Md. Paramedics Conduct "Heart Attack" Ridealong

Feb. 06--What happens when you have a heart attack?

I decided to find out with the help of county paramedics and the staff of the University of Maryland Baltimore Washington Medical Center in Glen Burnie.

With the cooperation and coordination of the Anne Arundel County paramedics from Earleigh Heights Station 12, and the Emergency Medical and CCL at UM BWMC, I was taken through the process of a "typical" heart attack.

Anne Arundel County Fire Department Firefighter Shawn Coleman, a paramedic, noted the average time elapsing from the initial call to 911 to a physician putting the finishing touches on the insertion of a life-saving stent or balloon via a slender catheter is 90 minutes. So, I noted times as I went through the process.

"Heart attack"

Inside a building located across Hospital Road from UM BWMC's main entrance, I was seated in the office of the hospital's head of marketing and communications, Kristin Fleckenstein.

At her signal, I feigned symptoms of a heart attack: pain in my left jaw and arm, fatigue, crushing pressure like an elephant sitting on my chest, shortness of breath, sweating and clamminess. Fleckenstein pretended to call 9-1-1.

Coleman and fellow paramedic John Bennett, entered the room. In a real emergency, they'd would have gotten to my side in less than seven minutes. Accompanying them was Lt. Jason Cornell, EMS supervisor for the northern part of the county.

The two paramedics quickly set up a LifePak System, one of 22 the hospital purchased and distributed to EMT units throughout the county. The LifePak System contains a heart monitor, defibrillator and an EKG -- electrocardiogram. It communicates the results to waiting hospital teams. The information is received there on LifeNet devices.

The paramedics explained, during an actual 9-1-1 call, the dispatcher would ask for an address and follow with more "yes -- no" questions about the victim. Is she awake and alert? Is she breathing normally? Is she clammy or changing color?

The dispatcher will suggest the heart attack victim chew an aspirin tablet while awaiting the ambulance's arrival.

While I remained seated in the chair, the two quietly asked questions about my symptoms, previous health issues, family history of heart disease, and medications I might be taking.

There was some paperwork.

In a real life situation, if the patient hasn't already chewed an aspirin before the paramedics' arrival, they would now give one to the patient with instructions to chew it.

Coleman explained they were preparing me for the trip to the hospital. An oxygen monitor was fastened to my right forefinger. A blood pressure cuff was attached to my right upper arm.

A blue constricting band was tied onto my left arm in preparation to take five blood samples.

My shirt was unbuttoned. Sticky pads containing electrodes were patted onto the skin of my chest, ribs and belly. Multi-colored wires were draped across my body. A portable oxygen tank was hooked up and a long clear tube was pulled over my ears and inserted into my nostrils.

Manipulating buttons and dials, the paramedics began transmitting EKG results and other data about my heart condition to technicians waiting in the Emergency Room and the CCL.

The stretcher was wheeled in.

It silently rose up more than a foot. I got onto it.

"It's battery operated now," said Coleman as the stretcher waswheeled down the hallway.

"Back strain has always been a problem with this work."

A relative or companion is able to ride along in the ambulance, in the front passenger seat. Otherwise, they are instructed to drive to the hospital carefully observing all traffic laws. They cannot speed along behind the ambulance.

On the road

The stretcher was lifted into the ambulance and locked into place.

Next to the stretcher, secured with several belts, Coleman sat in a chair that rotated. He could swivel to look at the monitor of the LifePak, locked onto a console, or turn to care for the patient on the stretcher.

He continued to send updates on my condition to the two waiting teams at UM BWMC.

Coleman set up a saline IV and prepared a needle he would have inserted into the back of my left hand in a real emergency.

The oxygen tube in my nose was hooked up to a spigot overhead in the ceiling. It leads to a larger, on-board oxygen tank on the year-old ambulance.

With gloved hands, he gingerly handled a tiny, but powerful, nitroglycerin tablet, used to rapidly thin the blood. Depending upon the responsiveness to the drug and a patient's condition, a heart attack victim would normally receive one every three to five minutes. The drug, Coleman said, "reduces pain and dilates blood vessels to let blood flow better." The technician places it under the tongue." (Not this time, however.)

At the emergency room

Emergency Department Clinical Operations manager Kelli Kitts, RN, and Dr. Neel Vibhakar, chair of Emergency Medicine, were waiting when the ambulance pulled up at the emergency room entrance.

They motioned to the paramedics who wheeled my stretcher into a side room. I was lifted onto a bed. Railings on either side were snapped upright.

In a real situation, the ER nurses would have removed all of my clothing and tucked it safely into a bag, while simultaneously garbing me in a hospital gown.

Vibhakar, Kitts and several nurses swarmed over me, verifying all the information they'd received from the paramedics.

