North Bay heart attack victims have access to exceptional care options.
Heart disease is still the leading cause of death in the United States, but thanks to the efforts of researchers and medical professionals—plus continually evolving technology and aggressive public awareness efforts—the Grim Reaper’s pace has been slowed significantly. Better imaging, advanced medical devices and new surgical procedures developed over the past decade have vastly changed the cardiac care landscape, particularly in the North Bay, where things are (pardon the pun) “hale and hearty!”
Kaiser Permanente’s San Rafael Medical Center, Marin General Hospital and both Sutter Medical Center and Memorial Hospital in Santa Rosa have state-of-the-art catheterization (cath) labs that have dramatically reduced the number of fatal heart attacks while at the same time expanded the lifespans of patients suffering from heart disease.
Northern California Medical Associates (NCMA), based in Santa Rosa, provides comprehensive, integrated cardiovascular services in three counties—Sonoma, Mendocino and Lake—and its vice president/secretary, Dr. Patrick Coleman, helped build the Coastal Valley STEMI Program to greatly expedite the treatment protocol for heart attack victims in Sonoma and Mendocino counties.
Ten years ago, Kaiser Permanente Santa Rosa and all other KP centers throughout Northern California simultaneously initiated a system-wide patient awareness program called PHASE (Preventing Heart Attacks and Strokes Everyday). It’s been so successful that, today, heart disease is no longer the leading cause of death among Kaiser’s Northern California patient population. (That dubious honor now belongs to cancer.) Kaiser Permanente, as well as the other cardiac medical services providers, also uses the latest detection technologies and surgical procedures in treating heart patients.
And since heart disease doesn’t discriminate by gender—but many women remain unaware of their risk factors—support groups like the North Bay’s InspiRed Women help spread the word through education while at the same time gathering support for critical medical research.
Cardiac care
One of the most common and severe heart attacks is known as an ST segment elevation myocardial infarction (STEMI). Simply put, it’s when one of the coronary arteries is totally occluded by a blood clot. Up until the new millennium, most hospitals used clot-dissolving medicines to break up the clot and restore blood flow to the affected heart muscle.
“The problem was that it only worked effectively in about 60 percent of patients and it didn’t work at all for 20 percent,” said NCMA’s Coleman. There also was increased risk of internal bleeding “and the underlying blockage remained, even if you could open up the flow.”
In the early 2000s, cardiologists switched their preference from clot-busting medications to stents, believing the best way to save patients was to “intervene, open up the artery, insert a catheter and put in the stent…expeditiously, of course,” Coleman says. Stent insertions are done in cath labs—expensively outfitted laboratories designed to provide immediate diagnostic and therapeutic procedures for cardiac patients. The labs are so costly that only 20 percent of hospitals in the United States have them.
There are two in Sonoma County—one at Sutter Medical Center Santa Rosa and the other at Santa Rosa Memorial Hospital—and two in Marin County at Kaiser Permanente San Rafael and Marin General Hospital in Greenbrae.
Dr. Barbara Boylan is the chief of cardiology at Kaiser’s San Rafael Medical Center. “Our cath lab is small but highly functional, and our performance times are exceptional,” she says. It’s generally accepted that, to achieve the best outcome, an individual suffering from a STEMI needs to be treated within 90 minutes of emergency room arrival. The longer the time interval, the greater the amount of heart muscle reliant on the affected artery that will die. Over the last year, Kaiser San Rafael’s average is 60 minutes, “well below the national expectation,” Boylan points out. Marin General has an even better average: 44 minutes. And in Santa Rosa, the average “door to device” time is 66 minutes, also spectacular.
Getting to such quick response times “didn’t come easy,” says Coleman. “At Sutter and Memorial, when we first started doing the procedure, only about a third were done within the 90-minute window. So we put processes in place and reviewed every heart attack patient we served to determine what we did right and what we did wrong.” Medical teams met monthly (and still do) to evaluate the processes and reduce their response time, and now “90 percent of cases are done in less than 90 minutes,” Coleman proudly points out.
