“Time is muscle,” cardiologists say. When someone has a heart attack, they don’t have much time. The longer blood flow through a coronary artery is blocked, the more heart muscle dies, and delays can mean permanent heart damage or death. Patients having a severe heart attack need to get to a hospital, the right hospital, as quickly as possible and get prompt, definitive treatment.
But for a long time, the City of Chicago did not have the muscle to make that happen. Instead, emergency responders – paramedics from the Chicago Fire Department – took patients to the closest hospital for evaluation. But some Chicago hospitals were not prepared to provide definitive treatment, a balloon angioplasty, to quickly reopen a blocked artery. Those hospitals had to call a second ambulance, while the clock ticked, to transport the patient to a hospital that could provide optimal treatment (called primary angioplasty).
But after years of preparation, negotiations and frustration, on June 15 the Chicago Fire Department announced that it had finally equipped all of its ambulances with the equipment necessary to diagnose the most severe heart attacks en route and take those patients directly to the hospitals that can provide optimal treatment.
The program previously lacked two ingredients: teamwork and technology. The teamwork required delicate negotiation between 33 hospitals. The technology called for funding, about $4 million to equip all 75 CFD ambulances with 12-lead electrocardiogram (ECG) equipment. The 12-lead ECGs enable paramedics to recognize a STEMI – short for an ST segment elevation myocardial infarction. This is the most deadly form of heart attack, in which a major coronary artery is totally occluded by a blood clot.
The policy negotiations began years ago. The City, the Fire Department and the hospitals all acknowledged the need: there are about 300,000 STEMIs a year in the US and about 1500 in Chicago. Some hospitals that did not offer round-the-clock angioplasty were hesitant to have heart attack patients pass by on their way to hospitals that did. But over time they acquiesced and joined the push for a coordinated system. To participate, even those hospitals that could provide “percutaneous coronary intervention” had to promise to keep their average door-to-balloon time – when the patient hit the ER to completion of the procedure – under 90 minutes.
The American Heart Association long ago declared improving STEMI care a national priority. A survey of the 34 largest cites in the United States, published in 2009, found that 33 of them had a fully equipped STEMI system. Many Chicago suburban ambulances already had 12-lead ECGs. The entire state of North Carolina was covered and by the end of 2009 had treated almost 7,000 patients, more than 90 percent of them in less than 90 minutes.
“We are 100 percent behind this,” Marc Levison, assistant deputy fire commissioner for EMS operations told the Chicago Tribune in 2009. CFD had applied for funding that year, but it was not granted.
“That Tribune article turned the heat up,” recalled cardiologist Stephen Archer, MD, the Harold Hines Jr. Professor of Medicine at the University of Chicago Medicine and president of the American Heart Association’s Metro Chicago board of directors. “It energized the discussion and may have been the catalyst for people to make this STEMI network happen.”
“Over the next year we assembled a team of emergency medicine directors, cardiologists and representatives form the Hospitals and CFD,” he said. This group worked well together and came up with a system, consistent with the AHA’s Mission Lifeline, that would, when implemented, “ensure the patient would be diagnosed in the ambulance and taken to a STEMI center.”
“All that was needed,” Archer added, “was the money to purchase the ambulance-based ECGs”
But the funding, in a time of global recession, still wasn’t there, not in 2010, not in 2011. When it finally arrived in 2012, it was a by-product of the thousands of protesters who announced plans to gather in Chicago in late May to try to disrupt the NATO Summit. The City’s agreement to host multiple heads of state, and to shield them from the protesters, brought federal funding to ensure public safety. A tiny, but critical, fraction of that funding went toward life-saving treatment for heart attack victims.
“Ironically,” Archer noted, “it was funding from the Department of Homeland Security that allowed realization of the Mission Lifeline objective — a STEMI network for Chicago.”
CFD activated the STEMI system on May 15, five days before the NATO summit. The team made their first transport that morning, diagnosing a severe heart attack in the ambulance, bypassing a closer hospital and taking a 52-year-old man to West Suburban Hospital, the closest STEMI-equipped facility, where the cardiologists met them at the door. The patient was rushed to the cardiac catheterization laboratory and his clogged artery promptly re-opened. He recovered.
By June 15, when the CFD held a press conference to announce the program, CFD had handled 96 STEMI cases, including half a dozen that came to University of Chicago Medicine. One of those was 18 years old, another 26.
Speaking at the Fire Department press conference, and wearing a black tie with a bright green STEMI ECG pattern, Archer praised all those who fought the long battle to make this happen. “This is a significant accomplishment in Chicago health care that did not happen overnight,” he said. “Our city now has the tools and system to give the best treatment to deal with cardiac events.”