I just came out of the cath lab after doing an emergency coronary angiogram on a man suffering a heart attack.
He was a youngish fellow with no prior heart problems but with a bad cigarette habit and genes that are not favorable (his father suffered a heart attack at about the same age).
We rushed him into the lab and prepped him for the procedure. As he lay on the table he seemed to watch with curiosity as our personnel ran about the room, tearing open sterilized packs of instruments and preparing monitors and tubing. To him, I’m sure, everything seemed to move at super fast speed, like a scene from a Charlie Chaplin movie. As I was getting ready to place the access tube into his femoral artery, he turned to me and asked why everyone was hustling about. “What’s the rush?”
The rush, of course, comes down to hard science. Years of study, data collection and real-world experience have taught us that we save more lives if we can shave even a few minutes off the time it takes to open a clogged artery. Your chance of surviving a heart attack, especially with your cardiac muscle intact, increases dramatically as the time between clot formation and stent placement decreases.
It’s for this reason that we track what we call the “door to balloon” (D2B) time. The term “D2B” refers to the time between a patient’s arrival in the emergency department to the first inflation of an angioplasty balloon in the clogged artery. Our current guidelines mandate a D2B time of 90 minutes or less, and over the last few years we’ve become very good at reaching this goal. In fact, a recent article in the Omaha World-Herald noted the remarkably rapid D2B time — only 54 minutes, on average —we achieve at Midlands Hospital (yes, I’m bragging here, although I can’t claim any credit for this since I’m not one of the doctors who does stents).
The concept of expediting the D2B time was obviously lost on my young patient. While I was evaluating him in the emergency room before the heart catheterization, I noticed a large fountain drink by his bedside. Not only had he and his wife not arrived via ambulance (meaning they had not called 911) but they had also stopped at a convenience store for a 32-ounce fix of Dr. Pepper on the way.
The patient’s symptoms, as he explained, had actually been present for at least eight hours before he decided to go to the hospital. As it turned out, the decision to seek medical care was made fairly quickly once the woman of the house was notified of ongoing events.
This man’s D2B was pretty quick — less than 50 minutes. Our emergency room and cath lab staff didn’t waste a single moment in their efforts to get the patient into the hands of our interventional cardiologist. The problem, obviously, is that our best efforts — while great for our D2B scorecard —don’t mean a whole lot if the patient has spent the last eight hours with a corked vessel.
The emergency medical system has put considerable effort into shortening the time between the initial 911 call and the point where patients land in the hands of emergency physicians. In our area, for example, a patient with chest pain can undergo an electrocardiogram (ECG) before arriving at the hospital. The ECG is transmitted to the emergency room doctor, who can alert the cardiologist and cath lab staff of the patient’s impending arrival and move the process along even faster.
What we can’t control is the time between the onset of symptoms (which happens the moment the vessel becomes blocked) and the 911 call. Even worse, we find that heart attack victims often choose to forgo the emergency medical services system altogether in favor of a commute in the Ford F-150 (remember, I’m writing this blog post in Omaha).
Recent studies have clearly demonstrated that the longer people wait before coming to the hospital, the higher their chances for death or long-term cardiac damage. A wait of more than four hours from the onset of symptoms is associated with a considerably higher rate of mortality.
What’s to be done? Here are a few simple tips:
- If you think you’re having heart problems and plan to go to the hospital, leave the car keys at home. Call 911 and let the paramedics handle the transportation.
- Chest, shoulder or arm pain at rest, especially if associated with sweating, nausea or difficulty breathing, is worth dialing 911.
- We won’t think less of you if your visit to the ER is a false alarm. I promise.
- If you’re a man and you wonder whether you should call 911, find the nearest female in your life and let her decide (that advice can actually apply to most things in your life).
If and when you have a heart attack, your doctors, nurses and technicians will break all kinds of records in their efforts to get your blocked vessel open. All we ask is that you get into the hospital promptly so all our rushing around is worth it.
