When patients are having a heart attack, the old thinking went, paramedics should get them to the nearest hospital as soon as possible. The latest thinking is that it's better to drive them farther to a hospital with the ability to unclog a blocked artery.
Now, paramedics and doctors in the Lakes Region are developing a program to help identify patients who need the surgery so ambulance drivers will know to drive right past Lakes Region General Hospital, which can't do the procedure, to Concord Hospital, which can. "To do this procedure, you need to get the patient down there," said Deputy Fire Chief Shawn Riley, who runs Laconia's ambulance service.
Clinicians who treat cardiac emergencies say the policy change could save lives and improve the health of heart attack survivors. But to make the program work, EMS providers need to invest in pricey new equipment and learn a new protocol. Though planning has been under way for months, the program won't roll out in full until February.
Cardiologists are fond of saying "time is muscle." When a coronary artery is blocked, heart muscle dies. So those who treat patients suffering the most serious kind of heart attacks are always looking for ways to speed up the process, in order to restore blood flow to patients' hearts as quickly as possible. Riley compares a coronary blockage to a clogged pipe, and the options as similar to a plumber's choices - Drano or a Roto-Rooter. Medicines can break up the clot but can sometimes be harmful. The Roto-Rooter - known as a cardiac catheterization - pushes the blockage out of the way and reopens the blood vessel.
Across the country, doctors have been working to squeeze as much time out of the process as possible. By changing emergency room procedures and choreographing the catheterization process, most have been able to shave what they call "door to balloon" times well below a 90-minute goal. Now, they've turned their attention to the time before the patient gets to the hospital.
Currently, Lakes Region EMTs bring patients to the Lakes Region General Hospital for a medical evaluation. If an emergency department doctor thinks the patient needs catheterization, they get back on the ambulance for a trip to Concord. The new program is designed to skip that step. "Those decisions can greatly impact the patient, because the minute you involve another system, there's just a built-in delay," said Dr. Mark Klinker, an interventional cardiologist and the medical director of Concord Hospital's cardiac catheterization lab.
But not every patient with heart attack symptoms will benefit from catheterization, and some will be helped by getting to the closest hospital. Doctors and EMTs are working together to eliminate the guesswork. Ambulances in the area have long been outfitted with 12-lead EKG machines that can diagnose different types of heart arrhythmias.
Towns have begun hooking those machines up to modems that can beam the reading right to the emergency room. In the Lakes Region, a local emergency room doctor will be able to review the readout and tell the ambulance where to go. At Concord Hospital, the EKG can tell the catheterization lab to get ready for a patient before he even reaches the hospital. In Concord, ambulances have had the devices since March. Though paramedics here nearly always go to Concord Hospital, the ability to warn cardiologists has meant that a team can be ready for surgery as soon as the patient arrives.
Fire Chief Dan Andrus said paramedics learned the value of the upgrade right away. "Within an hour of the time the device was installed, we had our first patient," Andrus said. "Because of the decrease in time to activate the cath lab, they were having a significant and possibly life-threatening heart attack that was quickly resolved." Most local communities got the modems for free through a grant. Towns and cities farther north are weighing their options. Riley said Laconia is not sure whether it will replace its EKG machines with new ones that can send the results, or buy add-ons for their current machines.
In Gilmanton, fire Chief K.G. Lockwood said his staff is investigating the cost of various options. He said he'll have to have the purchases approved at next year's town meeting. The new machines cost about $24,000 each. The modems run about $5,000. In the meantime, Gilmanton has decided to send every patient with heart attack symptoms directly to Concord. Lockwood said the drive time is similar to either hospital, so it seemed wise to opt for Concord when there was any doubt. "We've had three that have been correctly identified," he said. "It definitely made a difference."
The American Heart Association supports the effort. After seeing similar systems improve outcomes in other communities, it's pushing for them across the country. But the transition will not be instant. Communities will need to find money for the expensive new EKG modems, and they'll need to train their staff to use them. The challenges are not just financial. Klinker said the longer drive can cause problems for smaller services. "A small community can't always afford to allow their ambulance to keep driving south when there's no coverage for the next person who might have an emergency," he said. "We have to figure out networks of support."