
A Sea Change in Treating Heart Attacks - dankohn1
http://www.nytimes.com/2015/06/21/health/saving-heart-attack-victims-stat.html
======
Cass
A month ago, a friend who'd worked as a doctor in South Africa for decades was
interning with me to learn about the procedures in our German ER. I remember
the first time a patient with a heart attack came in while she was there, and
the speed of the proceedings just blew. her. mind.

What happens, if things go well, is this:

The EMTs transmit a picture of the electrocardiogram to us[1]. We confirm that
it's a STEMI (the kind of heart attack where speed matters the most, as
opposed to an NSTEMI, which isn't quite as urgent), and alert the catheter lab
and the attending cardiologist. Half the ER personnel drops everything else to
prepare for the patient's arrival.

The patient arrives. We transfer them to our gurney. One nurse gets the
patient's clothes off (with scissors if necessary) while another nurse
attaches electrocardiogram electrodes and a third shaves the puncture site for
the catheter.

The ER physician puts in an iv line and draws blood while informing the
patient of the treatment plan. The cardiologist takes a very quick history of
the patient and confirms the STEMI with the second electrocardiogramm. We
wheel the patient up to the catheter lab and get started.

Altogether, if everything goes well, it's something like five to twelve
minutes from the moment the patient comes through our doors to the moment
we've got the patient on the operating table.

[1]By taking a picture of it on their phone and transmitting it via Whatsapp,
which is just about the ugliest, hackiest and probably borderline-legal way of
transmitting patient data imaginable, but it gets the job done.

~~~
stephengillie
> _By taking a picture of it on their phone and transmitting it via Whatsapp,
> which is just about the ugliest, hackiest and probably borderline-legal way
> of transmitting patient data imaginable, but it gets the job done._

Congrats on the massive process improvement on using readily-available
technology. I'm no lawyer but I'm pretty certain that this violates HIPAA,
which means it's a new market just screaming for PII-managing image-transfer
networks and startups.

~~~
tgokh
The technology exists -- see [http://www.physio-
control.com/ProductDetails.aspx?id=2147484...](http://www.physio-
control.com/ProductDetails.aspx?id=2147484983) and
[http://www.zoll.com/medical-products/data-
management/rescuen...](http://www.zoll.com/medical-products/data-
management/rescuenet-12-lead/) from PhysioControl and Zoll, two of the biggest
EMS EKG monitor manufacturers, but its certainly not easy to use. In my
system, we used to have to upload the EKG to the computer and then "e-fax" it
from he computer to the Emergency Department -- practically, this took 3-4
minutes to do, and when you're in an urban area and nearly always < 10 minutes
from the hospital, its not the most productive use of time. Most of the time,
if was easier to do the EKG, and in case of a STEMI, call the "code STEMI" via
radio, print the EKG and spend the rest of the time doing important patient
care (IV access, aspirin, etc)

That said, we were in a Paramedic system with a relatively short to-hospital
drive time, and going to an academic medical center that had 24/7 in-house
interventional cardiologists. If you're in a aystem with only EMT-Basics (who
are trained to perform the EKG but cannot interpret the printout), or going to
a hospital where the interventional cardiologists need to come in from home,
or if your primary hospital doesn't even have a cath lab and will need to
divert you to another bigger hospital, it makes a lot of sense to be able to
send the EKG from the field and get the ball rolling early.

~~~
stephengillie
> _In my system, we used to have to upload the EKG to the computer and then
> "e-fax" it from he computer to the Emergency Department -- practically, this
> took 3-4 minutes to do, and when you're in an urban area and nearly always <
> 10 minutes from the hospital, its not the most productive use of time._

Those steps could be automated. And since this would usually be life-
threatened situations, they should be automated. I wonder how much HIPAA rules
complicate the technology; they certainly don't make the space attractive or
fun to work in. This sounds like a great disruption for a startup to make, if
they can deal with HIPAA effectively.

I interviewed for Physio, but turned down their offer due to mandatory drug
testing. They seemed to be really, really locked down due to regulations, and
I suppose I do want the regulations on defibrillators to be fairly strict.

