By Don Finley
The San Antonio Express-News
SAN ANTONIO — Perhaps the biggest collaboration in years by competing doctors, hospitals and emergency medical systems is nearing its launch in the San Antonio area, with the aim of speeding patients with the most deadly form of heart attacks to balloon therapy in 90 minutes or less.
The result will be an organized system of emergency heart attack care similar to the regional trauma system developed here a decade ago. When in place, paramedics using portable 12-lead EKG monitors will trigger what soon will be known throughout the region as a “heart alert” — often before the patient is even lifted into the ambulance.
Beginning early next year, these heart alerts will scramble heart teams at the closest hospital capable of treating them, regardless of the hour.
“We’ve developed heart alert criteria based on national standards,” said Eric Epley, executive director of the Southwest Texas Regional Advisory Council for Trauma, which organized the effort. “Those heart alert criteria then do things inside the hospital that decrease the time to get them back to the cath lab.”
Local hospital officials and various ambulance services, including San Antonio’s EMS, have gathered monthly for the past year to hammer out the details.
About a dozen so far have signed a “letter of attestation,” promising to follow national heart attack guidelines and work with EMS and each other to cut through red tape and get patients treated rapidly.
In the letter, hospitals promise to scramble the heart catheterization lab team with one call by the emergency room physician in communication with EMS, and to aim at having a cardiologist and support staff in the lab within 30 minutes of activation.
Ambulance companies promise to have 12-lead EKGs onboard their units, provide training and continuing education for paramedics in interpreting the results, and to set a goal of spending no more than 20 minutes at the scene with those severe heart attack patients.
And while a few bugs remain — mostly related to technical problems, including three different brands of EKG machines used by different ambulance services — the effort has moved forward remarkably smoothly given its complexity and the competition between participants, observers say.
By one estimate, 17 of 20 local hospitals have interventional cath labs capable of opening clogged coronary blood vessels — a procedure known as percutaneous coronary intervention, or PCI. Several government-supported and private ambulance systems are capable of transporting them in and around Bexar County.
And while communities throughout the country are working on similar systems, urged on by government and professional organizations, San Antonio appears to be among only a handful to be this far along.
“In San Antonio you have the ideal system happening there, where you have EMS talking to hospital systems talking to cardiologists and the cath lab team, so that the hospital is aware the patient’s coming,” said Loni Denne with the American Heart Association’s Mission: Lifeline program, which is pushing for such systems. “And the patient is much more likely to survive.”
Worst heart attacks
The system is designed around a type of heart attack known in medical circles as STEMI — ST-segment Elevation Myocardial Infarction — named for the pattern of squiggles on an EKG printout. They make up 20 percent to 40 percent of all heart attacks.
STEMIs, in which a major blood vessel to the heart is completely, blocked, “are the worst possible heart attacks,” said Lt. Col. Scott Moore, chief of cardiology at Wilford Hall Medical Center.
“In San Antonio and in most metropolitan areas, the best approach is to emergently take the patient to the cardiac catheterization laboratory, identify where this blockage is and inflate a balloon in that artery to reestablish flow,” Moore said. “And based on large clinical trials, we know the faster you do it, the better.”
Cardiologists have a saying: “Time is muscle.” Studies show that for every 30 minutes’ delay in treating a STEMI heart attack, the risk of dying rises by 71/2 percent. Even if the patient lives, delays in clearing the blocked vessel lead to more heart muscle damage.
“You end up having a patient who, instead of being able to go back to work and play soccer with their kids and live a normal, healthy life, they may take 10 steps and become short of breath and have to sit and rest,” Denne said. “They may not be able to go back to work because they’re disabled.”
In recent years, individual hospitals have been working to get these patients from the hospital door through the emergency room to the cath lab to have a balloon inflated within 90 minutes.
Those efforts have become more intense since the Joint Commission, the nation’s main hospital accrediting agency, began tracking these “door-to-balloon” times as one of its core measures of a hospital’s quality.
Today, anyone can check to see what percentage of a hospital’s patients had a door-to-balloon time of 90 minutes or less on the federal government’s Hospital Compare Web site (hospitalcompare.hhs.gov), and compare those results to other hospitals in the area. And if EMS can accurately diagnose the patient in the field so that the cath lab is ready when they arrive, it should improve those hospital scores.
