Most Utah Heart Attack Patients Skip the Ambulance

Hospitals review door-to-balloon time and symptom-to-balloon time


 
 

KRISTEN STEWART, The Salt Lake Tribune | | Tuesday, July 8, 2014


In his 69 years, Allan Wilson has made more than a few trips to the hospital.

The Postal Service retiree always drove himself, even in emergencies, rationalizing that it's quicker, more convenient and less expensive. But he wasn't given a choice last fall when his wife summoned an ambulance to a shop in Park City after he started talking nonsensically, his speech slurred -- and her fast thinking probably saved his life.

"I was having a stroke, which they were able to treat en route," said the Holladay resident. "And when I got to the hospital they were ready for me. They found a blocked artery in my left ventricle, the main one that feeds the heart, and whisked me into surgery."

Wilson is an anomaly.

Three of four Utahns having a heart attack arrive at an emergency room in private vehicles, according to data from MountainStar's urban hospitals. In rural areas the rate is probably higher.

It's a national problem, dubbed "the Achilles' heel" of efforts to combat heart disease in the United States, said Scott Hacking, a cardiovascular specialist at St. Mark's Hospital in Salt Lake City.

According to the Centers for Disease Control and Prevention, 720,000 Americans have a heart attack each year and about 30 percent die, largely because they didn't get help on time.

A national initiative shaved an average of 16 minutes off the time it takes to clear a blocked artery with a medical balloon once patients arrive at the hospital, according to a 2013 study in the New England Journal of Medicine. Ninety percent of heart patients are now treated within the recommended 90-minute time frame, and many are treated in 30 minutes or less.

But that same study found cardiac death rates remain unchanged -- even though patients with shorter door-to-balloon times were more likely to survive.

"Since 2005 door-to-balloon times have progressively improved, but it seems we have reached a nadir," Hacking said. "What's not changing is symptom-to-balloon time."

--

The need for speed - The door-to-balloon initiative exemplifies the limits of medicine.

It made the health system more efficient and effective, but there's a limit to what doctors and hospitals can do when so much of a person's health hinges on personal decisions.

With heart attacks, timing is everything. The longer the heart is deprived of oxygen, the more muscle is lost.

Patients fare best when they get to a hospital within the "golden hour" after symptoms start. But ,on average, it takes two to four hours for patients to arrive, said Michelle Pola, a chest pain center coordinator at St. Mark's.

Tips for surviving a heart attack aren't complicated: recognize the symptoms, dial 911 and chew an aspirin while waiting for an ambulance to arrive.

But many patients don't recognize the symptoms, or they downplay and deny them.

Others lose precious tissue-saving minutes behind the wheel of a car -- endangering themselves and others should they arrest and lose consciousness while driving.

"Even if you have a family member drive, what can that person do if you arrest?" said Pola. "Heart tissue doesn't regenerate. If you wait too long, you might survive, but you'll probably wind up with damage to the heart."

Women tend to take even longer than men to get to a hospital, and once they arrive it takes longer to diagnose and treat them, studies show.

This cuts against the common understanding of women as the decision-makers in family health care.

"Women's symptoms can be a little more vague," Hacking explained.

"They have more shortness of breath and fatigue than chest and jaw pain. Also when women come with those symptoms it takes longer to triage them for a possible heart attack and longer to get them into a [catheterization] lab."

--

Learning 'the hard way' - Encouraging ambulance rides doesn't solve the problem of ignored symptoms, but it can make a difference for patients who wait longer than they should to call 911.

"One benefit to an ambulance is most have EKG technology and can send an EKG [test result] to the hospital, triggering activation of the cath lab," Hacking said.

The tests, electrocardiograms, examine the electrical activity of the heart.

Alerting the lab is especially crucial at night when on-call teams need to be summoned to the hospital, he said. "Oftentimes we're able to wheel them right into the lab. We've achieved door-to-balloon times under 20 minutes for some of those patients."

Not wanting to waste doctors' time or to seem like a hypochondriac can factor into patients' decisions to shun emergency transport.

"But if you're going to err, of course err on the side of coming in by ambulance," said Hacking, whose father-in-law had a fatal heart attack in a grocery store after ignoring chest pains for two weeks.

"Interestingly, data show that those who become symptomatic at work are more likely to come in because they don't want to show vulnerability at work. At home they're able to rest and see if symptoms subside on their own."

The high cost of health care also plays a role.

"Several years ago my wife slipped on water in our backyard, broke her knee cap and kind of blacked out. I called my sister-in-law who lives next door and we put [my wife] in the car and drove her to the hospital," Wilson sheepishly admits. "I thought, 'Boy, they really charge a lot for an ambulance,' and figured it wasn't life-threatening. But it was stupid because we didn't immobilize her leg and could have caused additional damage."

The ambulance that responded to Wilson's stroke last fall took just three to five minutes to get to him, he said. He had been experiencing symptoms since that morning.

"I had this little rainbow flurry in my right eye," he said.

Wilson was told that the type of blockage near his heart probably would have killed him without swift care, he said. Today, following two surgeries, he is back to gardening and hitting the gym.

"Now I take the ambulance no matter what," he said. "I learned the hard way."

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