Posted on 08 January 2014.
If you have a heart attack, it won’t be a fast ambulance, a big hospital or high-tech gadgets that save your life.
It will be people.
But if you live in Wise County, you can be sure those people will have fast ambulances, a big hospital and some really high-tech gadgets – including a new application for their smartphones.
ON THE CLOCK – Wise County EMS Paramedics show the iPad with the Stop STEMI app opened on the screen. The application notifies the team and speeds the process of getting a heart attack victim into the cath lab for a lifesaving medical procedure. Messenger photo by Joe Duty
On New Year’s Day at 4 a.m., Wise Regional Health System’s heart-attack response team for the first time used this new “app” that helps speed up response times when someone has a STEMI – a heart attack caused by a prolonged blockage of blood supply to the heart muscle.
Heart attacks – myocardial infarctions, or MI’s – are always emergencies, but most can be treated with medication. But a STEMI, which creates a distinctive signature on an electrocardiogram (EKG), requires more drastic action. Those patients go to the cath lab, where a cardiologist inserts a “wire” up through the femoral artery into the clogged vessel, then unclogs it with a balloon – angioplasty – or a stent that props the vessel open.
Until that’s done, the heart muscle continues to suffer damage.
Lee Ann Cummings, registered nurse and director of the ER at Wise Regional, explained that on an EKG, a STEMI looks like a tombstone (see graphic at right).
“That means the heart is starving for oxygen, and you are infarcting,” she said. “Anytime there’s a STEMI and we’re watching it, that is emergent. That is actual damage being done to the heart muscle, and we want that to come down.”
The Stop STEMI app, developed by CommuniCare Technology, based in Longview, is designed to streamline communication among caregivers and reduce the time between the first medical contact with the patient and the restoration of normal blood flow to the heart. The program shares critical patient information among paramedics, the emergency department, the cath lab team, cardiologists and the cardiac care unit.
Cummings said the new app is simple and visual.
“EMS responds on the scene, they do an EKG, they take a picture of the EKG, put in the patient’s first name, last name, age and gender and boom! They send it to us,” she said. “The ER charge nurse logs in with her iPad with the STEMI app, and then a siren goes off. They look at it and acknowledge it. If Wise County EMS is telling us it’s a STEMI, we’re going with it.”
One of its key features is a clock that shows everyone involved exactly how long they’ve been working on the patient.
The national standard is to have a cardiac intervention done within 90 minutes. That clock used to start when the patient entered the hospital, but now it starts at the first medical contact.
On New Year’s Day, the Wise Regional team did it in 82 minutes.
“That’s good considering it was 4 o’clock in the morning on a holiday,” Cummings said.
ER Manager Kellye Souther, RN, said Wise Regional is only the second hospital to use the Stop STEMI app, which just came out last fall.
It was a connection with one of the company’s top people that brought the app here.
“BLOWN AWAY” BY THE PRODUCT
Shane Elmore, RN, is the director of business development for CommuniCare.
“I worked in the ICU, the ER and flew out of Wise Regional with Air Evac for about a year-and-a-half,” he said. He left in September 2011 and went to work at Trinity Mother Frances Hospital in Tyler, focusing on STEMI cases. Last September Dr. James Woodson, M.D., who heads up CommuniCare, came and presented the app there.
“I was blown away by this product,” Elmore said. “We started using it, and I immediately thought Wise Regional was the perfect place because of the ER staff, you have Advanced Heart Care with the cardiologists and the ongoing relationship with Wise County EMS.”
Woodson, a board-certified ER physician, and Elmore are now both full-time with CommuniCare, which is releasing the Stop STEMI app nationwide.
“The traditional way, all this information is going to go through two or three gatekeepers,” Elmore said. “With this, they all get it at the same time. Everyone sees that clock, and everyone knows where they are in the process.
“It unites the team.”
When someone calls 911, an ambulance is dispatched. Depending on where they are in Wise County’s 923 square miles, it can be 20 minutes or so before paramedics arrive.
When they determine the patient is having a heart attack, paramedics follow protocols that include administering certain medications and doing an EKG. They take a picture of the printout with their phone and send it to the ER along with the patient’s name, age and gender.
If it’s a STEMI, a lot of people start scrambling.
Cummings said this is where the Stop STEMI app eliminates a lot of little time-wasters.
“In the past, cath lab calls down, ‘Do you know the name? Do you know the age? Do you know how far out they are?’” she said. “With this app, everybody sees that information, including the EKG. It uses GPS and tells us an estimated time of arrival.”
Eliminating all that calling and checking saves valuable time – and lives.
TEAMWORK IS THE KEY
Cummings and Souther have high praise for Wise County EMS and the way they and hospital personnel work together.
“The EMS here is so amazing,” Cummings said. “That’s what’s so different about our program.”
WCEMS follows the same protocols as Wise Regional ER – they even use the same IV pumps and lines, so those don’t have to be changed once the patient arrives. They also train together, and several EMS personnel work in the hospital when they’re not on the ambulance.
The end result, for patients, is a team that’s all on the same page.
“A lot of places, no one can agree,” she said. “You have different EMS systems and whatnot, and they’re like, ‘Yeah, we’ll give an aspirin and we’ll do this, but we’re not going to give all those meds.’ There’s all these little things that increase your times.”
