Dangerous delays: Chicago ambulances lack equipment to detect the deadliest heart attacks early

3 hours, 6 minutes 50 minutes
Dangerous delays
Chicago ambulances lack equipment to detect the deadliest heart attacks early

By Judith Graham
Tribune reporter
September 2, 2009

















3 hours, 6 minutes was how long after 911 was called before Roy Frazier, 81, of Chicago had a balloon angioplasty performed. His ambulance lacked a 12-lead EKG machine. (Tribune photo by Brian Cassella / August 7, 2009)

If you're struck by crushing chest pain in Los Angeles or Boston and call 911, an ambulance will bring equipment that can tell if you're having a "widowmaker" heart attack -- the most consistently deadly kind.

The information allows paramedics to alert hospitals immediately so doctors can prepare to administer potentially lifesaving treatments soon after you arrive.

That's how it works in many U.S. cities and many Chicago-area suburbs, from Aurora to Cicero to Waukegan. But not in Chicago.

None of the Chicago Fire Department's 75 ambulances carries equipment that can identify "widowmaker" heart attacks, or STEMIs, which occur when a major artery supplying blood to the heart is largely or completely blocked.

As a result, medical experts say, treatment is often delayed, increasing the chances that the patient will suffer permanent heart damage or die.

"The ugly truth is that Chicago is behind the times" on its emergency response, said Dr. John Kao, director of cardiology at the Jesse Brown Veterans Affairs Medical Center in Chicago. "We are doing a disservice to our patients."

The cost of buying the diagnostic equipment, called 12-lead EKGs, and training Chicago paramedics to use it is estimated at $4 million, less than 1 percent of the Fire Department's annual budget.

Chicago fire officials say they plan to buy the equipment when it can be incorporated into a broader plan for improving emergency medical services for patients with STEMI heart attacks.

"We are 100 percent behind this," said Marc Levison, assistant deputy fire commissioner for EMS operations.In the meantime, officials say, ambulances respond rapidly to emergency calls and patients aren't compromised.

"Our patient care has not suffered at this time," Levison said.Medical experts disagree, noting that because Chicago paramedics can't determine which people are having the potentially deadly heart attacks, hospitals can't mobilize the appropriate treatment in advance.

"There's no question that patients are sometimes compromised," said Dr. Richard Feldman, a medical director for part of Chicago's EMS system who is based at Advocate Illinois Masonic Medical Center.

For every 30-minute delay in treatment, the risk of dying from a STEMI heart attack rises substantially, said Dr. Peter Kerwin, who directs the cardiac catheterization laboratory at Advocate Good Samaritan Hospital in Downers Grove.

Nationally, about 400,000 people a year suffer STEMI heart attacks (the term stands for ST segment elevation myocardial infarction), and half die before reaching the hospital. Of those who get hospital treatment, another 10 percent to 15 percent die. A little more than 2,300 STEMI patients were treated in Cook County hospitals in 2007.

The American Heart Association has made improving care for STEMI heart attacks a national priority, and many suburbs and private ambulance services in the Chicago area have outfitted their ambulances with 12-lead EKGs over the last five years. When the Journal of Emergency Medical Services surveyed 34 major U.S. cities this year, Chicago was the only one that didn't have the equipment for emergency medical responders.

"The question you have to ask is, how big a priority is this for them?" said Dr. Charles Davidson, medical director of the cardiac catheterization laboratory at Northwestern Memorial Hospital. "It should be a priority, because lives are at stake."

Leslee Stein-Spencer, the Fire Department's manager of medical administration and regulatory compliance, said the department requested $4 million for 12-lead EKGs in 2008 but withdrew the request because of other operational needs. Another request for funding is now outstanding.

She also said officials have been meeting for more than six months with hospitals to discuss a plan for improving care for heart attacks. Davidson is one of the participants.

The 12-lead EKGs provide a detailed representation of the heart's electrical activity and identify key abnormalities. Paramedics place six leads, or electrodes, on a patient's arms and legs; the other six go on the chest.

Oak Park bought new software for its current monitors in two ambulances, upgrading them to 12-lead status this year. "It's changed our way of thinking and responding," said Bob Rehse, an EMS coordinator with the suburb's Fire Department.

"It's more obvious what's going on and it's more clear to us what we need to do," he said.

