At heart, it’s the physician’s call
“ER”: “Scoop and Run,” Nov. 23.
The premise: ER resident Dr. Abby Lockhart (Maura Tierney) accompanies the crew of a medical evacuation helicopter to a local community hospital, where an 88-year-old woman is having a heart attack. Abby’s hospital is a Level One Trauma Center with a cardiac catheterization lab, which the other hospital lacks. But when Abby and the emergency response team arrive, they find that the woman is already in cardiogenic shock (extreme heart failure) and intubated (has had a breathing tube inserted in her trachea). The woman has a blood pressure of 74/38, a heart rate of 144, and she is receiving the vasopressor drug dopamine to keep her blood pressure from dropping further. A clot-dissolving drug has been given without any effect. Abby also discovers severe EKG changes -- known as “tombstoning” (giant abnormal waves) -- indicating much heart damage. Seeing the patient’s condition, Abby states, “She’s not coming back from this.” She favors leaving her in the community hospital, but the paramedics disagree. They tell the patient’s family: “It’s your mom’s only chance.” The paramedics prevail, and the patient is transported. But the woman develops a lethal arrhythmia en route (ventricular fibrillation) and dies.
The medical questions: Is it reasonable to airlift an intubated patient with extreme heart damage to a heart center for emergency catheterization? Is it possible to know if an elderly patient in this condition will survive? Does the fact that the patient has already received thrombolytic treatment interfere with the potential treatments she may later receive? In a disagreement between paramedics and a presiding physician, in which the family must go along with the decision, who is in charge?
The reality: Prompt treatment during a large heart attack, with injury apparent on the EKG, is obviously crucial. The American Heart Assn. and the American College of Cardiology suggest an ideal response time -- from first medical contact to undergoing a balloon procedure to open a blocked coronary artery -- of less than 90 minutes.
A study in the June 7 issue of the Journal of the American Medical Assn. showed that when a heart attack patient is unstable from heart failure and shock, early balloon angioplasty or heart surgery improves his or her chance of surviving six years by 67% over medical treatment alone. Although the elderly do not fare as well, the study suggests that they should at least be considered for transfer to a hospital with advanced facilities. “If there is doubt about the elderly patient’s suitability, then transfer and assess,” says Dr. Judith Hochman, lead author in the recent study.
Abby is right to hesitate before transporting a patient this old and in this condition who might die in transport -- but elderly people can still recover.
The fact that the patient has already received clot-dissolving agents increases her risk of bleeding during an emergency catheterization, but does not preclude the procedure (in which a catheter is threaded from a large artery up to the tiny coronary arteries that supply oxygen to the heart). Once the blocked arteries are identified, a small balloon followed by a tiny stent can be inserted or surgery can be considered.
As far as who is in charge, emergency response teams should defer to specially trained doctors known as medical control physicians when decisions are this complex. These physicians are on-call for trauma centers. Ideally, such a physician would have received the updated medical information before the rescue helicopter took off, so that a decision could have been made on the proper use of resources. Though Abby lacks the formal rescue training of a medical control physician, she is assuming this role once she boards the helicopter. According to one emergency medical services director interviewed for this story: “No paramedic is going to overrule a doctor on the scene. You just don’t see that. That’s just TV.”
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He can be reached at marc@ doctorsiegel.com.
