Bud Evans thought it was just an ordinary day in October.
Evans, manager of Oakwood Golf Club in Houston, went to the course early that day, just like he always did. Around 9 a.m., things changed. He decided he was feeling poorly enough that he should go to the Texas County Memorial Hospital emergency department to get medical advice.
“I wasn’t in pain, but I had some discomfort in my chest,” Evans recalled. “I thought I should get it checked out.”
Evans drove from the outskirts of Houston to the hospital parking lot, stopped at the corner, decided he was feeling better and drove back to the golf course.
By 10 a.m., Evans had driven himself back to the TCMH parking lot. This time he parked his vehicle and got out of the car, stopping momentarily to question whether or not he was imagining the discomfort in his chest.
“I called my wife and told her I was going to the ER,” Evans said.
Evans said the TCMH emergency waiting area was not busy that day. When Evans told the registration clerk that he was having chest discomfort, the clerk immediately sounded the “chest pain” alert to hospital personnel.
“I was quickly placed in a room, given a shot of blood thinner and an IV,” Evans said. “In a matter of minutes, the doctor was in my room telling me and my wife that I was having a mild heart attack and a helicopter was inbound to the hospital to take me to Springfield.”
Evans was a “hot load” –– the quickest type of air ambulance pick up –– for an interventional heart procedure at CoxHealth in Springfield. For a hot load the air ambulance personnel and the helicopter land on the helipad and immediately load the patient and leave with the patient without stopping the engine or rotors of the chopper.
STEMI DESIGNATION
TCMH has provided life saving care for patients experiencing heart attacks since its doors were opened in 1958. Later this year, the hospital anticipates receiving a designation from the state Department of Health and Senior Services as a “Level Four STEMI” hospital for their ability to respond to patients experiencing a ST segment elevation myocardial infarction or STEMI, commonly referred to as a heart attack.
Lauren Toman, cardiopulmonary director at the hospital, has been actively involved in the application process for the STEMI designation. She has worked closely with the emergency department and cardiopulmonary department teams to decrease crucial times in the medical process for area heart attack patients.
“The heart is a big muscle, and during a heart attack blood stops flowing to the heart which causes the muscle to die,” Toman said. “Every minute that we have with a heart attack victim is an opportunity to save more of that patient’s heart.”
The state of Missouri’s benchmark for STEMI response is 30 minutes from the time a patient is in the door of the hospital with heart attack symptoms to transfer to a higher level of cardiac care. However, most rural hospitals do not have everything in place to meet the 30-minute benchmark. Rural hospitals must recognize and stop the heart attack process and work around obstacles for getting the patient where he or she needs to be for cardiac intervention as quickly as possible.
Rural hospitals like TCMH face particular challenges in getting cardiac intervention for patients because most rural hospitals do not have an air ambulance on site to ship patients to a hospital where cardiac intervention can be provided. TCMH is a 24-minute flight from the nearest air ambulance base.
TCMH does have multiple ground ambulances available and on site at the hospital, but in the case of heart attacks, ground ambulances are only used during bad weather.
When a heart attack patient is diagnosed, there’s at least a 24-minute window of waiting for the air ambulance to arrive on the TCMH helipad. More time is spent loading the patient on the ambulance, too.
“To hot load a patient on a helicopter, it takes five minutes,” Toman said. “And that’s a really crazy five minutes –– rushing a patient to a helicopter and loading them while the helicopter’s still running.”
Going into the STEMI designation application, Toman knew that TCMH faced a lot of obstacles to cutting down STEMI response times just due to the hospital’s rural location.
STEMI PROTOCOLS
The first protocol implemented for the STEMI response was the “chest pain” alert that goes out to the hospital staff when a potential heart attack patient arrives at the emergency department registration desk or when an ambulance crew is in route to the hospital with a possible heart attack patient. Staff from multiple hospital departments work together to get the patient in a room and hooked up to vitals monitors, the cardiopulmonary team starts an electrocardiogram (EKG), and the heart attack is diagnosed or ruled out.
“Our goal is to have STEMI patients hooked up to an EKG within five minutes of coming through the door,” Toman said. If a patient is in a ground ambulance en route to the hospital, the paramedics can start the EKG before arriving at the hospital.
Once the hospital personnel receive confirmation through the EKG that the patient is indeed experiencing a heart attack, the emergency department staff make contact with a hospital with a higher level of cardiac care available and get the patient accepted into that care.
Depending upon the severity of the patient’s symptoms, various medical procedures will take place.
“We can give a medication to patients that will send blood back to the heart,” Toman said. “All of the patients will need some type of physical intervention to remove the blockage that’s stopping the flow of blood to their heart. Our goal is to get the patient to that intervention as quickly as possible.”
Toman said STEMI scenarios require “split-second decisions” because every action during a heart attack can save more heart muscle.
According to Toman, the new STEMI protocols have the TCMH door-to-door response time for patients down to a 34-minute average. “Door to door” refers to the moment a patient tells the registration clerk that they are experiencing chest pain to the moment the patient is shipped to a higher level of care.
TCMH has no control over what happens with a patient after they are flown from the hospital, but Toman said the overall goal is that a patient receives interventional care at the larger hospital within 120 minutes of entering the TCMH emergency room.
“When the ambulance with the STEMI patient arrives at the next hospital, they are ready and waiting for the patient,” Toman said. “The patient is unloaded and wheeled into a hospital procedure room.”
PERFECT RESPONSE
The staff at CoxHealth was ready for Evans when the chopper landed. Evans’ cardiac procedure was quite involved — open heart surgery for a three vessel bypass.
The TCMH staff, using the new STEMI protocols, had saved Evans’ life.
How has TCMH honed their STEMI protocols and decreased their door to door times for patients of heart attacks?
For almost a year, the emergency department and other hospital personnel have practiced their protocols with surprise mock drills. TCMH personnel work with other hospital STEMI coordinators and the cardiologists at other hospitals. Community education is also an important component to saving the lives of patients experiencing heart attacks.
Forty to 60 patients a month come into the TCMH emergency department complaining of chest pain. Approximately two of those chest pain patients are having actual heart attacks, but the STEMI protocols are always activated when a patient may be having a heart attack.
“Successful STEMI response is due to awesome communication,” Toman said.
She said the in-house hospital team must communicate quickly and effectively, and the admitting hospital must also have communication avenues open and in place to quickly respond to patients that need to be shipped in to them from TCMH.
Evans recalls his heart attack experience as “perfect” from the moment he walked into the TCMH emergency room doors.
Prior to his heart attack, Evans didn’t have much experience with hospitalization at TCMH or anywhere else. He does remember the “old days” when Evans Funeral Home operated the local “ambulance,” rushing people by car — the funeral home hearse –– driving 100 miles per hour down two lane roads to Springfield.
“The doctor and the staff worked together efficiently and quickly to save my life,” Evans said. “Everything worked exactly as I envisioned this hospital doing if I ever needed it.”
Since his heart attack, Evans has made some lifestyle changes, and he’s participating in the cardiac rehabilitation program at TCMH. Evans’ cardiologist told him recently to come back for a follow up visit in a year.
Evans said he is grateful for the technology and the quick actions of hospital personnel at TCMH and at CoxHealth that saved his life last October.
“I had a moment where I thought I might not make it,” Evans said, “and now I’m planning a vacation in Florida.”