's essential that these patients are taken directly to one that does. The new monitors also allow paramedics to alert the hospital that a STEMI case is on the way, giving the staff time to marshal resources.
"We've essentially extended the hospital out to the community," said University of Chicago cardiologist Stephen Archer, president of the American Heart Association's Metro Chicago board of directors, who has been pushing for the STEMI system of care for at least three years.
The Tribune reported in 2009 that Chicago was one of the only major cities in the country whose emergency medical responders did not have 12-lead EKGs, which provide a comprehensive picture of the heart's electrical activity. Instead, the city's ambulances used three-lead EKGs, which can pick up an irregular heartbeat but don't have the depth to diagnose a STEMI, short for ST-Elevation Myocardial Infarction.
Fire officials say that although they were eager to get the equipment, patient care was not being compromised. Some health officials disagree.
"It was a big problem," said Dr. Richard Feldman, a medical director for part of the city's Emergency Medical Services system who is based at Advocate Illinois Masonic Medical Center. Chicago was "way behind the curve" in terms of instituting a program of care for STEMI patients, he said.
"There wasn't sufficient will on the part of the city to elevate this to a higher priority," said Dr. Gary Schaer, an interventional cardiologist at Rush University Medical Center. Schaer, co-chair of a regional STEMI advisory committee, met with the heart association and the mayor's office multiple times to lobby for the 12-lead EKGs. "It was very frustrating," he said.
Officials had estimated that $3.2 million would be needed to buy 100 of the 12-lead devices, said Leslee Stein-Spencer, the Fire Department's manager of medical administration and regulatory compliance.
In the end, Chicago's role as host city for May's NATO summit opened up an unexpected source of grant money. To help bolster the city's emergency response capability, the Fire Department was allowed to buy the equipment with funding from theU.S. Department of Homeland Security, at a cost that turned out to be far lower than predicted.
In addition to the new monitors, Chicago's STEMI system includes a network of 25 hospitals in and near the city that are designated as STEMI-centers. At these hospitals, specialized teams are available 24/7 to open the blocked artery within about 90 minutes of arriving at the hospital.
The STEMI network also includes a new system for tracking severe heart attacks as well as quality control guidelines established by the American Heart Association as part of a national initiative to improve heart attack care called Mission: Lifeline. About 60 percent of the nation, including many Chicago suburbs, is now covered by a similar STEMI network, Archer said.
Each year, nearly 300,000 people in the U.S. and 1,500 Chicagoans experience a STEMI, according to the American Heart Association, which has made improving care for STEMI heart attacks a national priority.
The most effective treatment involves angioplasty, or clearing the blockage by opening the artery using a small balloon. A type of scaffolding called a stent is then inserted to prop it open.
Archer said the survival rate for STEMI patients is more than 95 percent when the "door to balloon" time is less than 90 minutes. The term refers to the period between the patient's arrival in the emergency room and the moment blood flow is restored. If that window is missed, the patient has a nearly 50 percent chance of dying.
In the past, Chicago's EMS teams routinely took heart attack patients to the closest hospital. But not every hospital can perform a balloon angioplasty around the clock, Archer said. If the STEMI is diagnosed at a hospital that can't perform the procedure, the patient must be transferred, a costly and potentially life-threatening delay.
After the Tribune's 2009 article, the American Heart Association convened a board meeting to start laying the groundwork for a new system of care, even though the funding wasn't yet available.
The committee, which included members of the Fire Department and EMS officials, spent a year designating which Chicago-area hospitals are equipped to take STEMI patients. It also hammered out specific ground rules. STEMI hospitals, for example, can't divert patients just because they are busy.
Meanwhile, fire officials discovered they could upgrade the current monitors to 12-lead capability by buying software and the 12 leads for far less than the original $3.2 million estimate. Once the funding finally materialized, the city spent $800,000 on 100 monitors, which includes equipment for the current fleet of 60 front-line ambulances as well as special event ambulances and spares, said Stein-Spencer.
The first STEMI transport was made May 15, five days before the NATO summit, when a 52-year-old man was taken to Vanguard West Suburban Medical Center in Oak Park, the closest STEMI hospital. He was treated with angioplasty and has recovered, hospital officials said.
Since then, 167 STEMI transport cases have been reported, Stein-Spencer said. One of them was Joyce Martin, who woke up in her Bronzeville home July 4 with indigestion and shortness of breath. Martin, 66, thought it was gas. Instead, the paramedics determined it was a widow-maker.
Bypassing a closer hospital, the ambulance took her to the University of Chicago medical center, a designated STEMI location, said Dr. Atman Shah, director of U. of C.'s coronary care unit. "She came right to the ER, and our team of physicians was waiting at the door," he said. "Within 70 minutes, we'd opened up her artery."
Thies, a 32-year-old graduate student, was getting ready to head out for an afternoon class two weeks ago when his chest pain intensified. He couldn't breathe, sit or stand. He called 911, but it didn't cross his mind that he was having a heart attack until a paramedic told him.
"I thought it was a respiratory issue because I had trouble breathing," he said.
Despite having a key artery completely blocked, Thies went home with normal heart function, doctors said. He has already returned to his business classes at the University of Illinois at Chicago.