As one can imagine, cath labs treating a STEMI patient operate at a frenetic pace. “It’s the stuff you see on TV—and it really does look like that. Everyone is going full bore. But you have to, because 30 seconds can be the difference between life and death,” Coleman says.
He’s not certain how many lives cath lab procedures have saved. “It would be impossible to guess,” Coleman says. “But that’s really the small part. The real impact is how we’ve been able to limit the damage to the heart muscle and enable the patients to go on to have good lives. Not only have we saved lives, we’ve saved lifestyles. Unfortunately, some of these people actually think they can keep eating at Wendy’s,” he laughs.
Time is of the essence
While North Bay cath labs have established themselves as top performers, they can only work their magic if cardiac patients can actually get to their doorsteps. And they have to get there fast.
“The problem is that a lot of people aren’t within 90 minutes of a hospital with a cath lab,” Coleman says.
Over the past few years, Coleman and his colleagues, including Dr. Thomas E. Dunlap, a fellow NCMA cardiologist, have worked with emergency medical service (EMS) teams in Sonoma and Mendocino counties to construct an elaborate-yet-efficient emergency response protocol—the Coastal Valley STEMI Program—to see that patients suffering heart attacks “get into a cath lab as quickly as possible.”
“The urgency of any heart attack situation requires that all caregivers involved—the paramedics, firefighters, emergency room [ER] triage nurses, physicians and cardiologists—perform precise tasks with efficient command and expertise,” Coleman says.
The coordinated response begins with EMS. “Physicians had the idea several years ago to put EKG machines into the paramedic rigs. [An EKG test checks for problems with the electrical activity of the heart.] We taught the paramedics how to crudely interpret them and, if they see evidence of a STEMI, they’ll immediately take the patient to Sutter or Memorial in Santa Rosa, depending on the geographic boundaries,” Coleman explains. “If possible, the paramedics will transmit results of the EKG to the cath lab while en route to the hospital, but at the least, the EKG comes with you as you roll in the door. The minute the ER doctor sees it’s a STEMI, he or she activates a cascade of notifications to get all hands on deck.”
STEMI treatment is automatic. Even if a patient is covered under Kaiser or another health insurance plan, the EMS crew will deliver them to Sutter or Memorial. If a Kaiser patient checks himself in at the Kaiser emergency room with evidence of a possible STEMI, he or she is immediately sent to Sutter or Memorial. The system is so streamlined that, even if a patient checks in at Kaiser first, “we’re routinely completing their STEMI care within an average of 70 minutes,” Coleman says.
Things are a bit more complicated if patients are in outlying areas like Ukiah, Lakeport or Fort Bragg. “They’re obviously more than 90 minutes outside the circle,” Coleman explains, “so STEMI patients there are given clot-dissolving medicines and are packed up and shipped quickly to the closest STEMI receiving center.”
The Coastal Valley STEMI Program didn’t come about by accident. Setting up an integrated process for a super time-driven problem required hard work, dedication and tremendous negotiating skills. Fortunately, according to Coleman, everyone has the same end goal—saving the life of a patient.
Coleman and Dunlap conduct biannual regional meetings called “STEMI Summits,” which have been extremely effective in developing a model for coordinated STEMI treatment. Ambulatory services, fire departments, ER physicians and cardiologists from Sonoma and Mendocino counties are invited to discuss effective protocols already in place, as well as areas and procedures that could be improved upon.
“When you get everyone that’s involved in STEMI response in the same room, conversations about the response process become increasingly detailed. Through collaboration, we’ve found that EMS workers and hospitals in other areas have already made their own efforts to expedite STEMI response. We’re able to share ideas and combine strategies,” Coleman says.
One step of the process that everyone agrees needs to be fine-tuned is the initial EKG test and transmission of its results. “While all ambulances are equipped to perform EKGs, rapidly changing transmission technology makes it extremely difficult to establish a lasting, reliable way to organize transmissions between EMS and hospitals,” Coleman says. “EMS is a state agency, and there simply isn’t funding to keep pace.”
