An Alliance to Save Lives by Saving Time

On Dec. 5, 2017, 57-year-old Ira Schalk began to feel nauseous on his job at a lead mining operation near Viburnum, Mo. For days he had felt tired, but thought it might be the flu. It wasn’t.

Discomfort, but no pain

“It didn’t hurt,” Schalk said. “It felt like I had a gas bubble in my chest that I couldn’t get out.” He was sweating and began to feel sicker as he walked to the mine site’s office.

In September, a stent had been placed into one of his heart’s arteries, and there was a history of heart disease in his family. Still, Schalk wasn’t sure it was anything serious, but he called a coworker. “When he got there I told him something was going on, but I didn’t know what,” said Schalk.

The (extremely) close call

The coworker asked if he should get the automated external defibrillator (AED). “I was still sort of joking with him when I said, “Well, go get it, we might need it,” said Schalk.

When he returned with the AED, the man said he wasn’t sure how to use it.  Schalk, who is a volunteer firefighter and an emergency medical responder, explained how the device worked. Just as he finished, Schalk said, “There, you’re ready to go.” Then, Schalk passed out.

Schalk had gone into ventricular fibrillation/cardiac arrest, a condition in which the heart quivers rather than beating in a normal rhythm. AEDs produce an electronic shock to stop dangerous heart rhythms. His coworker shocked him twice, and was performing CPR when Schalk awoke, then blacked out again.

Heart LifeLine Alliance℠ saves lives

The next thing Schalk knew was that a nurse in an Air Evac helicopter was putting headphones on him; she explained that because of the wind it was going to be a rough ride. He next regained consciousness just as he was being wheeled into the cardiac cath lab at Missouri Baptist Medical Center, known also as MoBap.

Schalk had entered a highly coordinated system of care – the Heart LifeLine Alliance (HLLA), the region’s leading heart attack network formed in 2008 to provide rapid treatment to ST-elevated myocardial infarction (STEMI) patients.

That care began with the ambulance crew – when they arrived at his job site and performed an EKG – then drove him to the nearest Air Evac landing zone. There Schalk was airlifted approximately 100 miles to MoBap’s cath lab. Waiting for his arrival were Stuart Higano, MD, Missouri Baptist interventional cardiologist and HLLA medical director, and his cath lab team.

The EKG results sent ahead of Schalk, revealed he had sustained a STEMI. Dr. Higano quickly determined the stent implanted three months earlier in Schalk was functioning well. It was another artery that needed attention.

Why is a STEMI different?

In the cath lab, Dr. Higano inserted a 14-thousandths-of-an-inch diameter wire through Schalk’s groin, up his femoral artery, then through the aorta and into his right coronary artery, which was blocked. With a STEMI heart attack, the artery is completely closed with the surrounding heart tissue receiving no blood flow.

According to the American College of Cardiology, STEMIs are not rare events. Nearly 400,000 patients are admitted to U.S. hospitals with a STEMI each year, and they are particularly dangerous.

Dr. Higano explained when the heart muscle receives no blood, it begins to deteriorate rapidly and irreversibly. This medical fact is why STEMIs are so dangerous and it is the driving force behind the HLLA. “Minutes mean heart muscle lost,” Dr. Higano said. “The idea is to get blood flow re-established as soon as possible.”

Eliminating the clot and the ‘silos’

Dr. Higano positioned a balloon over the wire in the section where Schalk’s artery was blocked. The balloon was inflated, then deflated, opening up the blocked artery. Then a metal-wire stent on a balloon was placed in the blocked artery. The balloon was inflated to expand the stent, then the balloon was deflated and removed. The artery was again supplying blood to the heart after a 15-minute procedure.

“What is important about STEMI programs is that before, we had these silos of activity,” said Dr. Higano. “A patient having a heart attack would come by ambulance to the emergency room; if that hospital did not have a cath lab, he would be put in a second ambulance or helicopter and sent to one that did. There a cardiologist needed to be brought together with a cath lab team. So you had a lot of people doing different things and they weren’t all tied together. The result was a loss of critical time,” he said.

Beating the standard

MoBap’s HLLA serves metropolitan St. Louis, as well as outlying rural communities within a 120-mile radius. The alliance between emergency medical services, rural hospital emergency rooms and MoBap’s cath lab is constantly monitored for its performance. For example: According to national standards, the time from when a STEMI patient enters a hospital emergency room until the time the balloon is inserted and inflated should be no more than 90 minutes (called door-to-balloon time or D2B). At MoBap, the HLLA standard D2B is 60 minutes or less. Dr. Higano noted the average is in the 50s.

Thanks to the coordinated care of the HLLA, Schalk’s prognosis is good. Though still regaining strength, he has returned to work, and realizes how fortunate he was.