A Sea Change in Treating Heart Attacks | Hacker News Reader

A Sea Change in Treating Heart Attacks

nytimes.com

123 pointsdankohn159 comments

A month ago, a friend who'd worked as a doctor in South Africa for decades was interning with me to learn about the procedures in our German ER. I remember the first time a patient with a heart attack came in while she was there, and the speed of the proceedings just blew. her. mind.

What happens, if things go well, is this:

The EMTs transmit a picture of the electrocardiogram to us[1]. We confirm that it's a STEMI (the kind of heart attack where speed matters the most, as opposed to an NSTEMI, which isn't quite as urgent), and alert the catheter lab and the attending cardiologist. Half the ER personnel drops everything else to prepare for the patient's arrival.

The patient arrives. We transfer them to our gurney. One nurse gets the patient's clothes off (with scissors if necessary) while another nurse attaches electrocardiogram electrodes and a third shaves the puncture site for the catheter.

The ER physician puts in an iv line and draws blood while informing the patient of the treatment plan. The cardiologist takes a very quick history of the patient and confirms the STEMI with the second electrocardiogramm. We wheel the patient up to the catheter lab and get started.

Altogether, if everything goes well, it's something like five to twelve minutes from the moment the patient comes through our doors to the moment we've got the patient on the operating table.

[1]By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.

Interesting... I would have assumed Germany would be a bit more advanced in prehospital care.

Here in the US (in a rural/suburban area outside a smallish city in upstate New York), the flow would look more like:

A paramedic recognizes a potential MI and takes a 12-lead EKG. If it is indeed a STEMI, then we'll call the ER and transmit the EKG and other vitals (via a cell modem embedded in the monitor). If the ER doc agrees with my diagnosis, then the cath lab is activated.

I'll have a couple large bore IVs in place before we arrive at the hospital, and when we get to the hospital, the patient stays right on our stretcher as we bypass the ER entirely at take them directly to cath.

For an unstable patient, our process is much the same - the EMTs will put in the IVs, and we'll bypass the ER to proceed directly to the cath lab. For stable patients, the EMTs will prioritize getting them to the hospital as fast as possible and often won't have the time to get the IVs into place before they arrive. (This part of the county has a ridiculous density of hospitals, so the ambulance ride is frequently not even five minutes long, which doesn't give the EMTs that much time to work.)

We've found that things go little more smoothly if we do some of the prep in the ER, where there's a little more space for people to undress the patient etc. without worrying about bumping into the expense catheter equipment or compromising sterility, but even stable patients aren't supposed to spend more than five minutes there before being rushed to cath.

I do wish we had some way to directly transmit EKGs and vitals. American hospitals seem to have more money available for electronic equipment like that. (On the other hand, in Germany, the whole hospital stay including the catheter and a day in the ICU, probably won't cost you more than 10.000 Euro, and usually less than that.)

Is there any opportunity (or practice) of other conditions bypassing the ER? If that's the bottleneck, I hope it doesn't have to be life-or-death for someone to thing "We should re-engineer this process".

E.g. uncomplicated fractures getting brought to the fracture clinic?

The reason for bypassing the ER in this case is because every minute means more damage to the heart. A fracture is not especially time sensitive. Stabilize it in the ER, take some images, and refer them to an orthopedist in a day or two. There would be no significant change in patient outcome by shaving any time off that process.

> By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.

Congrats on the massive process improvement on using readily-available technology. I'm no lawyer but I'm pretty certain that this violates HIPAA, which means it's a new market just screaming for PII-managing image-transfer networks and startups.

The technology exists -- see http://www.physio-control.com/ProductDetails.aspx?id=2147484... and http://www.zoll.com/medical-products/data-management/rescuen... from PhysioControl and Zoll, two of the biggest EMS EKG monitor manufacturers, but its certainly not easy to use. In my system, we used to have to upload the EKG to the computer and then "e-fax" it from he computer to the Emergency Department -- practically, this took 3-4 minutes to do, and when you're in an urban area and nearly always < 10 minutes from the hospital, its not the most productive use of time. Most of the time, if was easier to do the EKG, and in case of a STEMI, call the "code STEMI" via radio, print the EKG and spend the rest of the time doing important patient care (IV access, aspirin, etc)

That said, we were in a Paramedic system with a relatively short to-hospital drive time, and going to an academic medical center that had 24/7 in-house interventional cardiologists. If you're in a aystem with only EMT-Basics (who are trained to perform the EKG but cannot interpret the printout), or going to a hospital where the interventional cardiologists need to come in from home, or if your primary hospital doesn't even have a cath lab and will need to divert you to another bigger hospital, it makes a lot of sense to be able to send the EKG from the field and get the ball rolling early.

