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There is a saying
that all politics is local. This can also be said about emergency cardiovascular
health care.
There is no question
that medical centers such as the Mayo Clinic and the Texas Heart Institute
have reputations for excellence in the treatment of cardiovascular diseases.
That is of little help, however, when your abdominal aneurysm ruptures as
you are exiting the causeway in Mandeville, when your leg gets white, cold,
and extremely painful while you are shopping in Covington, when your arm becomes
numb and paralyzed as you watch television, or when you develop severe chest
pain at a local restaurant!
At those defining,
life-changing, and, unfortunately, sometimes life-ending moments, the Mayo
Clinic, the Texas Heart Institute, and even Tulane Medical Center, Ochsner
Foundation Hospital and East Jefferson General Hospital, are of little relevance.
What is important is the quality of the local health care system. Can it handle
your acute cardiovascular emergency?
Many years ago,
the northshore undoubtedly lagged behind New Orleans in the treatment of cardiovascular
disease. When I began my practice in Covington two decades ago, heart attacks
were treated conservatively with morphine, bed rest, cardiovascular monitoring,
oxygen and other measures. Physicians did an excellent job of treating patients
with the available resources. Those patients who survived or were critical,
however, had to be transferred to the southshore for further care or evaluation.
A limited amount of extremity arterial bypass surgery was performed, but the
peripheral arteriograms needed to plan those bypasses were frequently performed
across the lake. In the early 1980s, peripheral arteriogram suites became
available locally, followed by cardiac catheterization labs in the mid-80s.
With the development
of the first coronary angiogram suites, we saw the truth of the statement,
“You build it, and we will come.” Coronary angiograms are a trademark
of the specialty of cardiology. Without a cath lab, a cardiologist does not
have the tools he needs. Two of the first cardiologists to arrive on the scene
were Dr. Joseph Gerry and Dr. James Smith. Along with the cardiologists came
the cardiovascular surgeons. Dr. George Barnes was the first to live in the
parish. He and his partners began heart surgery programs at Slidell Memorial
Hospital, and then at Highland Park Hospital in Covington. Within a few years,
all four acute care hospitals in the parish had active cardiac surgery programs,
and increasing numbers of cardiologists and cardiovascular surgeons were practicing
in the community. In the past five years, the cardiovascular programs have
matured to the point that almost all cardiac services are available in St.
Tammany except pediatric cardiac surgery and transplantation.
Descriptions of four of the most common cardiovascular emergencies, as well as northshore capabilities for treating them, follow.
Heart Attack
When you have
a crushing chest pain beneath your breastbone, there is a good chance that
you might be having a heart attack. A heart attack, or acute myocardial infarction,
occurs when a portion of the heart muscle is not getting enough blood and
oxygen. The small artery supplying that part of the heart is blocked, most
often by build-up of atherosclerotic plaque. What turns a chronic blockage
into an acute heart attack is spasm, thrombosis, or plaque rupture. The most
important fact about a heart attack is that unless the blood supply is restored
to that muscle, it will die.
While certain medications such as nitroglycerin can sometimes temporarily
increase blood flow to the muscle, there are two approaches to save it. One
is to give clot-busting drugs (called fibrinolytic agents) in the emergency
room and follow up with an angiogram to see if a coronary balloon angioplasty
or a stent is required. Today, this approach is used primarily in smaller
hospitals.
The second approach is to take the patient directly to the cardiac catheterization
lab, perform an angiogram and re-open the arteries immediately. This requires
a functioning cardiac cath lab and a highly skilled team of cardiologists,
nurses, and technicians at all times. For those cases that require immediate
bypass surgery, an operating room and full cardiac care staff must be available.
This is the standard of care in acute care hospitals on the northshore for
the treatment of a heart attack.
Abdominal
Aortic Aneurysm
Another emergency
cardiovascular condition that must be treated locally is a ruptured abdominal
aortic aneurysm. An aneurysm occurs when an artery develops a weakness that
allows a portion of the artery to balloon out abnormally. Eventually, this
area of the artery can weaken so much that it leaks or ruptures. The abdominal
aorta, or the main artery in the abdomen, is one of the common areas for aneurysm
formation. Because of its location, however, an abdominal aortic aneurysm
may remain silent and unsuspected until it ruptures.