~~~
GoodOldNe
_Those steps could be automated. And since this would usually be life-
threatened situations, they should be automated. I wonder how much HIPPA rules
complicate the technology; they certainly don 't make the space attractive or
fun to work in. This sounds like a great disruption for a startup to make, if
they can deal with HIPPA effectively._

There are several companies (including a couple YC alums like Aptible) working
in the helping-developers-deal-with-HIPPA space already. Creating a compliant
application for transmitting ECGs wouldn't really be a new thing-- when
attending an emergency medicine conference two years ago I met a
physician/programmer who had done just this for both stroke and heart attack,
designed and marketed as a wraparound subscription-based solution. The trick
is doing it well, and if you could integrate the information with the
receiving hospital's workflows (e.g. EPIC integration or something) you could
sell it easier. Pictures of ECGs are also a fairly inelegant solution compared
to sending it to the ECG printers that a receiving hospital has, or sending
the actual waveform data, but for rural/underfunded EMS agencies it would be
nice.

(FWIW, I work in a Bay Area emergency department that is a STEMI receiving
center but does not receive field-transmitted ECGs prior to arrival. There's
room to work on this stuff. If anyone wants to do research relating to it or
build a system and then let me do research with it, get in touch.)

------
JshWright

      They included ambulance drivers’ transmitting electrocardiogram
      readings to emergency rooms, E.R. doctors’ deciding whether a
      person was likely having a heart attack, and hospital operators’
      summoning treatment teams with a single call. These hospitals
      also continually measured performance.
    

I know it's a really minor thing, but the term 'ambulance driver' is a little
irksome... It's like calling a doctor a 'prescription writer'.

In the case of a heart attack patient, a paramedic recognizes the possible
indications, takes an interprets an EKG, considers the possible differential
diagnosis, makes the appropriate hospital notifications, and provides advanced
level care to speed things along at the hospital (obtaining IV access,
administering various medications, etc). We do a bit more than just drive the
ambulance...

~~~
mindcrime
To be fair to the author, not every ambulance crew is paramedic level. And the
term "ambulance attendant" was, at one time, in widespread use - to the point
that the first level of EMS certification was actually called "Ambulance
Attendant", if memory serves correctly.

I know it's annoying when non-domain-specialists misuse terminology, even
slightly, but I could see giving them a pass on this one.

~~~
JshWright
Yeah, hence my being 'irked' not 'really offended'.

I suspect most folks here consider themselves more than just "typists".

~~~
toufka
Though to be fair, I have a pretty high level of respect for 'Ambulance
Drivers,' as conveyed by the inarticulate, if descriptive term. It's kinda
like saying a 'Aircraft Carrier Steerer', or 'Space Shuttle Driver'. It might
not be the actual term of art, but I do know that person is pretty badass.

------
mindcrime
Yeah, this jibes with my experience. I was rushed to UNC Hospital in Chapel
Hill last Nov. with a STEMI, and I was amazed at how fast things progressed.
Granted, time seems to compress in highly stressful situations, and I wasn't
exactly timing with a stopwatch, but subjectively, I feel like I was in the ER
maybe 15-20 minutes top, before they had me on my way to the cath lab. And the
catheterization procedure took somewhere around an hour (maybe more, maybe
less, hard to recall exactly). I never asked for the exact time until they had
the catheter in my artery, but I'm pretty sure it was well less than 90
minutes.

At any rate, it was enough that I survived and the amount of heart damage I
suffered was minimal enough that I was able to resume a completely normal life
afterwards. By 3 months after the MI, I was biking 20+ miles at a time, and by
4 months had worked up to 75 miles a week, and then I raced in a 6 hour MTB
endurance race about 5 months afterwards.

So yeah, speed is definitely of the essence. Luckily for me, and I am
fortunate enough to live near a good hospital, in a community with top notch
911 and EMS providers.

~~~
eplanit
I'm grateful to be in the same club. My Myocardial Infarction was in 2005:
blockages in coronary arteries of 100%, 98%, 95%, and 80%. From the time I
arrived at the E/R to the time the acted on me in the Catheterization lab was
< 15 minutes. One hour and three stents later I was in recovery. My
cardiologist explained that people with my symptoms, had they come to the E/R
3 years earlier, usually would die. I try to never forget to be grateful to
all those who acted so quickly.