Our integration is much better. We have cell modems on our LP15s, so it's just a matter of hitting the 'send' button, using the scroll wheel to pick the hospital, and click to send...

> In my system, we used to have to upload the EKG to the computer and then "e-fax" it from he computer to the Emergency Department -- practically, this took 3-4 minutes to do, and when you're in an urban area and nearly always < 10 minutes from the hospital, its not the most productive use of time.

Those steps could be automated. And since this would usually be life-threatened situations, they should be automated. I wonder how much HIPAA rules complicate the technology; they certainly don't make the space attractive or fun to work in. This sounds like a great disruption for a startup to make, if they can deal with HIPAA effectively.

I interviewed for Physio, but turned down their offer due to mandatory drug testing. They seemed to be really, really locked down due to regulations, and I suppose I do want the regulations on defibrillators to be fairly strict.

Those steps could be automated. And since this would usually be life-threatened situations, they should be automated. I wonder how much HIPPA rules complicate the technology; they certainly don't make the space attractive or fun to work in. This sounds like a great disruption for a startup to make, if they can deal with HIPPA effectively.

There are several companies (including a couple YC alums like Aptible) working in the helping-developers-deal-with-HIPPA space already. Creating a compliant application for transmitting ECGs wouldn't really be a new thing-- when attending an emergency medicine conference two years ago I met a physician/programmer who had done just this for both stroke and heart attack, designed and marketed as a wraparound subscription-based solution. The trick is doing it well, and if you could integrate the information with the receiving hospital's workflows (e.g. EPIC integration or something) you could sell it easier. Pictures of ECGs are also a fairly inelegant solution compared to sending it to the ECG printers that a receiving hospital has, or sending the actual waveform data, but for rural/underfunded EMS agencies it would be nice.

(FWIW, I work in a Bay Area emergency department that is a STEMI receiving center but does not receive field-transmitted ECGs prior to arrival. There's room to work on this stuff. If anyone wants to do research relating to it or build a system and then let me do research with it, get in touch.)

Physio absolutely has an automated version of that, it just requires integration on the part of the hospital (and an upgrade to the LifePak to add a cell modem).

The entire process: - Hit the send button - Click the wheel to pick the destination - Spin the wheel to highlight the destination hospital - Click the wheel to select - Spin the wheel to 'Transmit' - Click the wheel to send it

Done...

Are there procedural hurdles for the reasonably local hospitals to automatically get copies of any emergency EKG being done in the region?

There would clearly be some concerns with making sure that the right data was matched up with the right patient, I'm just wondering about how the technology could work, and what the more subtle issues might be.

I'm not sure how to approach the topic, but there is competition between hospitals. They are ultimately forced to be businesses and have bottom lines.

Why would you want to send it anywhere other than the hospital you're heading to?

It isn't clear to me that the destination is always strictly determined; in the article, the ER doctor or consulting cardiologist would sometimes divert the ambulance. So the simplest implementation has the copy being easily available at the 'reasonably local' hospitals, rather than having someone push a button to send it to the diversion destination.

edit: I see in your other comment that you are talking about scrolling to the correct hospital. It seems less good for the immediately involved technician to spend time on this than for whoever it is at the hospital to do it (I did already mention the caveat about record matching).

It adds, _maybe_ three seconds to the process of transmitting an EKG. The interface is pretty well designed. It makes more sense for me to be the person making that decision as I am the person with the most complete clinical picture at the time that decision is made.

If I'm sending an EKG, I'm also going to be picking up the phone shortly to talk things over with the doc at that ER. There would never be a situation where I don't already know where I'm going before transmitting an EKG.

My question could be rephrased as: Why is it a decision?.

When you pick up the phone and are talking to someone, the system could be showing them the EKG you did, with no intervention on either end.

