Saving minutes. Saving lives; Started locally as an experiment, special paramedic training is now giving heart attack patients across the state a second chance.


 
 

Lindsay Tice | | Monday, June 9, 2008


LEWISTON, Maine -- Jim Trundy didn't think anything was wrong.

The Hebron fire chief felt tired while he drove to a mid- afternoon fire scene in Minot, but he worked three jobs and had just finished a 16-hour overnight shift as an ambulance worker. Fatigue was nothing new or frightening to him, even if this fatigue seemed somehow greater.

Trundy decided to leave the heavy lifting to other firefighters. He set about directing fire trucks instead.

"There were a couple of guys from Hebron that were there with me and I was talking to them. I turned around and all of the sudden I felt really lightheaded," Trundy said. "I reached out to grab somebody and I collapsed."

He woke minutes later on the ground. Paramedics - on scene for the fire - wouldn't let him get up.

"They said 'We're going to put you in the ambulance. We've got a helicopter coming,'" Trundy recalled. "I said, 'I don't need no f- ing helicopter.' My language was pretty salty. I was pretty angry. I was like, 'I don't have time for this. I've got too much to do.' It was crazy."

Trundy's heart had stopped twice. In an unusual step at the time, paramedics ran a EKG, confirming what they already suspected: a heart attack.

LifeFlight whisked Trundy to Central Maine Medical Center in Lewiston. Armed with the EKG reading, paramedics in the ambulance then did something few Maine paramedics had the power to do: They called ahead and told the hospital to open up its cath lab.

Minutes after he was rushed through the hospital doors, doctors opened, unclogged and secured Trundy's artery with a stent.

That was in 2006. Two years later, the 54-year-old husband, father and grandfather is back working three jobs. Because of the quick response, there was little to no damage to his heart, despite the fact that his type of blockage has a mortality rate so high that medicine dubs it "The Widowmaker."

Trundy was lucky paramedics were close by - few people collapse with an ambulance already on scene. But he was lucky in another way, too.

His paramedics were among the few in Maine trained to read the EKG. They were among the few authorized to order CMMC's cath lab to open.

It was a time-saving experiment that helped save Trundy's life.

And now it's becoming standard in Maine.

'Minutes are muscle'

In simple terms, a heart attack often unfolds this way: A person has symptoms (see list) and either drives to the emergency room or calls 911 for an ambulance. At the hospital, emergency room doctors run tests, confirm a heart attack and, if it's a hospital with a cath lab, call in specialists to perform an angioplasty. In the cath lab, doctors insert a balloon to open the artery and place a stent in to keep it open.

If a hospital doesn't have the ability to do an emergency angioplasty, doctors will typically give patients clot-busting drugs or transfer them to a hospital with a cath lab. St. Mary's Regional Medical Center in Lewiston, for example, transfers heart attack patients to CMMC.

National experts and advocates, including the American Heart Association, say door-to-balloon time - the time it takes a patient to go from the hospital's front doors to an angioplasty - should be 90 minutes or less. Because blood flow is so restricted during a heart attack, minutes can make the difference between a full recovery and a damaged heart.

In an effort to make or break that 90-minute benchmark, some American hospitals began experimenting with paramedic-given EKGs several years ago. The idea was to get that critical test done in the field, so the hospital could be ready to jump into action if a heart attack were detected.

Kevin Kendall was medical director for United Ambulance in Lewiston when he noticed the trend in 2004.

"The literature was basically saying that paramedics could do just as good of a job as ER physicians or cardiologists in terms of interpreting EKGs. The literature in the big cities all supported that," said Kendall, who now serves as medical director for EmergencyMedical Services at CMMC. "So I thought, 'Do you think they could do just as good a job in Maine?'"

A 15-month pilot program with United Ambulance workers suggested the answer was yes. Between March 2004 and June 2005, trained paramedics correctly identified all patients who were having a heart attack. In addition, they had a 6 percent false-positive rate, meaning the paramedics also identified six out of 100 people as having a heart attack when they really weren't.

The results were good enough to impress CMMC. On July 1, 2005, the hospital became one of the first in the state to give EKG- trained paramedics the power to open a cath lab with a phone call. (York Hospital started its own program around the same time. It's unclear which hospital was first.)

