“On call” is a familiar phrase. For anyone who knows a doctor, nurse, caseworker or other hands on medical professional, being on call means immediate availability for patients and other health care providers. For cardiologists who are on STEMI call, it truly means the difference between life and death for the patient.
STEMI – ST-Elevation Myocardial Infarction – is a very serious type of heart attack, during which a major artery is blocked. ST-segment elevation can be detected on an EKG. The right tools and techniques, used swiftly can save a person’s life, even in the case of a most serious heart attack.
“Abundant data has been collected that demonstrates that immediately going to a cath lab when there is a STEMI event reduced mortality rates,” said Dr. Alvaro Gomez, a HeartWell cardiologist who is board certified in internal medicine, cardiovascular disease and interventional cardiology. “This provides the very best option for the patient to recover.”
Dr. Gomez is among a specialized group of physicians skilled in the science of interventional cardiology. He notes that in the past 10 years, mortality due to heart attack has been dramatically reduced due to the swift work of EMTs and physicians working with patients in the cath lab.
When he is on STEMI call, he is never very far from Baptist Hospital, where there is a state-of-the-art cath lab. He says there are numerous protocols utilized from the time a patient makes a 911 call to the time he or she arrives at the hospital. This process provides the best possible chance of the patient recovering.
“Once we get to the hospital, see the patient and review the EKG, and determine that the attack is a STEMI event, we open up the vessels and work promptly to reduce the blockage,” said Dr. Gomez.
“Timing is critical,” adds Dr. Bernardo Lopez-Sanabria, who is also on STEMI call at Baptist. “There’s a saying ‘Time is muscle’ and that is so true when it comes to a STEMI call.” He explains that the more quickly doctors react, the more cardiac muscle is saved.
Dr. Lopez notes that because there are certain criteria that must be met to classify an event as STEMI, occasionally a call is a false alarm, but when it is real, there is no time wasted.
“Everyone involved moves quickly and when things works as they should – and fortunately, they often do – a patient’s life is saved, and there is nothing more rewarding,” he says.
Doctors who are on STEMI call must sacrifice some of their personal freedom when they are on call, and remain close by. This is often a burden to the families and friends, because it demands a certain level of inflexibility.
“This is what we signed up for,” says Dr. Marcus St. John, who completed his interventional cardiology fellowship at Johns Hopkins Hospital. He says being on STEMI call is hard on the family, but echoes Dr. Lopez’s sentiment that it is extremely gratifying to know that you can save a life. “The reward far outweighs the burden.”
Dr. St. John says that the protocols have evolved in the recent past, and there is a more prudent discovery about the patient. “We used to be more aggressive, but haste may not be the best answer,” he says. “Although speed is always important, we have the tools to assess the patient rapidly and deal with each one individually to provide appropriate management and good decision making.”
“Door-to-balloon time” is a quality metric that doctors use to evaluate their efficiency in emergency cardiac care, especially in in the treatment of STEMI. This is determined from the moment the patient arrives at the door of a hospital to the time the time that the catheter guide guidewire crosses the lesion. The goal is for this time span to be 90 minutes or less, and in Miami-Dade, doctors strive for 60 minutes or less.
Thrombolytic therapy – what was commonly called “clot busters” – had been the rule of thumb for heart attacks, but it is now well established that prompt and expertly performed primary percutaneous coronary intervention is a better approach. In fact, ambulances may pass the nearest hospital to find the nearest hospital with a cath lab if the timing differential is not significant. The doctors agree that these blood thinners are still a valuable option but the best bet for patients is swift work in a cath lab.
The American College of Cardiology (ACC) launched a Door-to-Balloon (D2B) initiative ten years ago with the stated mission to “take the extraordinary performance of a few hospital and make it the ordinary performance of every hospital.” While it is not universal, hundreds of hospitals have joined the alliance, and making this another factor in the reduced mortality rate.