I realize there is much opportunity there for bad implementation, I'm more interested in understanding the characteristics of a great implementation. Maybe there are reasons to leave it to the discretion of the EMT, but it being easy for the EMT to handle isn't one that I find very satisfying (I find it arbitrary to the implementation).

It's a decision because different hospitals have different specialities. Trauma, stroke, cardiac, etc. The most appropriate facility is a combination of what the patient needs, what they want, and the logistics involved (travel time, relative busyness, etc).

I call the hospital because I want to make sure they got the transmission and are going to be ready for me when I get there. The transmission and the call are generally a couple minutes apart.

There are certainly _plenty_ of places where the workflow in the back of the rig could be improved, but this really isn't one of them.

I get that it isn't a big time taker, so this is just abstract commentary.

This is an obvious opportunity for improvement: I call the hospital because I want to make sure they got the transmission. The ideal case would be that you don't even have to think about whether they have the information or not, the system should handle that with very high reliability.

You've also taken "decision" differently than I meant it. I meant, why do you have to decide to transmit the EKG, not the decision about which hospital to go to. Repeating myself, it would seem to be an improvement if you didn't have to pay any attention to whether the appropriate hospital had access to any readings/recordings that you had (I would think it would be better if it were trivial for someone there to pull them up, of course with high reliability).

I'm not feeling around for some opportunity to innovate/improve, I'm just curious about the factors that such a system has to deal with, and which of those factors are less idea than they could be, and why. That it isn't a big opportunity for improvement is useful feedback in general, but it doesn't really address the curiosity.

When I say I'm confirming they got it, I mean I'm confirming someone actually looked at it. The fact that it was delivered successfully is indeed reported to me.

The act of transmitting the EKG serves to give the hospital a heads up that I'm coming, and that I think this patient needs care right away. I understand you're suggesting a system where every bit of data my monitor collects is available in every hospital in real-time, so I just have to call them up and reference it. My point is that is that the act of sending the EKG is a really miniscule part of the process. You're talking about 5 seconds over the course of a 30 minute event.

I don't think the tradeoffs in complexity and quiet failure modes would be worth it. If I transmit something, I get a confirmation right then that it did or didn't work. If a passive data aggregation system fails (and I'm used to it 'just working'), then I may not notice that it failed.

Have to say, this seems like an area where I'd be very happy there's an experienced human weighing all the various factors and making the judgement call.

After reading the procedure you've described I feel very grateful for our highly developed acute care system, and the dedicated pros who make it all work.

Yes, it is. HIPAA doesn't apply to Germany though, unfortunately. Despite its reputation for privacy Germany's healthcare regulations are severely lacking in that respect.

Implementing a more stable - and legal - system for exchanging medical data is next to impossible because there's a bunch of stakeholders who actively undermine what's in the interest of the patients for their own good.

So, for the time being, transmitting patient data via WhatsApp and the likes unfortunately - and quite bizarrely - probably is the only option to act in the patient's interest. Besides, the regulators won't notice anyway because for them the Internet still is some passing fad.

HIPAA doesn't apply in Germany...

PS - its HIPAA not HIPPA.

No redaction necessary!

There are already several HIPAA-compliant messaging apps that take care of that.

Though I can't find any reference to it, I'm fairly certain that TextSecure would be HIPAA compliant. I think I'll try to point that out to Moxie and see if they can make it official.

HIPPA... Germany...

We don't put the patient's name on the EKG, so it's not directly identifiable, and we get their consent before submitting (if they're in any state to consent, which often they aren't), but I'm sure it does violate all kinds of rules and guidelines, if not actual laws.

It depends on whether the message/pic is identifiable. If it's not -- just "HEY IS THIS BAD?!" -- then it probably would not constitute protected health information, for HIPAA purposes. (Presuming this is in the US.)

HIPAA is a set of American laws, and this is in Germany.

For the curious, differences between {N}STEMI http://imgur.com/HbREzfo

Hmm... ST depression often means there is ST elevation somehwere you can't see. ST depression is generally a 'reciprocal' change, and there will be elevation on the opposite side of the heart.

A 'standard' EKG looks at the front, bottom, and left side of the heart. If the area of the heart affected by the heart attack is on the right or back side, then you won't see elevation, but you may see the reciprocal depression.

