“OFTEN, THE PATIENT IS AT DEATH’S DOOR.”

BREVARD COUNTY, FLORIDA – Early one Sunday morning, as Dr. Cesar Jara began his rounds at Holmes Regional Medical Center, his STEMI Alert pager went off.

The race was on to save Lynn Gornto’s life.

The STEMI Alert, the 911 for patients with acute heart attacks, signals to a highly skilled healthcare team the critical need to stabilize a patient suffering from ST Elevation Myocardial Infarction, or STEMI.

Gornto was an unlikely poster girl for a STEMI. “If it happened to me, it can happen to anyone,” said the Satellite Beach, Florida resident.

She had no family history of heart disease, did not smoke or drink and she exercised regularly, ate healthy and was not overweight.

“Two weeks before the heart attack, I had been whitewater rafting in Coasta Rica, and a week before I had been hiking,” she added.

At six in the morning that Sunday, however, Gornto experienced unbearable back pain. “It hurt so bad I told my husband I needed to go to the hospital,” she said. “It was excruciating pain between the shoulder blades.”

The couple opted for Wuesthoff Medical Center Melbourne because Gornto was familiar with the hospital after hip surgery. “A half-hour after I got there, I flat-lined,” said Gornto. “I didn’t remember anything for the next three hours.”

Gornto had suffered a STEMI.

Dramatic and Deadly

A Stemi is usually recognized by singular changes on an electrocardiograph, typically significant elevation in the ST segment, which denotes severe lack of blood flow to the heart muscle. Each year, about 400,000 persons will suffer a STEMI.

“When it happens, it’s dramatic and deadly,” said John Heller, Holmes Regional Medical Center’s director of cardiac services and a registered cardiovascular invasive specialist.

A STEMI is usually recognized by singular changes on an electrocardiograph, typically significant elevation in the ST segment, which denotes severe lack of blood flow to the heart muscle. Each year, about 400,000 persons will suffer a STEMI.

“When it happens, it’s dramatic and deadly,” said John Heller, Holmes Regional Medical Center’s director of cardiac services and a registered cardiovascular invasive specialist. “Often, the patient is at death’s door.”

A STEMI causes significant coronary artery obstruction, which deprives the heart muscle of blood and oxygen, leading to irreversible heart damage or death if not treated within six hours of symptoms onset. “This is why dissolving the clot and mechanically opening the artery have to be started swiftly,” said Jara.

When the STEMI Alert goes off, the entire STEMI team, from emergency room personnel to cardiac catheterization laboratory technicians to physicians, is notified to begin the finely tuned process that moves the patient rapidly through recovery.

Running Against the Clock

Time is the enemy of a STEMI patient. With a STEMI, a few minutes can make the difference between a complete recovery or death. “You are running against the clock,” said Jara. “In other types of heart attack, the patient can be stabilized.  With STEMIs the goal is 90 minutes for treatment.”

“Door to balloon time,” the time from arrival at the ER to opening the blocked artery in the cath lab, should, in a perfect world, be no more than 90 minutes.

“Only 15 percent of hospitals hit that 90-minute range,” said Heller. “Most are in the 120-minute range. At Health First, we’re hitting the 90-minute range about 85 percent of the time.”

Not all hospitals can provide this time-critical service, but well-designed systems have been established to ensure timely transfer of STEMI patients to healthcare facilities that can treat them most effectively.

Gornto had wasted precious minutes by having her husband drive her to the hospital instead of calling 911.

“It is paramount for the patient to call EMS instead of driving, because EMS can activate the STEMI team,” said Jara.  “If the patient doesn’t call 911, you might lose the whole game.”

Emergency Medical Services are the starting point in the STEMI treatment chain. “First responders commence a very intense medical treatment and at the same time triage the patient to the proper level and place of care, in this case activating the STEMI Alert,” said Jara.

“EMS will alert the Emergency Department that a STEMI patient is on the way,” said Nicki Andersen, manager for Holmes Regional Medical Center’s emergency department, the busiest ED between Daytona and West Palm Beach.  “We treat a STEMI the same as a trauma case.”

