In my last diary I described how the London Ambulance Service (LAS) is using paramedics on bicycles to get to patients within the target time of eight minutes from an emergency (999 or 112) call for help. In this diary I would like to describe a pioneering cooperation between the LAS and the hospitals in London for the treatment of heart attack victims. The approach is so new it has not been rolled out over the rest of the country which still uses the sort of approach described on the New York Presbyterian Hospital (NYP) site.
So you have had a heart attack and the ambulance has turned up. Very likely treatment like CPR has started - otherwise you may not be here. If you read the NYP page, the next step is for you to be taken to the Emergency Room. In London these are usually called Accident and Emergency Departments (A&E) but if you have a heart attack there, you will probably never see one - all because of cost savings and socialised healthcare.
(First, apologies to NYP or New York hospitals if their practice is not as described on the site, maybe any physicians would like to comment)
In the NYP Emergency Room you will get treatment which may include:
intravenous therapy - nitroglycerin, morphine
continuous monitoring of the heart and vital signs
oxygen therapy - to improve oxygenation to the damaged heart muscle
pain medication - by decreasing pain, the workload of the heart decreases, thus, the oxygen demand of the heart decreases
cardiac medication - such as beta-blockers or calcium channel blockers to promote blood flow to the heart, improve the blood supply, prevent arrhythmias, and decrease heart rate and blood pressure
fibrinolytic therapy - intravenous infusion of a medication which dissolves the blood clot, thus, restoring blood flow
antithrombin/antiplatelet therapy - used to prevent further blood clotting
antihyperlipidemics - medications used to lower lipids (fats) in the blood, particularly Low Density Lipid (LDL) cholesterol
In contrast, London paramedics will not immediately rush you to hospital.
When our staff arrive, they will assess you and may give you some drugs to relieve the pain.
They may give you aspirin so your blood flows more easily through your blocked artery. And they may spray glycerol trinitrate under your tongue to relax the heart muscle.
Unlike many ambulance services in the UK, our staff are trained to diagnose a heart attack using a piece of equipment called a 12-lead electrocardiogram (ECG).
Using the 12-lead ECG, which records the activity of your heart, our staff will diagnose whether you are having a common type of heart attack, often called an ST-elevated myocardial infarction.
If we find that you are having a heart attack, we will immediately take you for specialist hospital treatment.
By that they do not mean specialist treatment in a hospital but treatment in a specialist hospital, one of eight in the London area with a dedicated heart attack center. There, not the ER is where you will be taken. Nor, in all likelihood, will you be medicated and stabilised. Instead they will, if appropriate, assess you and take you straight to an operating theater for an angioplasty and insertion of a stent.
Angioplasty is a procedure for unblocking the arteries carrying blood to the heart muscle. A catheter and subsequently a balloon is inserted into the patient’s artery, and once in place the balloon is inflated and the artery widened. A device called a stent (short tube of stainless steel wire mesh) is then left in the artery to ensure the artery remains open. This re establishes blood flow and limits damage to the heart muscle.
If you go back to the NYP page you will see that this procedure is considered there after the patient has been stabilised. Why the difference? Because it has been shown to be more effective. Again from the King's College Hospital page:
Traditionally, people suffering a heart attack are taken to the nearest A&E department and given clot-busting drugs (thrombolysis). However, thrombolysis has only a 60-70 per cent success rate and the rate of patients who go on to suffer a further clot is high. Angioplasty has been shown to be more effective, achieving a normal flow of blood in around 90-95 per cent of cases
Dr Martyn Thomas, Consultant Cardiologist, King’s College Hospital commented: ‘We are extremely proud of the service we are able to offer to patients suffering acute myocardial infarction. The partnership working between King’s College Hospital and London Ambulance Service has enabled patients to be diagnosed en route, in the ambulance, and then brought immediately to the Cardiac Unit, bypassing A&E. Diagnosis is then confirmed by an angiogram, and an angioplasty performed straight away when appropriate. For the patients this treatment has a much better outcome, as many patients treated with clot busting drugs in A&E departments will also need to go on to angioplasty in the future. I believe delivery of this type of treatment will prove highly cost effective.
So that 2006 statement makes it clear, rather than hanging about in the ER being medicated and then having an angioplasty, it is more cost effective to go straight to the procedure. Not only that, the LAS site makes it clear that most patients treated this way leave hospital within three days. Let's see how this worked for one patient at another of the specialist units in April last year..
One heart attack patient who is alive today as the result of the team work of London Ambulance Service paramedics and doctors at Barts & The London Heart Attack Centre is 54 year old Robert Ainsworth from Bethnal Green.
After experiencing chest pain and indigestion on the night of 7 April, Mr Ainsworth was quickly diagnosed by paramedics and taken straight to the Heart Attack Centre from his home.
When he arrived at the Centre last month he was not just in a serious condition but close to death. His heart speed was 15 beats a minute compared to the normal 70 beats a minute. He had virtually no blood pressure and an extremely weak pulse.
He was taken from the back of the ambulance straight to the angiography suite where experienced consultant cardiologist, Dr Duncan Dymond, quickly inserted a catheter and unblocked his affected artery.
Dr Dymond is in no doubt that if Mr Ainsworth had not received immediate specialised care - and emergency angioplasty within minutes of arrival at hospital - he would not be alive today.
I am tempted to offer a repost to the teabaggers' condemnation of the NHS that Robert Ainsworth would not be alive if he had had to stop off to give his insurance company details before going to the angiography suite. On the other hand one anecdote is not good evidence, what about some real statistics?
More than 120 Londoners are alive today as a direct result of cutting edge treatment offered at Britain’s largest heart attack centre, which has just celebrated its second anniversary.
Barts and The London Heart Attack Centre has halved the number of patient deaths since opening its doors to the public in April 2006. Doctors attribute this fall in mortality rate from 12 to 4.5% to advances in specialised care.
So by having a socialised ambulance service that can train its skilled staff in the use of some equipement and going straight to a procedure that is probably initially more expensive, large amounts of in patient treatment costs are saved and, more importantly, half the most seriously ill are dying.
But according to the likes of Faux News, this cutting edge treatment is only going to be given to those who are economically active so they pay taxes. Oh really? Again at King's College:
17 July 2006 - King’s College Hospital has achieved a world first in cardiac surgery. For the first time, an acute rupture of the inner wall of the heart1 was closed using a device instead of conventional surgery. The new surgical technique used in this case is less invasive on the heart and may allow the patient a quicker recovery with less risk of complications.
The patient, a 75-year old man, experienced a rupture of the ventricular septum (the wall dividing the right and left heart chambers) after a myocardial infarction (heart attack). A rupture of this inner wall is an acute complication after a myocardial infarction, and is fatal without treatment. The hole allows blood flow from the high pressure left heart chamber into the low pressure right heart chamber, which can cause severe breathlessness and low blood pressure. There is also risk of multiple organ failure. Without immediate medical intervention, 95 percent of people with this condition suffer severe heart failure and die. The conventional treatment for an inner heart rupture is open-heart surgery, where a patch is stitched over the hole. Depending on the condition of the patient, the surgeon must assess whether they are eligible for the procedure. Of those who undergo conventional open-heart surgery, up to 50 percent do not survive. However, in this case the patient’s recovery chances were greatly improved by the use of a less invasive surgical technique, where a device was used to close the hole in the heart.
World first in the use of a technique in heart attack patients. Halving the mortality rate of heart attack patients by innovative treatment regimens. Clearly socialised medicine is, as Sarah Palin would say, EVIL.