My EKG results flashed on the LifeNet monitor, and were printed out on the spot. Results were also being printed upstairs in the CCL, and in Barbara Hamilton's office next to the CCL. The three lines that blipped along the sheet were fairly placid looking, unlike the sharp, high spikes usually indicating a heart attack in progress.

There was another round of questions and paperwork. Vibhakar, affiliated with the hospital for 10 1/2 years, calmly explained the condition of my heart, and options available. Almost all patients opt for immediate catheterization.

After a comforting pat on the shoulder, I was wheeled down two halls to an elevator.

About 30 minutes had passed.

At UM BWMC, the average door-to-balloon time, from where the patient first arrives at the emergency department to when the first device is used to reestablish blood flow to the heart muscle is 52 minutes.

Upstairs in the cath lab

In the CCL or cath lab, I was instructed to slide over onto the examining bed. Arching above it was an X-ray camera. Radiation emanated from beneath the bed. The camera could move and rotate above my body to capture various views of my heart and arteries.

Had it been a real heart attack, nurses would be preparing me for the insertion of a catheter tube into either the left or right groin by shaving the area.

I would have been injected with a moderate "twilight" sedation to would make me sleepy, and pain-free, but aware of my surroundings and able to communicate. Lidocaine, a local anesthetic, would be injected at the site where an incision would be made to insert the catheter.

My wrists were placed into soft restraining straps. Nurses wrapped my bare legs in a warm blanket. Another covering was placed over it; my torso was used as a tabletop for the doctor's instruments. A cap was placed on my head to cover my hair.

In lieu of an actual procedure, Dr. Samuel Yoon, an interventional cardiologist, showed me a catheter and demonstrated how the long, narrow, slightly curved tube could be inserted into an artery or vein in the groin and, using the camera's monitor, guided up my torso toward the heart. Once inside the heart, Yoon would inject a dye containing iodine inside the heart's chambers and vessels.

On the digital X-ray monitor, the dye would illuminate the heart, its valves, and arteries. He could see how the organ was pumping blood and how the blood flowed through the arteries.

Using the equipment, Yoon would ascertain which of three arteries was blocked, causing the heart to lose oxygen and malfunction: the left artery, the right artery or the circumflex artery that curves around behind the left side of the heart.

To open the blocked artery, the catheter is moved to that area. A tiny balloon is threaded through the catheter on a thin guide wire. When it reaches the blocked area, the balloon is inflated, pressing the blockage against the vessel walls.

Some arteries, weakened by the blockage, need to be reinforced. A stent slid over a balloon is guided to the spot. The balloon is inflated, pushing back the walls, then deflated, leaving the stent in place.

Visualize the tube-like metal spring in a ballpoint pen. A stent, made of surgical stainless steel mesh, is vaguely similar in shape and length.

The catheter is withdrawn and the small incision is closed up.

The patient is placed back on a stretcher and wheeled into the hospital's Critical Care Unit to recover for two or three days.

Later, Yoon and his team will visit the patient to discuss what happens next.

Unlike a real heart attack patient, I got up off the table.

It had all happened in about 88 minutes.

Call 9-1-1

At the University of Maryland Baltimore Washington Medical Center (UM BWMC) in Glen Burnie, 23 percent of those arriving at the hospital in the throes of a myocardial infarction or heart attack either drove themselves there, or were transported to the emergency room in a relative's or friend's vehicle.

For Dr. Samuel Yoon, medical director of the Cardiac Catheterization Laboratory at UM BWMC, that's too high a percentage.

"Don't drive," he urges.

"Call 9-1-1."

"With heart attacks, time is muscle," Yoon says. "If the blood flow is not restored quickly, the heart starts to die. The 'door to balloon' time is critical."

A person driving in full cardiac arrest is more likely to crash the car, potentially causing injury or death to themselves and others.

The hospital's Cardiac Catheterization Laboratory (CCL) receives as many as 250 cardiac arrest patients in a year, many in the middle of the night.

A person having a heart attack who does not call 9-1-1, denies themselves the life-saving benefits of receiving expert medical aid within minutes.

The hesitation to call 9-1-1 might arise from a concern about what a ride in an ambulance to either UM BWMC or Anne Arundel Medical Center might cost.

According to Russ Davies, spokesman for the Anne Arundel County Fire Department, if a patient is a county resident, the insurance company is billed and the balance is written off. If the patient has no insurance, the entire balance is written off. "So, no out of pocket cost for any county resident," Davies said. "Out of county residents get billed for what insurance doesn't pay."

Barbara Hamilton, director of Cardiology and Cardiac Catheterization, notes the hospital and its staff are proud of their record of speedy response and care time. In 2014, they received the American Heart Association's Mission Lifeline Gold Plus Award, the only one awarded at that level in the state.

This story has been revised to clarify response times and to correct Dr. Samuel Yoon's title.

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