Time is Critical

Brevard County ambulances and First Flight play vital roles in treating STEMI patients. Many times, the gleaming First Flight helicopter is the best and fastest way to whisk a patient to the cath lab.

“First Flight sets out the call to the whole system, setting it in motion, with the goal of hitting that 90-minute range,” said Heller.

In Gornto’s case, Jara gave his okay to airlift the patient to Holmes Regional Medical Center, the closest hospital with the resources necessary to treat her case. The First Flight helicopter whisked the unconscious Gornto from Wuesthoff Melbourne to the landing pad atop Health First’s Heart Center.

The First Flight helicopter lifts off within five minutes after receiving a call and can turn around a patient in a hospital within 15 minutes. “We can provide quick transportation if there’s a patient in another hospital or in the field,” said Mark Clemens, Health First’s director of emergency services. “Our focus is in providing quality care in a very short time period.”

Clemens is also chairman of the Emergency Management Services Advisory Council, which approves grants for emergency services in Brevard.

Within six months, Brevard County ambulances will all be outfitted with Bluetooth telemetry technology that will allow emergency personnel to send ECG strips right to the emergency department, so the physician on duty can start preparations even before the patient arrives, shaving additional minutes in the treatment of STEMIs. “Eventually, the goal is to go directly to the cath lab,” said Clemens.

STEMIs are very bad news, but the good news is that Brevard is particularly well positioned to treat them. “Brevard County counts with one of the best systems in the nation to treat patients with heart attacks,” said Jara.

Interventional Specialists

On the Space Coast, both Holmes Regional and Wuesthoff Medical Center Rockledge have interventional cardiology cath labs to promptly treat STEMIs. Effective STEMI treatment is the result of a strong partnership between specialists and hospital management and staff.

Of the 20 Heart Center cardiologists, six are specialists in interventions. Health First’s team of dedicated cardiac interventionalists includes Drs. Charles Croft, Shashin Desai, Gopal Gadodia, Cesar Jara, Steve Karas and Norberto Schechtmann.

“It is important to recognize these men as the “physician team” that works 24/7 365 days a year to keep Brevard County residents in a place that can provide expert care,” said Heller.

Interventional cardiologists go through an additional year of specialty training. Besides board certification, continuous experience with a high volume of cases provides the best outcome. “This is a top-shelf staff,” said Heller. “The skill set of the people in the room is critical. Health First has made a huge investment in the community.”

The team continues to be committed to finding ways to further streamline the system. “The interventional cardiologists came here as a group because they wanted to devote their time to hit the 90-minute mark,” said Holmes Chief Operating Officer Judy Killebrew.

“Holmes Regional Medical Center has dedicated a considerable amount of energy and resources to developing a STEMI program.”

Cardiologists meet every month with staff and management to review cases and determine how they can do better.  “We’re constantly working to improve the process and our patients’ outcomes,” said Sandra D’Cruz, the HRMC’s Vice President of Operations.

In the emergency room, a STEMI patient such as Gornto receives lightning fast assessment. “The emergency department basically starts the process in the hospital,” said Andersen.

After ED, it’s up to the precise, efficient and timely process in the catheterization lab for patients like Gornto. “She was stable, but dependent on the medical support of the team,” said Jara.

Percutaneous Coronary Intervention

Vital communication between Jara and the emergency room physician at Wuesthoff included the patient’s clinical status and initial medical management to ensure she was optimally prepared to go directly into Holmes’ catheterization lab for diagnostic evaluation and the potentially life-saving procedure called Primary Percutaneous Coronary Intervention, or PCI, which opens up the blockage in the artery to prevent permanent damage to the patient’s myocardium, or heart muscle.

“We have shown that an invasive approach is better than giving a drug,” added Jara.

In the cath lab, Jara commenced treatment, assisted by nurses with broad knowledge of ICU and emergency care, and radiology technologists who specialize in catheter-based cardiovascular procedures.