EDIT: s/almost certainly/often/

I wouldn't say certainly, but sometimes. There are a lot of more common causes of ST depressions than STEMIs. For example, left ventricular hypertrophy with tachycardia.

Fair point. I meant that if you see ST depression in an MI, then it's probably not _actually_ an NSTEMI, you just probably don't have the leads you need.

It's kind of startling that what is essentially a straightforward process improvement can have such a large impact. It's fantastic that it is happening, but it raises the question of whether there are similar opportunities, or more forcefully, where the similar opportunities are lurking. I'm reminded of the famous stuff about checklists and infections.

By taking a picture of it on their phone and transmitting it via Whatsapp, which is just about the ugliest, hackiest and probably borderline-legal way of transmitting patient data imaginable, but it gets the job done.

Patient privacy laws really do put some perverse constraints on the system sometimes.

  They included ambulance drivers’ transmitting electrocardiogram
  readings to emergency rooms, E.R. doctors’ deciding whether a
  person was likely having a heart attack, and hospital operators’
  summoning treatment teams with a single call. These hospitals
  also continually measured performance.

I know it's a really minor thing, but the term 'ambulance driver' is a little irksome... It's like calling a doctor a 'prescription writer'.

In the case of a heart attack patient, a paramedic recognizes the possible indications, takes an interprets an EKG, considers the possible differential diagnosis, makes the appropriate hospital notifications, and provides advanced level care to speed things along at the hospital (obtaining IV access, administering various medications, etc). We do a bit more than just drive the ambulance...

As an EMT, I too found this rather disturbing. Throughout the article, prehospital interventions were repeatedly not acknowledged. From the reference to "ambulance drivers" that you mentioned to things as subtle as saying that the clock starts when the patient rolls into the ER rather than when the ambulance arrives on scene, the article completely misses (or does not fully acknowledge) a hugely important factor in improving outcomes for STEMI: the prehospital care involved.

To be fair to the author, not every ambulance crew is paramedic level. And the term "ambulance attendant" was, at one time, in widespread use - to the point that the first level of EMS certification was actually called "Ambulance Attendant", if memory serves correctly.

I know it's annoying when non-domain-specialists misuse terminology, even slightly, but I could see giving them a pass on this one.

Yeah, hence my being 'irked' not 'really offended'.

I suspect most folks here consider themselves more than just "typists".

Though to be fair, I have a pretty high level of respect for 'Ambulance Drivers,' as conveyed by the inarticulate, if descriptive term. It's kinda like saying a 'Aircraft Carrier Steerer', or 'Space Shuttle Driver'. It might not be the actual term of art, but I do know that person is pretty badass.

Yeah, this jibes with my experience. I was rushed to UNC Hospital in Chapel Hill last Nov. with a STEMI, and I was amazed at how fast things progressed. Granted, time seems to compress in highly stressful situations, and I wasn't exactly timing with a stopwatch, but subjectively, I feel like I was in the ER maybe 15-20 minutes top, before they had me on my way to the cath lab. And the catheterization procedure took somewhere around an hour (maybe more, maybe less, hard to recall exactly). I never asked for the exact time until they had the catheter in my artery, but I'm pretty sure it was well less than 90 minutes.

At any rate, it was enough that I survived and the amount of heart damage I suffered was minimal enough that I was able to resume a completely normal life afterwards. By 3 months after the MI, I was biking 20+ miles at a time, and by 4 months had worked up to 75 miles a week, and then I raced in a 6 hour MTB endurance race about 5 months afterwards.

So yeah, speed is definitely of the essence. Luckily for me, and I am fortunate enough to live near a good hospital, in a community with top notch 911 and EMS providers.

I'm grateful to be in the same club. My Myocardial Infarction was in 2005: blockages in coronary arteries of 100%, 98%, 95%, and 80%. From the time I arrived at the E/R to the time the acted on me in the Catheterization lab was < 15 minutes. One hour and three stents later I was in recovery. My cardiologist explained that people with my symptoms, had they come to the E/R 3 years earlier, usually would die. I try to never forget to be grateful to all those who acted so quickly.