"You work in a field like this, you see little things that happen and every so often there's something that's kind of big," said Liz Delano, education coordinator for United Ambulance. "We can actually say we made a difference. Sometimes you really can't tell if you've made a difference or not, but with this one we can say we do."

After a short time, the false-positive rate fell and the program slashed door-to-balloon time: The average time for patients transferred to CMMC from other hospitals was 108 minutes (the clock starts at the original hospital); the average for a walk-in patient, 77 minutes; the average for a patient transported to the hospital by EKG-trained paramedics, 44 minutes.

A 2007 study from the American College of Cardiology's National Cardiovascular Data Registry showed CMMC's overall door-to-balloon times were 60 minutes better than the average hospital.

Soon, 11 other ambulance services (spanning from Durham to Rangeley) had trained their paramedics to read EKGs and call ahead to open CMMC's cath lab. It became the standard.

And it came just in time for Trundy.

"I think it's probably the best thing going and critically important," he said. "I mean minutes are muscle."Standard of care

CMMC's experiment came at a good time for Mainers, as well.

Various organizations, including Maine EmergencyMedical Services, a bureau within the Maine Department of Safety, were starting to look at cardiac care in Maine. Door-to-balloon times became one focus, a tangible way to gauge good, better and best treatment. At conferences, hospital officials began to talk, among them officials from CMMC, Eastern Maine Medical Center and Maine Medical Center - the other three facilities that perform emergency angioplasties in the state, along with York Hospital.

"Fast forward a couple of years later and the hospitals have the same transfer protocols. Twelve-lead EKG training is becoming a regular part of all paramedic training," said Jay Bradshaw, Maine EmergencyMedical Services director.

EMMC in Bangor started allowing EKG-trained paramedics to open its cath lab a little over a year ago.

The hospital's overall door-to-balloon time averages 72 minutes. For patients transported by trained paramedics it's 45 minutes, with four cases handled in 35 minutes or less.

"When you can open an artery in 35 minutes, everything is just clicking," said Cathy Mingo, quality project coordinator for EMMC.

Maine Medical Center in Portland started training Portland and South Portland paramedics in 12-led EKG interpretation last fall. The hospital has allowed emergency workers to open its cath lab since January.

Maine Medical's program is so new that it doesn't have comparative numbers yet, but officials say the program has potential.

"We're getting our feet wet," said Bud Kellett, chief of the Department of Cardiac Services.

Maine Medical plans to expand the program beyond Portland and South Portland, helping to train paramedics from surrounding areas.

CMMC plans to expand, too. Two other ambulance services have approached CMMC about joining its program. And starting July 1, EKG- trained paramedics with heart attack patients can make the call to bypass Bridgton Hospital, a subsidiary of CMMC's Central Maine Health Care. They'll have the power not only to open CMMC's cath lab with a phone call, but also to activate LifeFlight. CMMC hopes to do the same with Rumford Hospital, also a subsidiary, by theof the year.

"Heart disease runs throughout my family. This is what I would want for my family to have if they should have a heart attack," Kendall said.

Experts say EKG training will likely become standard for paramedics throughout the country in the coming years.

It's already becoming the standard in Maine.

Starting July 1, the state will include performing and interpreting EKGs in its protocols for paramedics. Not all paramedics will have the power to activate a cath lab - most hospitals in Maine don't have emergency cath labs to activate. But trained paramedics can call ahead to the nearest hospital and alert doctors they'll be getting a heart attack patient, cutting the time it takes for the patient to get clot-busting drugs or transfer to hospital with a cath lab.

It's a change experts believe will save even more lives.Heart attack symptoms:

Chest discomfort that lasts more than a few minutes or goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain.

Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach.

Shortness of breath with or without chest discomfort.

Breaking out in a cold sweat, nausea or lightheadedness.

Note: Although the most common heart attack symptom is chest pain or discomfort, symptoms vary from person to person. Women are somewhat more likely than men to experience some of the other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain.

Source: American Heart AssociationWhat you should do:

Learn the signs of a heart attack

Call 911 if you think you're having a heart attack. (Even if you're not sure it's a heart attack)

Do not drive yourself to the hospital or ask someone else to do it. Paramedics can save time; minutes can make the difference between full recovery and a damaged heart. Paramedics can also handle the situation if your heart stops.

Source: American Heart Association




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