John asked me to weigh in on the Chris Christie bridge scandal, specifically with regard to the report that EMT response was slowed in the case of a 91 year old unconscious woman who later died of cardiac arrest at the hospital.
[UPDATE FROM JOHN: A new story says that the woman died at home, couldn't be resuscitated. Her daughter, who voted for Christie, doesn't think the delay affected the outcome. And she's entitled to her non-medical opinion, but generally speaking I wouldn't recommend delaying an ambulance coming to resuscitate anyone whose heart has stopped, let alone someone that old.]
As you may know, after Gov. Christie’s office shut down traffic at the George Washington Bridge last fall, in order to punish the local mayor who didn’t support Christie’s re-election campaign, the resulting traffic jam affected local EMT service, including slowing the emergency response to the elderly woman. This is a look at how medical response time affects your potential recovery in a case such as the 91 year old woman’s.
It goes without saying that I don’t know the specifics of this woman’s case, so I won’t be diagnosing her. But I can speak generally about how delays in treatment affect potential recoveries in similar cases.
First, here’s how a local paper described what happened to the woman:
It also took EMS seven minutes to reach an unconscious 91-year-old woman who later died of cardiac arrest at a hospital. Although he did not say her death was directly caused by the delays, Favia noted that “paramedics were delayed due to heavy traffic on Fort Lee Road and had to meet the ambulance en-route to the hospital instead of on the scene.”
With regards to the second line of that quote, it may be that the ambulance is staffed with Emergency Medical Technicians (EMTs) who are limited in what they can do to assist a patient. Paramedics have more advanced training and can do more than EMTs can. For example, paramedics can start large, central IV lines, use advanced airway devices and perform other procedures that EMTs can’t. So a delay in the paramedics getting to the victim may have had an negative influence on the outcome.
Let’s start with a little medical background. The coronary arteries supply the heart with oxygenated blood. A heart attack occurs when plaque, on a wall of a coronary artery, activates platelets in the bloodstream. A clot forms obstructing all or virtually all flow of blood.
The heart, which is a muscle that works constantly, even during sleep, needs oxygen, just as other muscles do. With the coronary artery blocked, the heart muscle cells are deprived of oxygen. Over a short time the cells begin to die off. Most often, the longer the time till the heart gets its blood supply restored, the greater the damage. More heart cells die. Those cells can no longer help the heart pump blood. So the efficiency of the heart to get blood to itself and to other tissues (brain, kidney, liver and all other organs) decreases. As a result, those organs may become less- or non-functional. Also, the dead heart tissue cannot help conduct electrical impulses, necessary for the heart to beat regularly. So the heart may begin to beat erratically, causing another decrease in the tissue perfusion (perfusion: supplying tissue with oxygen and nutrients via the blood supply).
There are a few sayings in medicine that specifically mention this. One is “Time is myocardium (heart muscle tissue).” It means that the longer the area of the heart muscle goes without being reperfused, the worse the damage is. Ideally the faster the reperfusion occurs, the less damage. Reperfusion can be accomplished by removing the clot. This can be done by “clot buster” medications injected intravenously (anticoagulants), or the preferred method, putting a catheter into the affected coronary artery and placing a stent.
Often the phrase “door to balloon time” (sometimes written D2B) is used. Meaning the time the patient arrives at the ER till the time the patient gets a cardiac catheterization done to get the heart tissue reperfused. At first, when the benefits of time to reperfusion were first studied, a D2B of 120 minutes was thought to be good. Research showed that the faster the clot was removed allowing reperfusion, the better the outcome (less damage to heart and other organs.) Many hospitals are trying to bring D2B time down to less than 60 minutes. So ELAPSED TIME IS CRITICAL (Remember the phrase, “time is myocardium.”)
Of course, no one can say exactly what would have happened in this woman’s case. We don’t have all the details. For example, we don’t know if she had a previous heart attack, how long an area of her heart was without blood, or which coronary artery(ies) were involved. All of those, and several other factors, can bear on the outcome.
Actually, for the EMS to reach her in seven minutes (according to news reports) is a fairly rapid response time. The problem lies in how long it took them to get her to the hospital where the clot busting drugs could be given or cath could be done. The delay in getting her to the hospital would be just as important as how soon the EMTs got to her. Presumably, traffic congestion could have also delayer her transport to the hospital – it’s an important question for someone to look into.
If, when when EMS reacher her, she was unconscious, that could mean that she had suffered cardiac arrest due to the heart attack, or that her blood pressure was low (shock) because the heart was not pumping efficiently, or that her heart was pumping too erratically to get enough blood to her brain, or she could have fallen from the heart attack (MI = myocardial infarction) and knocked herself out.
Also, the story says she died from cardiac arrest. She may have arrested in transit to the hospital or after she got there.
In cardiac arrest there is no blood flow to any organ heart, brain, etc. So if there were no flow, she’d have had brain damage that would have started soon after the brain was deprived of oxygen. (Time is also neurons – the longer brain cells are without blood, the more of them will die.) Neither the brain nor heart can regenerate very well.
1. Delay in getting treatment is critical. And that delay will have a negative impact on the outcome. There could have been a delay in getting to patient initially, a delay in making diagnosis, a delay in transporting her to hospital, a delay in starting treatment, or a combination of these. The bottom line is that the longer it takes, the worse the outcome (in general). Time is myocardium.
2. Depending on the area of the heart attack, the size of the area of heart involved, history of previous heart attacks, etc., it’s possible that nothing would have saved her life. But it’s also possible that prompt treatment would have saved her.
3. Heart attack and cardiac arrest are different. It sounds like she may have had a heart attack (MI) at home, and later had a cardiac arrest at the hospital. An MI could have lead to cardiac arrest. Cardiac arrest, even in a hospital, has poor survivability.
4. It’s more likely that, at 91 she may have had previous heart disease or even a previous heart attack. If that were true, her odds of surviving a heart attack at her age were probably less than those of a healthy 60 year old, but it’s impossible to say for sure. I’ve treated a 103 year old for an MI and she walked out of the hospital. I’ve treated a 14 year old who couldn’t be resuscitated and died.
The upshot is that rapid treatment can be crucial, and delay can lead to death.