Souther said that doesn’t happen here.
“Some people have to take it to the ER doctor and say, ‘Do you think the medics are right?’ but with us it’s like, if they say it’s a STEMI, it’s a STEMI,” she said.
“That’s why a lot of other places, their times are not as good because the ER docs are just not as cooperative,” Cummings said.
“The medics are wrong in other places, but our guys aren’t,” Souther added.
Charles Dillard, WCEMS director, said his service’s relationship with Wise Regional is “excellent.”
“When the paramedics say, ‘Hey, here’s what I’ve got,’ just off his word they’ve been able to go ahead and activate the STEMI team,” he said. “That’s not seen in a lot of other places. There’s a lot of trust that goes into that.”
EMS crews bring patients all the way into the cath lab, help get them set up and often observe the procedure – and come back the next day to check on the patients in the CCU.
Most of the new ER nurses do ride-alongs with the ambulances, too – “to see their world a little bit,” Souther said.
“They come to our meetings, we discuss cases with them and find ways to improve – and it’s usually not on their end,” Cummings said. “They really, really do a great job.”
Dillard said his people work hard to relay accurate information.
“We try to make sure the people on the ambulance are able to look at the monitor, read the monitor and determine that this is or is not a STEMI,” he said. “We don’t want to call up here 100 times and five of them are STEMIs, and they’ve already activated the team. You’d kind of wear them out after a while.
“They’re pretty good at recognizing when it does need to go to the cath lab.”
Cummings said like any relationship, both the hospital and the EMS people work at it.
“We have a mutual respect, and we work hard,” she said. “The medics and the nurses, there’s an expectation that you treat each other with respect and professionalism. There’s been some people who got in trouble because they spoke unkindly to each other. We call them on the carpet for it.”
EARLY DETECTION, REACTION ARE CRITICAL
Of the 1.4 million heart attacks each year in the United States, roughly 400,000 are STEMIs. Souther said few come with no warning.
“From being in the ER for 20 years, most people do not just all of a sudden have a heart attack,” she said. “There’s Rolaids in their truck, they’ve been eating Tums for days, they felt a little weak, they felt a little nauseous – they usually have symptoms for five days before they have a heart attack.
“There’s very few people who just have a heart attack and die. They ignore the symptoms.”
Souther said most people who come to the ER are given an EKG just to make sure what they’re feeling isn’t an early warning of a heart attack.
“We have some people who come in and say, ‘I just don’t feel right.’ They feel weak, just a general nausea, heartburn, flu-like symptoms, elbow pain, finger pain – if something feels weird and different, that you haven’t felt before, we’re going to check it out,” she said. “These people who come in just with a generalized weakness, flu – everybody pretty much gets an EKG during flu season.”
She said because of the skill and technology EMS brings, it’s important to call 911 and get an ambulance if you suspect a heart attack.
“It’s hard to get out to the public that you need to call the ambulance because they say, ‘I can beat the ambulance there.’ But when you call them, your care starts from your house.”
Cummings said the geographical area the Wise County EMS covers makes that even more critical.
“If they respond, they’re already starting on the scene, activating,” she said. “If it’s a 20-minute transport, the cath lab can be just about here, set up and ready to go – as opposed to you driving here, then we have to call cath lab.”
Souther said a campaign to increase awareness of heart problems and encourage calling 911 began about four years ago and has had good results.
“About 50 percent of our population were walk-ins with heart attacks, and now we’re down to about 40 or 30 percent who are walking in,” she said. “So we do have more patients calling 911.”
Last Wednesday’s patient, like most, said she wishes she’d come in sooner.
“She knew she didn’t feel quite right,” Souther said.
Of course, she had no idea she would be the first to use the new smartphone app.
Cath lab director Lacretia Miles, RN, said watching the app in action, even at 4 a.m., was riveting.
“I was home in bed,” she said. “It goes off at 4 in the morning. This is the first time we’ve used it. You log in, you see who all has responded, everybody’s on the go, we’re all getting set up.
“Typically, knowing that the team has arrived, I’m good. I’m going back to sleep.”
But not this time.
“You can see when the team is assembled, when the cath lab is ready – all these times are right there, visual. I’m just lying there watching it on my phone. I should have just come on in.
“Finally,” she said, “I put the phone back down and then I hear the ding. I pick the phone up and think, ‘OK!’ The device was deployed, everything’s OK.”
Miles said the phone provides a record, too, of the entire procedure – what happened and when – giving the team an opportunity to review and see where they can do better.
“We actually have the person who’s monitoring, documenting, watching our procedures – they actually have their smartphone right there in front of them,” she said. “Typically whenever the doctor is getting close to going down with the balloon, someone in the room circulating will say, here’s our time, and that monitor person will actually push a button on their phone and that’s going to alert everybody that this is open, there’s our time.”
Cummings said that ability to review is extremely valuable.
“They’ve been transmitting EKGs from the field for five years now,” she said. “We had that. But this puts another layer and makes us more efficient. Hopefully the patient, the family and everyone can understand that we’re timing ourselves.
“We’re hitting on-scene, STEMI confirmed, arrival to the ER, cath team responding, cardiologist arrived, time they go to the cath lab, time the lesion is crossed, time the case is over – we’re watching every single piece.”
Watching lives get saved by highly-trained people – with some high-tech toys.