Coleman says building the Coastal Valley STEMI Program has been hard work, but it’s been rewarding to see the medical communities “band together to do it. It’s a win-win for everyone. With one phone call, a physician knows that a STEMI patient is on the way. It’s a win for the patient and it’s a win for the medical team. They know they’ve made a difference in that person’s life, and that’s a very cool thing.”
An ounce of prevention
It’s been said that an ounce of prevention is worth more than a pound of cure. If you don’t believe it, talk with Dr. Stan Nussbaum, staff cardiologist at Kaiser Permanente in Santa Rosa.
Ten years ago, Kaiser initiated its PHASE program. Today, it’s the nation’s first large medical center to see deaths from heart attacks drop below those of cancer.
“We took all patients we deemed to be high risk—those who’d already suffered vascular events, those with diabetes and so forth—and we made a super-concentrated effort to get them on a host of medications shown to reduce the risk of heart attacks,” Nussbaum says. But Kaiser didn’t stop there. It also started a major heart disease prevention and education program. If a patient’s medical chart shows any risk factors, Kaiser medical personnel make it their business to constantly remind them about special things they can do to cut their chances of getting heart disease.
“More recently, we’ve been very aggressive with blood pressure control,” Nussbaum says. “Right now, 88 percent of Northern California Kaiser patients suffering from hypertension are on some sort of control medication, whereas the national average is about 45 percent,” Nussbaum explains.
“We also have follow-up programs where we monitor their blood pressure and make recommendations for lifestyle changes.”
Kaiser, for example, considers physical exercise as a vital sign, right up there with pulse, temperature and blood pressure. “We ask every patient how much they are exercising and then we explain how some sort of exercise, done 30 minutes per day, five times per week, can greatly decrease their risk for heart attack and stroke, plus lower their blood pressure,” Nussbaum says.
“We believe exercise and diet are the main keys to reducing risk as time goes forward. We’re really recommending that people consider vegan diets. We know it’s not for everyone, but if we can get people to eat more fruits and vegetables and consume less meat, we’re pushing them in the direction of eating better, which will reduce their weight and their exposure to vascular disease. It’s all intricately woven together.”
Kaiser, Sutter, Memorial and NCMA all promote prevention, but when patients with acute problems present themselves at their doorsteps, they also rely on a host of treatments that, with technological improvements, just get better over time.
NCMA—with 15 cardiologists, two heart surgeons and 37 physicians in both primary care and other surgical and medical specialties—has “one of the best programs in the whole United States,” says Wendy LaBranche, NCMA COO and director of cardiovascular services.
“Our nuclear and echocardiology laboratories are accredited by the Intersocietal Accreditation Commission. That means they’re at a level of excellence that’s very hard to achieve. Most hospital programs aren’t accredited,” LaBranche says.
NCMA has the capability of conducting comprehensive cardiovascular testing to determine the best treatment options for all sorts of heart disease. Its physicians have privileges at both Sutter and Memorial in Santa Rosa and also serve patients at satellite locations in Lakeport, Ukiah, Petaluma, Sonoma, Healdsburg, Mendocino, Gualala and Fort Bragg.
Kaiser Permanente, like the other medical centers, uses cutting edge procedures to better serve its heart patients. These include transcatheter aortic valve replacements (TAVI or TAVR), a procedure which was just approved in the last two years for patients who are inoperable or too high risk for conventional aortic valve replacement surgery. Another innovation is off-pump bypass surgery. “In traditional heart bypass operations, the heart is stopped and a bypass is attached outside the heart to keep the blood circulating,” Boylan explains. “There’s a lot of risk attached, and it can affect a person’s cognitive function after surgery. Now there are techniques that, in certain types of surgery, let us keep a heart beating while we operate.”
Boylan also notes that heart surgeons are moving toward less invasive procedures, much like the rest of the medical industry. “Instead of an open sternotomy, we’re now looking at ways [to enter the chest cavity] under the armpit, for example,” she says.
There’s also more that can be done without resorting to a heart transplant. “Left ventrical assist devices used to be inserted for failing hearts if a patient was on a waiting list for a heart transplant,” Boylan explains. “Now we have what we call destination LVADs, which aren’t intended for bridging, but instead are used to keep people alive as long as possible [without a transplant].”
