An article in the October 4 issue of the Journal of the American College of Cardiologyexplores why patients arriving in the emergency room with heart attacks often experience dangerous delays in receiving appropriate treatment.
Heart attacks are caused by an acute blockage in one of the coronary arteries, usually due to the sudden clotting of blood at the site of a plaque within that artery. The key to surviving with minimal heart damage is to get that artery opened as rapidly as possible, ideally within 2 hours. One way of doing this is to administer intravenous "clot-busting" drugs. The other way is to perform emergency angioplasty in the cardiac catheterization laboratory. There is evidence that the angioplasty method may be more effective than using clot busting drugs, at least in centers whose catheterization labs are equipped to respond immediately. Whichever method is used, however, time is of the essence. Indeed, the recommended standard is to have the occluded artery opened within 90 minutes of arrival to the emergency room.
Unfortunately, many hospitals fail to achieve this 90-minute window. Instead, effective therapy is often delayed well beyond this time limit.
To study why therapy is delayed, Dr. Elizabeth Bradley from Yale University studied the procedures used by various hospitals in responding to acute heart attacks. She found 2 commonly-occurring problems in hospitals where therapy is often delayed.
First, in some locations paramedics are not equipped to perform ECGs prior to the patient's arrival in the hospital. When paramedics can transmit an ECG before the patient arrives, the wheels can be set in motion to treat the patient's acute heart attack as soon as the patient rolls through the door. On the other hand, when an ECG must await the often-glacial patient sign-in procedures in the emergency room, treatment is delayed.
Second, in many emergency rooms the ER physicians do not have the authority to mobilize the cardiac catheterization team. Instead, if a heart attack is diagnosed, mobilization of the catheterization team must await the OK of a cardiologist. What this means is that the angioplasty is delayed until a cardiologist gets his/her (self) down to the emergency room to re-evaluate the patient, a requirement that can add an hour or longer to the initiation of therapy.
Fixing both of these problems, Dr. Bradley points out, is a "simple" matter of changing policy, and does not require much money. It should be an easy fix.
DrRich comments:
Here is yet another example of how turf battles between various medical specialties can harm patients. In this particular case, one suspects, the cardiologists simply don't want to give emergency room docs the authority to manipulate the cath lab schedule. The authority to do this, even among the cardiologists themselves, is often a matter of seniority, prestige, and power. Cath lab scheduling, indeed, is a common battleground for power politics within cardiology departments; and the notion of a mere ER doc being allowed to interfere with this process is utterly laughable.
Most hospitals worked in this way at some point in the past. In the ones that have changed (and there are many,) physician leaders have consciously decided to devise procedures that place patient outcomes first, ahead of petty turf battles. Any hospital that has committed to the performance of emergency angioplasty for heart attack patients ought to have procedures in place that streamline, not inhibit, the initiation of this complex, team-oriented approach. If they cannot do this, they should just let the ER doc give clot-busting drugs.
Patients can't do much about hospital procedures on the spot; when you are having an acute heart attack you get what you get. But realize that not all hospitals respond equally well, and maybe you can differentiate the good from the bad before the time comes. If you are at high risk for a heart attack, you may want to discuss with your cardiologist which local hospitals respond the best to this emergency. You may even want to ask a few pointed questions about just how the cath lab team becomes activated to respond to a heart attack. Perhaps you can direct the paramedics to the most appropriate place if and when the time comes. (Read more - How to survive a heart attack: the first 24 hours.)
