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A Sea Change in Treating Heart Attacks

nytimes.com

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Re: A Sea Change in Treating Heart Attacks

#21

Post by sliverstorm »

Cass wrote: post #2

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 (…

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.

Patient privacy laws really do put some perverse constraints on the system sometimes.

Re: A Sea Change in Treating Heart Attacks

#22

Post by Herodotus38 »

JshWright wrote: post #18
agumonkey wrote: post #3

Earlier quoted context omitted.

For the curious, differences between {N}STEMI http://imgur.com/HbREzfo

Hmm... ST depression often means there is ST elevation somehwere you can't see. ST depression is generally a 'reciprocal' change, and there will be elevation on the opposite side of the heart. A 'standard' EKG looks at the front, bottom, and left side of the heart. If the area of the heart affected by the heart attack is on the right or back side, then you won't see elevation, but you may see the reciprocal depressio…

I wouldn't say certainly, but sometimes. There are a lot of more common causes of ST depressions than STEMIs. For example, left ventricular hypertrophy with tachycardia.

Re: A Sea Change in Treating Heart Attacks

#24

Post by 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...

Re: A Sea Change in Treating Heart Attacks

#26

Post by JshWright »

Herodotus38 wrote: post #22
JshWright wrote: post #18

Earlier quoted context omitted.

Hmm... ST depression often means there is ST elevation somehwere you can't see. ST depression is generally a 'reciprocal' change, and there will be elevation on the opposite side of the heart. A 'standard' EKG looks at the front, bottom, and left side of the heart. If the area of the heart affected by the heart attack is on the right or back side, then you won't see elevation, but you may see the reciprocal depressio…

I wouldn't say certainly, but sometimes. There are a lot of more common causes of ST depressions than STEMIs. For example, left ventricular hypertrophy with tachycardia.

Fair point. I meant that if you see ST depression in an MI, then it's probably not _actually_ an NSTEMI, you just probably don't have the leads you need.

Re: A Sea Change in Treating Heart Attacks

#27

Post by mindcrime »

Animats wrote: post #23

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

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

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

Re: A Sea Change in Treating Heart Attacks

#28

Post by JshWright »

maxerickson wrote: post #19
JshWright wrote: post #17

Earlier quoted context omitted.

Why would you want to send it anywhere other than the hospital you're heading to?

It isn't clear to me that the destination is always strictly determined; in the article, the ER doctor or consulting cardiologist would sometimes divert the ambulance. So the simplest implementation has the copy being easily available at the 'reasonably local' hospitals, rather than having someone push a button to send it to the diversion destination. edit: I see in your other comment that you are talking about scrol…

It adds, _maybe_ three seconds to the process of transmitting an EKG. The interface is pretty well designed. It makes more sense for me to be the person making that decision as I am the person with the most complete clinical picture at the time that decision is made.

If I'm sending an EKG, I'm also going to be picking up the phone shortly to talk things over with the doc at that ER. There would never be a situation where I don't already know where I'm going before transmitting an EKG.

Re: A Sea Change in Treating Heart Attacks

#29

Post by 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.

Re: A Sea Change in Treating Heart Attacks

#30

Post by mindcrime »

JshWright wrote: post #24

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 'prescript…

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.

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