I live in Louisville, KY, which is the epicenter for heart disease in the United States. My state ranks 49th out of 50 states for heart attack mortality. This is a complex issue with many contributing factors, including access to care, patient education, health insurance, cooperation between EMS and hospitals, among others. The thing is: heart disease is our number one killer. So it matters.
We have been building a regional heart attack network at our institution. Patients with acute heart attack are best served by emergency percutaneous coronary intervention (PCI). It’s amazing. One minute the patient is writhing and literally dying, and in the next moment after a PCI they are pain free and getting up off the table. I’ve been on interventional call this last week and spent a couple of late nights in the cath lab. Needless to say, I was looking forward to the family vacation and getting away to recharge my batteries.
I arrived at the airport with my family and was walking toward the TSA area when I saw him. Off to the side was a middle-aged man slumped against the wall. He was ashen with a light sheen of sweat on his forehead and his hand on his chest (Levine sign). I’ve seen this look a thousand times. This guy is having a heart attack. I go over and identify myself as a cardiologist to the security guard and ask, “Can I help?”
The man pleads: “Can somebody make this chest pain go away?” I think, yes I can. Let’s go. I’ll take you up to the cath lab and have this over in 20 minutes. Except, I’m outside the TSA line at the airport. I don’t have my cath lab team or my fluoroscopy machine or my angioplasty balloon. Heck, I don’t even have an ECG. What a helpless feeling. There is one guy in the building, me, that can stop this heart attack and I am stuck just watching.
EMS is on the scene minutes later. Yes, the cavalry has arrived. I tell the EMS personnel that I’m a cardiologist and I think this guy is having a heart attack. “We need a 12 lead ECG now.” The EMS personnel respond: “We can’t do an ECG because we are a basic life support ambulance.” Are you kidding me? I think to myself.
An abnormal ECG is the portal to entry for heart attack care and the key to unleashing the fury of modern day medicine to save this guys life. Once the ECG is abnormal, a cath lab team can be activated.
EMS in my county—an urban area–is great and they do a wonderful job. But it turns out there is up to a 50% chance that when an ambulance pulls up on a scene they can’t provide even an ECG. It’s the same in many areas in my state and throughout the country. If a paramedic is on board then an ECG is done at the scene and it is transmitted to the PCI center. However, for a variety of reasons, in most locales, basic EMTs are not allowed to perform ECGs. This means the diagnosis of heart attack has to wait until arrival in the ER. That’s a significant delay–and it makes no sense.
ECGs are cheap to do, easy to perform and confer no risk to the patient. The accompanying computer software correctly recognizes a heart attack the vast majority of the time. The recently released heart attack guidelines for the US have as the second recommendation “performance of a 12-lead ECG by EMS personnel at the site of first medical contact (FMC) is recommended in patients with symptoms consistent with STEMI.” Furthermore, just last month in JACC Intervention a study was published showing a greater than 50% reduction in mortality with pre-hospital activation of the cath lab during STEMI care.
Back to our patient. We gave him aspirin and I told the EMT to go to the nearest PCI center—although without an ECG there would be no pre-activation of the cath lab. I called the PCI center and identified myself as a cardiologist, I don’t practice at that institution, and explained the situation to the ED physician. Once the patient arrived at the PCI center he was diagnosed with a heart attack and underwent successful PCI.
Standing there with this patient and not being able to offer any more than aspirin, oxygen and rapid transfer to a PCI center was a very frustrating and helpless feeling for me. It strengthened my resolve to improve the process of heart attack care.
I am working with our state EMS board to allow all EMTs to perform ECGs. We have to improve access to state of the art heart attack care.
Acute heart attack care is surely a complex issue, but allowing EMTs to perform an ECG should not be controversial. It should be an easy step forward in treating our number one killer. Time is of the essence. Speed is life and death.
William C. Dillon is an interventional cardiologist and can be reached on Twitter @Wmdillon.
Image credit: Shutterstock.com