“I’m a pretty competitive guy,” said Bill Waechter, chief operating officer at Northeast Baptist Hospital and a former paramedic. “I don’t want to be in last place. But the great thing about the door-to-balloon program is, this is a program that is obviously wonderful for the patient. It’s good for the hospital. It’s good for the physician. If you treat the heart attack earlier, your length of stay is going to be less in the hospital because you don’t have the other problems associated with it. With the cost of health care, that’s better for everybody.”
EMS piece of the puzzle
At the same time, EMS systems and private ambulance companies had been buying portable 12-lead EKGs capable of detecting STEMI heart attacks. The units often came with a little-used feature capable of transmitting the results back to a hospital emergency room — either by fax or digitally to a computer.
Usually, paramedics read the EKG tape and called the emergency room with their interpretations — with varying degrees of accuracy. Or they rolled the patient into the ER with the tape draped over their chests.
San Antonio EMS added the $24,000, 12-lead EKGs to each of its 35 ambulances in May 2007, although they still lack the ability to transmit the results. The committee has formally asked the City Council to upgrade the units so they can.
“We’ve had the 12-lead capability on our ambulances since 2003, but it was in 2006 when the Baptist system wanted to start activating their cath lab off of what we did in the field that we invested a little more money in each of the monitors and got the capability to transmit those to the ER,” said Dudley Wait, director of Schertz EMS.
Along with Alamo Heights EMS and the privately owned American Medical Response, Schertz EMS participated in a yearlong pilot project at Northeast Baptist to see if transmitting EKGs would speed up door-to-balloon times.
Although paramedics are trained to interpret those EKGs - and that training has intensified with the Heart Alert initiative here - it was felt by some hospitals and cardiologists that transmitting the results and allowing the emergency room doctor to see the EKG tape would reduce the odds that teams would be scrambled unnecessarily for a misdiagnosed STEMI.
“Compared to the hospitals and physicians and nursing, EMS is a relatively new profession, if you will,” Waechter said. “And when you talk about activating resources and having the cath lab team come in (on nights and weekends), or maybe you’re taking a patient who was there for an elective procedure off the table (to make room for an emergency case), the physicians are going to be somewhat cautious.”
Meanwhile, Methodist Hospital has offered more training to paramedics to interpret EKGs, and gives them feedback on every STEMI patient, said Susan Sewell, senior director of the adult emergency department at Methodist Hospital.
“We’ve opened our ED (emergency department) for them to come in and do a rotation with ED physicians if they wanted more knowledge about interpreting EKGs,” Sewell said. “We’ve offered to have them come in with our cath lab staff and to view caths. And we also provide 100 percent feedback to any EMS agency on their patients that come in with STEMIs.”
Convincing the patient
Although he admits with a laugh he should have known better, 46-year-old Jesse Renteria Jr. flunked the basics when it came to his own heart attack last April.
First, he ignored the chest pain that began shortly before attending his daughter’s high school softball game. Then when he couldn’t ignore it any longer, he asked his wife to drive him to the Methodist emergency room — refusing her offer to take him to the neighborhood fire station to have the paramedics take a look at him.
Actually, his paramedics. Renteria is a San Antonio EMS supervisor, as well as a member of the local cardiac committee organizing the STEMI system.
“My cardiologist, he says you don’t want to be a chillón, a crybaby,” Renteria said, referring to people who deny their symptoms. Nevertheless, Renteria proved lucky and survived his ordeal with little permanent heart damage.
And that, experts say, is the next step in the STEMI chain — getting people to recognize the symptoms of a heart attack and call 911. Studies show that people who drive themselves to the hospital have much longer door-to-balloon times than if they arrive by EMS.
“Not wait and see, and not drive themselves in,” cardiologist Moore said. “Because we know that patients who drive into the hospital have longer door-to-balloon times than patients who arrive by EMS. I had a patient recently, a young guy, his heart went into a lethal rhythm in the ambulance on the way to the hospital. If someone had been driving him in, he might not have survived that heart attack.”
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