Door To Balloon

I just came out of the cath lab after doing an emergency coronary angiogram on a man suffering a heart attack.  He is a youngish fellow (have you noticed how the term “young” keeps getting more generous as you get older?) with no prior heart problems, but with a bad cigarette habit and genes that are not favorable (a father suffered a heart attack at about the same age).

We rushed him into the lab and prepped him for the procedure.  As he lay on the table he seemed to watch with curiosity as our personnel ran about the room, tearing open sterilized packs of instruments and preparing monitors and tubing.  To him, I’m sure, everything seemed to moving at super fast speed, like a scene from a Charlie Chaplin movie.  As I was getting ready to place the access tube into his femoral artery, he turned to me and asked why everyone was hustling about.  “What’s the rush?”

The rush, of course, comes down to hard science.  Years of study, data collection, and real-world experience have taught us that we save more lives if we can shave even a few minutes off the time it takes to open a clogged artery.  Your chance of surviving a heart attack, especially with your cardiac muscle intact, rises dramatically as the time between clot formation and stent placement decreases.

It’s for this reason that we actively track what we call the “door to balloon” (D2B) time and have to explain ourselves if we drag our feet and go over the mark.  The term “D2B” refers to the time between a patient’s arrival in the emergency department to the first inflation of an angioplasty balloon in the clogged artery.  Our current guidelines mandate a D2B time of 90 minutes or less, and over the last few years we’ve become very good at reaching this goal.  As an example, please see a recent article in the Omaha World-Herald about the remakably rapid D2B time—only 54 minutes, on average—we achieve at Midlands Hospital (yes, I’m bragging here; although I can’t claim any credit for this since I’m not one of the doctors who does stents).

The concept of expediting the D2B time was obviously lost on my young patient.  Prior to the heart catheterization, when I was evaluating the patient in the emergency room, I noticed a large fountain drink by his bedside.  Not only had he and his wife not arrived via ambulance (and, hence, had not called 911) but they had also felt relaxed enough to stop at a convenience store for a 32-ounce fix of Dr. Pepper on the way.  The patient’s symptoms, he reluctantly explained, had actually been present for at least 8 hours before he finally decided to saunter into the hospital.  As it turned out, the decision to finally seek medical care was made fairly quickly once the woman of the house was notified of ongoing events.

This man’s D2B was pretty quick—less than 50 minutes.  Our ER and cath lab staff didn’t waste a single moment in their efforts to sweep the patient into the hands of our interventional cardiologist.  The problem, obviously, is that our best efforts—while great for our D2B scorecard—don’t mean a whole lot if the patient has spent the last 8 hours with a corked vessel.

The emergency medical system has put considerable effort into shortening the time between the initial 911 call and the point where patients land in the hands of the emergency physician.  In our area, for example, a patient with chest pain can undergo the electrocardiogram (ECG) prior to hospital arrival; the ECG is transmitted to the ER doctor, who can alert the cardiologist and cath lab staff of the impending arrival and move the process along even faster.

What we can’t control is the period of time between the onset of symptoms (corresponding to the moment the vessel becomes blocked) and the 911 call.  Even worse, we find that heart attack victims often choose to forgo the EMS system altogether in favor of a commute in the Ford F-150 (remember, I’m writing this blog post in Omaha).  Recent studies have clearly demonstrated that the longer people wait before coming to the hospital, the higher their chance for death or long-term cardiac damage.  A wait of more than 4 hours from the onset of symptoms is associated with a considerably higher rate of mortality.

What’s to be done?  Here are a few simple tips:

1. If you think you’re having heart problems and plan to go to the hospital, leave the car keys at home.  Call 911 and let the paramedics handle the transportation.
2. Chest, shoulder or arm pain at rest, especially if associated with difficulty breathing, sweating or nausea, is worth dialing 911.
3. We won’t think less of you if your visit to the ER is a false alarm.  I promise.
4. If you’re a man and wonder if you should call 911, just find the nearest female in your life and let her decide (that advice can actually apply to most things in your life).

If and when you have a heart attack, your doctors, nurses, and technicians will break all kinds of records in their effort to get your blocked vessel open.  All we ask in return is that you get into the hospital promptly so that all our rushing around is worth it.