Educating the public
While great strides have been and continue to be made in cardiovascular health—and people in general know much more about heart health than they did in the past—an ongoing education and outreach effort remains critical to helping stem the tide of heart disease.
NCMA offers a wide array of community programs—all free—to North Bay residents. It sets up booths that offer free blood pressure, cholesterol and body mass index (BMI) tests at such events as Heart Smart Health Fair in Ukiah and Lakeport, the Willits Health Fair, the AMGEN Tour of California and the American Heart Association’s Go Red and Heart Walk. “We also work with churches, companies, agencies and large corporations that want to have health screening for their employees and/or members,” LaBranche says.
One major project currently underway is called PAD (public access defibrillation) to put more automated external defibrillators (AEDs) out into the communities NCMA serves. “There are no AEDs on the public soccer fields, for instance,” LaBranche says. “So this year, Dr. Coleman introduced me to Bryan Cleaver, who’s involved with ‘Save Lives Sonoma,’ a community CPR training initiative. We’re teaching hands-only CPR [cardio pulmonary resuscitation] to as many people as possible, and we’re also training people how to use the AEDs.”
As the result of a student’s presentation to the Santa Rosa School Board, the first four to six AEDs will go to Maria Carrillo High School in Santa Rosa and, as the program gains steam, other schools will get the devices and receive the training. The goal is to increase survival rates from sudden cardiac arrest. “Our cardiologists don’t just go into the office every day and do their thing. They’re directly involved in the communities in which they live and work,” LaBranche says.
Another organization that’s extremely active in getting out the word about heart health is InspiRed Women, a group of Santa Rosa women who’ve been active in the American Heart Association’s (AHA) “Go Red for Women” movement.
Kathy Perotti and Corrine Byrd are volunteers and co-chairs of the North Bay AHA InspiRed Women Group, which they describe as a “new frontier of women setting the pace for the rest of the nation” when it comes to getting the word out about heart disease, particularly among women.
“Heart disease is the number one killer of women,” says Perotti. "While there’s a lot of focus on breast cancer, which kills one in 29 women, there’s much less awareness about heart disease, which kills one out of every 2.4 women."
Now in its third year, InspiRed Women has 30 members, each of whom has been personally affected in some way by cardiovascular disease. The group holds quarterly meetings to keep up-to-date with the latest in women’s health awareness and disease prevention and to plan ways in which to educate the public and raise money for women’s health research. In conjunction with the local AHA office, they sponsor “Lunch and Learn” programs in North Bay schools and businesses, CPR training classes for Boy Scouts and high school students, and conduct “Jump Rope for Heart” programs in more than 20 Santa Rosa schools.
Women are their primary focus because, “We’re not always number one in our own lives. We have children, husbands and family to care for, and we frequently don’t want to own up that we might be vulnerable to heart disease,” says Perotti. “But the numbers are out there—we really are.”
“Women’s lives are chock-full of responsibilities, day-to-day,” Byrd adds. “We often feel we don’t have time to run to a doctor. Many of us don’t do anything until we have an obvious problem.” Byrd notes that her grandfather “dropped dead of a heart attack when I was six. It was my first recollection of death. Since then, I’ve spent my whole life making sure I didn’t have a heart attack.”
“Many women feel there’s a stigma to having heart disease and they really don’t want to deal with it,” Perotti says. “We promote awareness all the time. We talk about this disease whenever we can. After all, it’s better to be embarrassed than in the ground.”
It takes a lickin’ and keeps on tickin!
While there’s always room for improvement—and the medical pros we talked to never stop in their quest for heart care excellence—to see how far we’ve come, not only in the North Bay but nationwide, one only has to look at one man: Dick Cheney.
The former vice president “has had about every cardiac procedure known to man,” says Nussbaum. “In a sense, his survival mirrors the progress of heart care in our lifetime.”
And no matter how you may feel about the controversial Cheney, you have to admit he’s a survivor. And what’s good for Dick Cheney is good for heart patients everywhere.
