Innovation

Clotbusters

Winnipeg paramedics use new tools to save lives

Winnipeg paramedics use new tools to save lives

BY SUSIE STRACHAN
Winnipeg Health Region
Wave, Summer 2009

Herb Griffith was about to go to bed one January evening when his left shoulder started to ache.

More puzzled than concerned, the 40-year-old industrial painter headed into the kitchen in search of some Aspirin. Within seconds, the pain made him forget what he was looking for. Within minutes, the husband and father of a four-year-old daughter was on his back on the floor, having trouble breathing and unable to think.

Awakened by the commotion, Griffith's wife, Mary-Lyn, called 911 and relayed the information that her husband was in severe pain and with an irregular heartbeat. Herb was having a heart attack, a medical emergency that kills 19,000 Canadians a year.

"My chest hurt so badly, it felt like I wanted to rip out my muscles, Griffith says, recalling the events of that evening. "I've never experienced chest pain like that."

Fortunately for Griffith, he lives in Winnipeg. Just last July, the Winnipeg Fire Paramedic Service, in partnership with the Winnipeg Health Region's Cardiac Sciences Program, launched a new initiative for treating heart attack patients like Griffith in the field, one that provides the right treatment at the right time in the right place faster than anywhere else in Canada. The result is that patients receive the appropriate treatment quicker than they would have a year ago, a development that has resulted in lives saved.

Here's how the new program, known as the STEMI Management Protocol, works: Paramedics responding to a call send a reading of the patient's heart via a secure, wireless network to a computer server at City Hall, which in turn sends an e-mail to hand-held BlackBerrys carried by four cardiologists: Drs. James Tam, Steven Hodge, Roger Philipp, and Davinder Jassal, and two emergency physicians: Drs. Erin Weldon and Rob Grierson. After conferring with the paramedics via cell phone, the physician determines the best course of treatment. Options include injecting the clot-busting drug Tenecteplase (TNK), rushing the patient to the state-of-the-art Bergen Cardiac Care Centre at St. Boniface General Hospital for emergent percutaneous coronary intervention (PCI), or taking the patient to the closest hospital.

Dr. Roger Philipp, adult cardiologist and Director of the Heart Catheterization Laboratory explains, "PCI is a direct method of treating the blockage. A small catheter is inserted into the leg or arm and advanced to the coronary arteries, allowing the physician to steer a soft tip guidewire across the blockage. This allows for direct clot removal, and/or insertion of a balloon and stent to keep the artery open."

In Griffith's case, the decision was made to have the paramedics inject the clotbusting drug. "Three minutes after my wife called, the paramedics were on the scene. I was barely conscious. The paramedics put me right into the ambulance and put a 12-lead EKG on me to monitor my heart," Griffith recalls. "There were three people working on me. One was sending my information to the cardiologist. They injected the (clot-busting) drug into my system, and 30 seconds later I was coherent. It was like a switch had been thrown. It was 28 minutes from the point my wife called for the ambulance to having the drug injected."

Dr. Rob Grierson, Medical Director of the Winnipeg Fire Paramedic Service, says Griffith's case illustrates the effectiveness of the STEMI program. "The important thing about this program is that the definitive treatment decision is being made right in your living room or in the ambulance," says Grierson, adding that the process dramatically cuts treatment time. In the past, paramedics didn't have the ability to consult with a physician about injecting a clotbusting drug, nor did they have the ability to designate a patient as a priority for the Bergen Cardiac Centre, which is the go-to facility for serious heart attack patients.

"We get the EKG literally within 45 seconds of transmission, and then talk to the paramedic crew about the best treatment. I've taken calls while coaching my son's football team in the field, so you can literally be anywhere, and still save lives," says Grierson, adding that the physicians are volunteering their time for this program, along with paying for the airtime on their BlackBerrys. The BlackBerry devices for the program were donated by MTS Allstream.

"Before this program, people like Herb Griffith would have been transported to the nearest hospital, assessed upon arrival and treated then. But that is precious minutes lost. Herb is not a cardiac cripple today because of the STEMI program. His heart is normal because he was treated in the field," he says.

Dr. James Tam, Section Chief of Cardiology for the Winnipeg Health Region's Cardiac Sciences Program, says being in contact with paramedics in the field is advantageous even when the patient is being conveyed to the Bergen Cardiac Centre. "We have a receival team at the hospital, made up of three nurses and a resident physician, who meet the patient as they are brought in. This gives time for the catheterization team, who may have gone home for the night, to return to the hospital," says Tam. "The co-operation between the WFPS and the hospital allows us to achieve treatment times unheard of in most other cities."

The numbers tell the story. Out of 80 patients treated by the STEMI program between July 21, 2008 and April 21, 2009, 67 were taken straight to the Bergen Cardiac Centre at St. Boniface, and 13 were given a clot busting drug in the field. Of those taken to the Bergen Centre, the treatment time from EMS arrival to eventual opening of the artery by PCI averaged about 74 minutes, compared to the national standard, which is over 90 minutes. In the world of critical care, that's something of a world record. Bottom line: The mortality rate forheart attack calls involving STEMI program paramedics dropped to two per cent from eight per cent during this time.

Winnipeg is the first city in North America to utilize digital data transmission this way. "Halifax has something similar, and so does Edmonton, and more recently, Toronto, but we were the first to put the technology together in this fashion," Grierson says.

Going forward, Grierson says he would like to see the STEMI system used more often. The WFPS responds to about 6,000 calls from people with chest pain every year. Of these, about 200 cases involve heart attacks. But Grierson says WFPS only responds to about a third of the total number of heart attack cases in Winnipeg. About two thirds of the people who suffer heart attacks make their own way to the hospital. "It would be nice to get the word out about this program, to get more people with chest pain to call 911. The ideal would be to treat 70 or 80 per cent of STEMI (heart attack) patients in this protocol instead of the current 30 per cent," says Grierson.

Other cities in Canada, and around the world, will learn about Winnipeg's STEMI program at a presentation in Barcelona, Spain, in August at the European Society of Cardiology meeting.

"Winnipeg is on the cutting edge in our use of the technology and co-operation between segments of the system," says Grierson, who envisions the STEMI program expanding to other centres in Manitoba and beyond. "Calgary EMS came to see how we do it. When is the last time someone came from the oil capital of Canada to see what Winnipeg is doing?"

Herb Griffith credits Winnipeg's program with saving his life. "I'm just awestruck at the change technology has made."

Griffith is working to ensure he doesn't have a repeat visit from the paramedics. He doesn't smoke, keeps his weight down, exercises regularly, has his doctor monitor his blood pressure and cholesterol levels, and doesn't let the little things in life stress him.

"I appreciate my wife and child more. I'm gratified I'm here to see my daughter grow up," he says. "The heart attack came out of the blue, and today, I'm living proof that technology is helping the medical system save lives."

Susie Strachan is a Winnipeg writer

Wave

About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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