Few weeks ago I woke up with massive chest pain, struggling to breathe and pouring with sweat, rang ambulance and went to open door by time I'd limped to unlock it one of the fast response cars not ambulance was at my home total time was <5 mins and they had 12 leads on me.

Turned out to be an awful gallstone attack blnot heart attack but damn was I impressed with speed of response for early hours of Sunday morning - traditionally their busiest time.

Still ended up in hospital as they recommended that since I was projectile vomiting I should get checked out.

Perhaps too cynical after seeing medicos botch treatment for two family members. The main reason is the bottom line. If the allow people of marginal health to die too early, then their maximum utility diminishes unless the victim/patient can be kept alive for another 5 to 10 years.

This is a similar monetary basis for the cancer model - to extend the treatment period. Prolonging life has little to do with quality and meaning of life. The medical community is fundamentally corrupt.

Reading articles like this you suddenly realise that living in a sparsely populated rural area you sacrifice a hell of a lot in health care as as well as the more obvious career, education and entertainment benefits.

Having some risk factors like age and weight and living hundreds of km from a cardiologist is a bit of a worry. Are there cheap, effective ways of screening people with no history of heart problems so perhaps they could be more closely monitored or something?

Probably the biggest two that we have are mentioned in the article. Blood pressure and cholesterol. Hopefully you are getting your yearly checkups including blood work done.

But who calls an ambulance? Now that's an opportunity for a wearable device.

It would have to be a pretty awkward device if you wanted to automatically detect a STEMI. An EKG capable of diagnosing a STEMI requires at least 9 electrodes (most use 10+), placed in very specific locations around the body.

After I had my heart-attack last year[1], I was asked to participate in a clinical trial of a device called a "Life Vest". I did so briefly, although I ditched it pretty quickly because it was too uncomfortable to sleep in. But this thing was basically a wearable EKG/defibrillator. It monitored your heart rhythm and, if you went into a bad rhythm, would actually give you a shock from the defibrillator. Handy if you were asleep or had already fallen unconscious and couldn't call for help.

Of course it gave you a warning buzz first and had a "cancel" button so you could avoid being shocked if you were actually still OK. And it wouldn't shock you, AFAIK, unless you were in a "shockable rhythm"[2].

Anyway, it's still a bit big, bulky and uncomfortable and I doubt you'll see millions of people wearing something like this anytime soon, but as things get lighter and cheaper and better, it might just become mainstream.

[1]: https://news.ycombinator.com/item?id=8550315

[2]: https://suite.io/elizabeth-batt/4z1520d

Other than being slightly less invasive, this seems significantly inferior to an AICD [1]

[1]: https://en.wikipedia.org/wiki/Implantable_cardioverter-defib...

They are usually used as bridge devices until a patient can be scheduled for an AICD placement. Not all patients that need a permanent defibrillator are immediately fit for surgery and having a device like the Life Vest allows for them to be safely discharged from the hospital until it's time for surgery.

You generally want to wait six weeks after a heart attack before implanting an AICD, because the patient's heart frequently recovers to the point where an AICD won't be necessary at all. The LifeVest is supposed to bridge those six weeks.

Significantly less invasive. Not everybody needs a defib after a heart attack, especially in the case of minor, atrial infarctions.

Yeah, I'm not entirely sure about all the rationales behind the device. I just agreed to do the clinical trial, then wore the thing about a day and ditched it. :-)

My doctors initially suggested that I might need a implantable defibrillator if my EF didn't recover sufficiently, but it turns out that by about 3 weeks after, my EF was back close to normal, so no defibrillator required. Now I'm hoping I can talk my cardiologist into taking me off of Metoprolol at some point, since I do some competitive endurance athletics and that stuff supposedly hurts your performance. And from what I've been reading, some newer research suggests that there's no real benefit to continuing to take it more than a year after an MI.

It's like an F1 pit stop.

If only.

http://img.pandawhale.com/post-41481-ferrari-f1-pit-stop-per...

But you know, maybe someday it will be like this. You suspect heart attack, ambulance pulls up, does procedure on the spot, and you're back in business in 60 minutes. If they detect major tissue damage, then a quick stem cell injection plus you have to call in sick for a week.

All of today's medicine would have been impossible to believe even a century ago.

Nice, this makes it even more likely I will die a slow death from cancer instead.

Reply on news.ycombinator.com