------
noir_lord
Few weeks ago I woke up with massive chest pain, struggling to breathe and
pouring with sweat, rang ambulance and went to open door by time I'd limped to
unlock it one of the fast response cars not ambulance was at my home total
time was <5 mins and they had 12 leads on me.

Turned out to be an awful gallstone attack blnot heart attack but damn was I
impressed with speed of response for early hours of Sunday morning -
traditionally their busiest time.

Still ended up in hospital as they recommended that since I was projectile
vomiting I should get checked out.

------
BJBBB
Perhaps too cynical after seeing medicos botch treatment for two family
members. The main reason is the bottom line. If the allow people of marginal
health to die too early, then their maximum utility diminishes unless the
victim/patient can be kept alive for another 5 to 10 years.

This is a similar monetary basis for the cancer model - to extend the
treatment period. Prolonging life has little to do with quality and meaning of
life. The medical community is fundamentally corrupt.

------
shirro
Reading articles like this you suddenly realise that living in a sparsely
populated rural area you sacrifice a hell of a lot in health care as as well
as the more obvious career, education and entertainment benefits.

Having some risk factors like age and weight and living hundreds of km from a
cardiologist is a bit of a worry. Are there cheap, effective ways of screening
people with no history of heart problems so perhaps they could be more closely
monitored or something?

~~~
fragmede
Probably the biggest two that we have are mentioned in the article. Blood
pressure and cholesterol. Hopefully you are getting your yearly checkups
including blood work done.

------
Animats
But who calls an ambulance? Now that's an opportunity for a wearable device.

~~~
mindcrime
After I had my heart-attack last year[1], I was asked to participate in a
clinical trial of a device called a "Life Vest". I did so briefly, although I
ditched it pretty quickly because it was too uncomfortable to sleep in. But
this thing was basically a wearable EKG/defibrillator. It monitored your heart
rhythm and, if you went into a bad rhythm, would actually give you a shock
from the defibrillator. Handy if you were asleep or had already fallen
unconscious and couldn't call for help.

Of course it gave you a warning buzz first and had a "cancel" button so you
could avoid being shocked if you were actually still OK. And it wouldn't shock
you, AFAIK, unless you were in a "shockable rhythm"[2].

Anyway, it's still a bit big, bulky and uncomfortable and I doubt you'll see
millions of people wearing something like this anytime soon, but as things get
lighter and cheaper and better, it might just become mainstream.

[1]:
[https://news.ycombinator.com/item?id=8550315](https://news.ycombinator.com/item?id=8550315)

[2]: [https://suite.io/elizabeth-batt/4z1520d](https://suite.io/elizabeth-
batt/4z1520d)

~~~
JshWright
Other than being slightly less invasive, this seems significantly inferior to
an AICD [1]

[1]: [https://en.wikipedia.org/wiki/Implantable_cardioverter-
defib...](https://en.wikipedia.org/wiki/Implantable_cardioverter-
defibrillator)

~~~
mrestko
They are usually used as bridge devices until a patient can be scheduled for
an AICD placement. Not all patients that need a permanent defibrillator are
immediately fit for surgery and having a device like the Life Vest allows for
them to be safely discharged from the hospital until it's time for surgery.

------
sebouh00
It's like an F1 pit stop.

~~~
kzhahou
If only.

[http://img.pandawhale.com/post-41481-ferrari-f1-pit-stop-
per...](http://img.pandawhale.com/post-41481-ferrari-f1-pit-stop-perfection-
bzNw.gif)

But you know, maybe someday it _will_ be like this. You suspect heart attack,
ambulance pulls up, does procedure on the spot, and you're back in business in
60 minutes. If they detect major tissue damage, then a quick stem cell
injection plus you have to call in sick for a week.

All of today's medicine would have been impossible to believe even a century
ago.

------
ajmurmann
Nice, this makes it even more likely I will die a slow death from cancer
instead.

