I got a call from the emergency room at about ten pm. I headed for the car and made my way to the hospital as quickly as I could. I walked quickly into the ER and saw my patient almost immediately. He looked terrible and time was of the essence. He was in his mid-forties. He was pale and sweaty. His skin was cold to the touch and it looked like he was going into shock. They had already done an EKG and it showed the changes that meant he had a heart attack on the front of his heart that went through the entire wall. They call those EKG changes tombstone elevations and the artery responsible the “widowmaker.” That tells you how dangerous this situation is. His pain was still severe and had just begun an hour ago. His face was twisted with discomfort and worry. We still did not have a cardiologist in town. A new medicine had come out the year before, and I had never used it. It looked like this might be it. We knew now that heart attacks are caused by clot, and TPA was a clot buster. Every minute his artery was blocked, heart muscle was dying. I knew if we did not do something, this guy may not make it to Savannah or Charleston. We were an hour away over two lane roads. There was no helicopter and we had no cardiologist or cath lab. We were all that stood between him and disaster.
I told the nurse to get the TPA ready and give it in his vein. I knew the medicine took a while to work, so I was not surprised when nothing changed. Thirty minutes later, something happened I had never seen. His hands began to move across his chest as if looking for something. His twisted face smoothed out. The color returned and the sweat started to dry up. He told me his pain was gone!
I was elated. I knew that everything in heart attack depends on how much heart muscle is lost. By dissolving his clot, we had opened his artery and preserved heart muscle. That improved the outlook for him dramatically and he recovered without further incident. When he had a heart cath not long after the event, the artery involved only was blocked by about 50%. A stent prior to the attack would have made no difference. I had seen it with my own eyes. Heart attack is a clotting event. The new medication could save patients even in rural hospitals with no cardiologist.
Even today, even in big cities and medical centers TPA is vital in treating stroke. The quality question is this. From the time the stroke symptoms begin, how quickly can you get the CT scan of the brain done to prove there is no bleeding and begin giving TPA in the vein. Every minute of delay means more brain tissue is dying just as in heart attack.
Heart attack and stroke management is all about the time it takes to open the clot. That is the whole story in heart attack and stroke. If you are walking by the emergency room of a big medical center and you have a heart attack, there is a stent team on site and they can get you to the cath lab very quickly. The can save your life and that is where a stent means everything. If you live in a rural state out west and you are 200 miles from a cath lab, that is different. You may have had to drive 45 minutes to get to an EKG, and then the staff must call the doctor at the cath lab to accept the patient and get the helicopter going. It just takes too much time. Those places are like Beaufort SC 20 years ago. Everything depends on the primary care providers at the scene.
That makes optimal medical treatment (OMT)for patients with stable heart artery disease, high blood pressure, high cholesterol, chronic kidney disease, diabetes and stroke all the more important. The best way to deal with heart attacks and strokes is to treat vascular disease much more effectively. OMT in patients with stable heart artery disease reduces mortality by up to 90% compared with patients on usual care. Patients with high risk type 2 diabetes on OMT have one fourth as many heart attacks, one fifth as many strokes, and they live 8 years longer than patients in usual care. Very few communities of any size in America are set up to deliver OMT consistently and we must get started.
If primary care providers in those rural settings have support from a telemedicine company with teams focused on OMT, it can be much easier for the provider and much more convenient for patients because they don’t need to travel miles to an office visit. Support with population health tools identifies high-risk patients who have not been seen at all, have not had a test or a visit within 6 months, are not at goal, or not on best practice medications. I have been working on bringing these elements together for over 20 years. If you would like to know more, please contact me at wbestermann@congruityhealth.com. We can help.
Actually, this patient got really lucky. His abnormal ECG was obvious. In reality, majority of people (70,000 annulay estimated), especially women, die from heart attackes/herat failure within 30 days after they visited the Emergency Departmenst for chest pain complaints tested "normal" on their ECGs and Troponnin levels, sadly. Many of them die while waiting to be cared for in the wating rooms of the ER! More American women die from cardiovacular diseases than men due to lack of a better test. This was one of the reasons we developed Multifunction Cardiogram Technology to eliminate the tragedy.
Welcome to the 21st Century!
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