The eight procedure rooms at Holmes’ Cath Lab, where the lab’s 26 skilled cardiac professionals assist physicians, are sometimes booked solid, and that is a good thing, because it reflects the hospital’s high volume of cases. “There is proven superior outcome if a patient with a heart attack is treated in a high volume center,” said Jara.

Although the lab boasts a 30-room prep and recovery section, STEMI patients bypass this area. “They do not pass go, do not collect $200,” said Theresa Dunne, manager of cardiac services. “Time is critical.”

Holmes’ cath lab contains the most modern technology available, including highly specialized equipment such as laser catheter therapy for dissolving large clots and the Angio-jet, a high-pressure saline jet with vacuum.

“The cath lab team is not only in the top 75 percentile in the nation, but they don’t forget that a heart attack is also an emotional experience for the patient and relatives,” said Heller.

Jara began with cardiac catheterization to identify the anatomy of the blockage, first inserting an Intra-Aortic Balloon Pump (IABP). This balloon attached to a catheter is inserted through a leg artery and advanced into the aorta, which is the main arterial trunk of the vascular system. The balloon is inflated and deflated to more effectively maximize flow to specific arterial branches off of the aorta.

In his 32 years in the field, Heller has seen a vast change in treatment of STEMIs, and a dramatic decrease in mortality rates. In the 1980’s, STEMIs were primarily treated with medication...and a lot of crossed fingers. Mortality rate was between 25 to 30 percent of patients, versus the current rate of only four to five percent.

“The current trend started about five years ago as an evidence-based clinical practice recommendation from the American College of Cardiology,” said Heller.

“It was intended to create awareness of the need to treat STEMI heart attacks in a timely manner. Out of that action came the ninety-minute target of door-to-balloon time, and evolving efforts across the country to create STEMI heart attack programs.”

STEMI is Quick, Dramatic

The Florida State Legislature has identified two different levels related to a hospital’s available cardiac services. Level I hospitals do not have open-heart surgery on site, but can support on site elective and emergency primary coronary intervention through a transfer back-up coverage agreement with a provider of level II services. “The intent is to provide a pathway to facilitate STEMI intervention in a timely manner,” said Heller.

“Parrish Medical Center is the only Level I cardiac center in Brevard County. They have a transfer agreement in place with Health First to provide back-up cardiac surgery if needed.”

Level II centers are the big heart program hospitals like Holmes Regional, Wuesthoff Rockledge, Orlando Regional Medical Center, Halifax and Florida Hospital. At Holmes, physicians treat about 300 STEMIs annually. “STEMIs are but a small fraction of heart attacks, but they are the most deadly,” said Heller.

Everything about a STEMI is quick and dramatic, including recuperation time.  After the plaque in her artery was cleared and a stent placed, Gornto remained in intensive care for three days, followed by two days on the “heart floor,” where nurses began preparations for her discharge. After just five days in the hospital, she was home. Not bad for such a close brush with death.

“Nursing is an integral part of the STEMI care team,” said Bonnie Rudolph, Chief Nursing Officer for Health First. “From the emergency department to the cath lab to ICU, nurses coordinate the care of STEMI patients.”

Education to prevent reoccurrence is an important aspect of nursing care. “The discharge process starts when the patient is admitted,” said Killebrew.

Nursing staff, together with the hospital’s tele-education program available in every room, clearly explain the patient’s condition and what lifestyle changes are necessary to minimize a recurrence of a STEMI.

For Gornto, the ordeal ended happily. She recovered without brain or heart damage and was quickly back to normal.  “I was definitely very lucky,” she said. “I know Dr. Jara and the Holmes team saved my life.”

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Tagged as: American College of Cardiology, Angio-jet, Bonnie Rudolph, BREVARD COUNTY FLORIDA, cardiac catheterization, catheterization lab, Dr. Cesar Jara, Florida Hospital, Halifax, Holmes Regional Medical Center, John Heller, Judy Killebrew, Lynn Gornto, Orlando Regional Medical Center, Parrish Medical Center, Sandra D’Cruz, ST Elevation Myocardial Infarction, STEMI ALERT, Theresa Dunne, Wuesthoff Medical Center