Our acute care
hospitals do have the capability to treat a ruptured aneurysm. Many such patients
die without reaching a hospital, however - and even in the best hospitals
the mortality rate is about fifty per cent. The best way to treat an aneurysm,
therefore, is before it ruptures.
The standard treatment, to replace the abdominal aneurysm with an artificial artery, requires a long abdominal incision and a somewhat lengthy hospital stay. In recent years, however, an exciting new method has been developed to treat the aneurysms from inside the arteries, avoiding the large abdominal incision. In certain patients, two small incisions can be made in the groin, the arteries can be opened, and the graft deployed inside the aneurysm using angiogram techniques. This procedure has been successfully used by Dr. David Kaplan in Slidell and by Dr. Barnes and me in Covington. Other local surgeons are learning the new procedure.
Blood clots
A third cardiovascular
condition that requires emergency care is the treatment of sudden blockages
in the arteries to the extremities. When a blood clot moves from the heart
to the leg, or when a narrowed area in an artery to an extremity clots completely,
or when a previously placed bypass graft to the leg stops working, the patient
usually needs urgent attention. Unless the patient has enough secondary circulation,
the physician has only six to eight hours to restore the circulation before
permanent damage results. This may lead to paralysis or amputation. Emergency
surgical thrombectomy has been the standard of care for several years and
is often effective.
In recent years, however, non-surgical techniques have been developed to treat this problem. One technique is to place a catheter into the clot and drip clot-dissolving drugs directly into the blockage. Once the clot dissolves, any remaining narrowing can often be treated with balloon angioplasty stent placement. Alternatively, a small suction catheter can be used to suck out the clot through a puncture hole. This same technique has also been used to open clotted dialysis shunts. All the techniques just described have been successfully used on numerous occasions in St. Tammany Parish.
Stroke
A fourth cardiovascular
condition that requires emergency care is a stroke. A stroke can occur when
a small artery to the brain is blocked by a piece of debris or when a blood
vessel ruptures and there is bleeding into the brain. The symptoms of a stroke
can be sudden weakness or numbness on one side of the body, sudden blindness
in the eye, or loss of speech. These symptoms require immediate medical attention.
Patients with
a non-bleeding stroke documented by a CT scan within a few hours of the onset
of symptoms can be offered a clot-busting drug to try and reverse the stroke.
Some studies suggest that such an approach may reduce long-term disability.
There are stringent criteria for the use of clot-busting drugs in stroke,
however: Only a few victims will actually be candidates to receive the drug,
not all will benefit, and there is an increased risk of significant bleeding
from this medication. This treatment is available on the northshore.
Cardiovascular
Care
on the Northshore
Do we have every
available cardiovascular treatment or procedure on the northshore? Of course
not. Some procedures, such as cardiac transplantation and certain pediatric
cardiac procedures, require the services of teams that are not available here.
Furthermore, some procedures and therapies remain experimental or are regulated
by the FDA in such a way that they are not yet available for general use outside
of experimental protocols. An example of this is carotid artery stenting.
As therapies
do become available, however, they are rapidly introduced locally. A recent
example is cardiovascular radiotherapy to reduce the rate of re-narrowing
of stented arteries. Our cardiologists have already teamed with our radiotherapists
to make this available to our community.
Another new procedure,
available at NorthShore Regional Medical Center in Slidell, is trans-myocardial
revascularization. Surgeons use a laser to drill very small holes in the heart
muscle to allow blood to reach the area that lacks oxygen. Dr. John Breaux
and Dr. Lou Hebert have successfully performed the procedure.
What is the take
home message? The treatment of all emergency cardiovascular care is local.
You don’t have time to cross the bridge to hospitals across the lake,
no matter how prestigious their names. That might seem frightening, but I
can say with authority, that the local treatment of emergency cardiovascular
conditions is of good quality and up-to-date with emerging procedures and
technology.
Perhaps even more important, not only is the emergency treatment good, but our local hospital and physician providers also do an excellent job of treating chronic cardiovascular diseases.
Copyright © 2002 L&M Publishing, L.L.C. All rights reserved.
