In the event of a heart attack, even the smallest increment of time can drastically–often tragically–change a patient’s prognosis. One common and severe type of heart attack, known as an ST segment elevation myocardial infarction (STEMI), requires rapid intervention for the victim to have the best chance of survival. In a STEMI, the coronary artery is completely occluded by a blood clot. The clogged artery can no longer supply blood and oxygen to the heart muscle, and virtually all the heart muscle reliant on the affected artery starts to die. Northern California Medical Associates (NCMA) Cardiologist Patrick S. Coleman, MD, FACC, understands the vital importance of providing precise, unerring care under the pressure of time. Over the last ten years, he has personally helped build the Coastal Valley STEMI Program, a two-countywide effort to expedite the treatment protocol of STEMI heart attack victims for hospitals and emergency medical service (EMS) teams throughout Sonoma and Mendocino Counties. Dr. Coleman continues to direct the STEMI Program today.
The acceptable “door-to-device” time for a STEMI patient is 90 minutes, meaning that the doctors and nurses have 90 minutes to open the patient’s clogged artery to achieve the best outcomes. The clock starts ticking the moment the patient arrives at the hospital, and doesn’t stop until the lifesaving catheterization device is implanted into the heart to open the clogged artery. In light of new information regarding STEMI care, and of the variability of STEMI care in the area, Dr. Coleman and colleagues, including fellow NCMA Cardiologist, Dr. Thomas E. Dunlap, joined with EMS to start the Coastal Valley STEMI Program. Today, STEMI care in Sonoma County is as good as anywhere in the country, with credit due to Dr. Coleman’s two-countywide STEMI Program.
Dr. Coleman asserts, “In the late 1990’s and early 2000’s cardiologists began treating heart attack patients with emergent intervention as opposed to just giving the patient drugs that would open up the clogged artery. This new treatment strategy yields remarkable benefits for patient prognoses. The heart continues to suffer damage as long as the arterial occlusion remains. Catheterization and surgical procedures free up blockage much faster and more reliably than drug treatments.”
“The urgency of any heart attack situation requires that all caregivers involved–the paramedics, firemen, ER triage nurses, ER physicians, and cardiologists–perform precise tasks with efficient command and expertise,” he continues. “It is our job as cardiologists to educate everyone involved about their essential roles in saving heart attack patients’ lives. We know what needs to happen for STEMI patients to have a good chance of survival, and the process happens to be complicated. Only through unified countywide planning and optimal utilization of local emergency cardiac facilities can we give patients their best odds.”
When a patient with heart attack symptoms calls 911, EMS (an ambulance or fire truck) arrives on scene and an electrocardiogram (EKG) is performed to look for ST elevation, the primary indicator for detecting a heart attack. It is imperative to get the EKG results as soon as possible. The paramedics, therefore, perform the EKG test and interpret the results immediately after arriving on the scene.
“The paramedics are trained to provide a preliminary interpretation of the EKG test results and they communicate that with the hospital,” says Dr. Coleman. “In fact, that’s one step of the process that we are still working to fine-tune. While all ambulances are equipped to perform EKGs, rapidly changing transmission technology makes it extremely difficult to establish a lasting, reliable way to organize transmission between EMS and hospitals. There simply isn’t funding to keep pace. Ideally, the EMS would be able to transmit the EKG results to the STEMI receiving center, where an ER physician or cardiologist could confirm the STEMI from a distance. Having a confirmed diagnosis before the patient even arrives gives the STEMI receiving center a head start in their preparations. Once confirmed, the STEMI patient goes to the catheterization lab for immediate intervention.”
It is vital that a STEMI patient goes directly to a medical facility that has a cath lab for his or her treatment. In Sonoma County, Sutter Medical Center and Santa Rosa Memorial are the only hospitals with cath labs equipped to provide STEMI treatment. Both hospitals have been designated STEMI receiving centers by EMS. If a patient has chest pain and the paramedics make the diagnosis of STEMI, then EMS automatically takes the patient to the nearest STEMI receiving center. This quick response strategy ensures that the right patient gets to the right facility at the right time. If a patient arrives at one of the other Sonoma County Hospitals such as Palm Drive Hospital, Healdsburg District Hospital, Petaluma Valley Hospital, Kaiser, or Sonoma Valley, the physician at that facility makes the diagnosis from the EKG and then notifies the nearest STEMI receiving center. The STEMI receiving center prepares for the arriving patient while he or she is in transfer, so that the lifesaving device can be implanted upon arrival.
Drs. Coleman and Dunlap at NCMA Cardiology have arranged for biannual regional meetings, called “STEMI Summits,” that have proven extremely effective in the development of a model for coordinating STEMI treatment. Ambulatory services, fire departments, ER physicians, and cardiologists from Sonoma and Mendocino counties are invited to discuss effective STEMI response protocols already in place, as well as areas that could be improved upon.
“In order to really fine-tune the overall response protocol, we must first have a comprehensive, detailed understanding of everyone’s responsibility. The STEMI Summit meetings have been really eye-opening,” Dr. Coleman explains. “When you get everyone that’s involved in STEMI response in the same room, conversations about the response process become increasingly detailed. Through collaboration, we’ve found that EMS and hospitals in other areas have already made their own efforts to expedite STEMI response. We’re able to share ideas and combine strategies.”
Dr. Coleman adds, “The STEMI program has been so successful that it’s not uncommon for STEMI patients that get picked up by EMS in Petaluma or Healdsburg to have their lifesaving device implanted within the next 90 minutes.The STEMI Program has instilled a pervasive sense of urgency in people involved in all parts of heart attack response protocol, and our efforts are paying off. For as far as we’ve come, there’s still plenty of work to do to increase STEMI response efficiency even further, and it will require the continuity of cooperation and collaboration between cardiologists, EMS, physicians, and hospitals.”
Since 1975, NCMA Cardiology has offered comprehensive, innovative, and cost-effective health care to its patients. Dr. Coleman’s specialties include cardiovascular and peripheral vascular diseases, endovascular medicine, interventional and nuclear cardiology, and he has been in practice for over 20 years.
Heart attacks remain the leading cause of death in the United States. People involved in the STEMI Program are currently working to resolve the issue of transmitting EKG results from EMS to hospitals, and to educate the public on signs that lead to early recognition of heart attack. Thanks to Dr. Coleman’s STEMI Program, Sonoma and Mendocino Counties are much safer places.