For Ken Roush, 75, of Glen Ellyn, rapid response by a suburban fire department helped lead to a full recovery from a massive heart attack that could have proved fatal last October.

Roush, who owns a marketing company, was on the way to a client meeting early in the morning when he started feeling "sweaty and clammy." Turning around, he went home and asked his wife to take him to a hospital. Instead, she called 911.

When paramedics identified a STEMI at Roush's home, the cardiac catheterization lab at Advocate Good Samaritan Hospital was activated. Doctors and nurses met him at the hospital door, and 14 minutes later Roush's completely blocked left anterior descending artery was opened via an angioplasty procedure.

"I was lucky to live in this district," Roush said.

By contrast, in Chicago the electrocardiograms are done at the hospital, which slows things down by 15 to 20 minutes and in some cases much more, said Dr. John Lopez, director of interventional cardiology research at Loyola University Medical Center.

Although paramedics call in all suspected heart attacks, according to Stein-Spencer, medical experts say the information is of limited value.

"The cardiac cath lab isn't going to be activated off a phone call like that," Northwestern's Davidson said. If it were, he said, there would be too many cases where medical teams mobilized unnecessarily.

During the day, such teams may be able to assemble relatively quickly. But at night, doctors and nurses on call may be at home, adding to delays.

Complicating the situation, only about half of Chicago's hospitals can perform the preferred treatment for STEMI heart attacks -- balloon angioplasty -- expeditiously around the clock, Feldman said. Yet the Fire Department takes heart attack patients to the closest hospital, regardless of its medical expertise.

Balloon angioplasty involves snaking a catheter through the groin to the site of a blood clot and inserting a thin wire with a tiny balloon. Inflating the balloon destroys the clot, and blood flow resumes.

Most hospitals can administer clot-busting drugs to patients with STEMI heart attacks, but 25 to 40 percent of the time, these don't work, said Dr. Atman Shah, interventional cardiologist at the University of Chicago Medical Center.

Roy Frazier, 81, experienced gaps in care that can occur in Chicago when he had a heart attack in February. Frazier knew what to do after he began to feel a burning sensation in his chest -- he'd had a first heart attack 10 years ago -- and quickly called 911.

He recalls asking dispatchers to take him to the University of Chicago, his regular hospital. Instead, the ambulance rushed him to St. Bernard Hospital, which was closest to his home but wasn't able to perform balloon angioplasty.

Since the ambulance didn't have a 12-lead EKG, Frazier had to get that test at St. Bernard. After more than an hour and a half there, he was transferred to the University of Chicago, where doctors opened his right coronary artery, which was 99 percent blocked.

It's likely Frazier's heart was permanently damaged because he didn't get the medical intervention sooner, said Dr. Neeraj Jolly, senior interventional cardiologist at the U. of C. Medical Center.

"We see this all the time: patients who get taken to the ER of a hospital that does not have the capacity to do emergency angioplasty and then are transferred here and their outcomes are worse," Jolly said.

"It's a bad policy they've got right now, taking you to the closest hospital instead of the right hospital for you," Frazier said.

Other cities have made different arrangements. For instance, for several years Los Angeles ambulances have taken patients to designated "STEMI ready" medical centers, bypassing closer hospitals.

The Chicago Fire Department and local hospitals are discussing a similar setup, but there's little agreement so far on what it might look like.

The Fire Department wants to ensure that "citizens get equal care throughout the city," said Levison, the EMS official. That's difficult because North Side hospitals tend to be better funded and have more robust cardiology programs.

Also, no hospital wants to be identified as not being able to deliver the best care. And medical providers that might be bypassed don't want to lose business.

Meanwhile, experts agree it's better to call 911 and let paramedics come to your aid than to ignore symptoms of a potential heart attack or drive to a hospital on your own -- in Chicago and the suburbs.

Roush was among the patients who thought: "I don't want to inconvenience the paramedics. What if they get here and nothing is wrong?" Now, he's glad his wife called 911.

"If everyone knew not to deny what is happening, not to put it off, to call for help," he said, "that would be a very good thing."

www.chicagotribune.com/health/chi-ambulances-heart-attacks-02-sep02,0,7168938.story


jegraham@tribune.com
Chicago Tribune