Mega Doctor News
By Michael Merschel, American Heart Association News
You’re having chest pain, or you fear that your spouse is having a stroke – and you’re thinking of just driving to a hospital instead of calling 911.
What do emergency department doctors think of that plan?
“I think it would be an extraordinarily rare situation where that’s a good idea,” said Dr. Eric Isaacs, director of the age-friendly emergency department at Zuckerberg San Francisco General Hospital.
Here’s why: He’s often seen people show up at the hospital, pounding on the door, with somebody in their front seat, not breathing and with no pulse, because they mistakenly thought it would be better to drive them, said Isaacs, who also is a clinical professor of emergency medicine at the University of California, San Francisco.
Dr. Ameera Haamid, the associate emergency medical services medical director of the Chicago South EMS System, agreed that people should always call 911 when they’re having heart attack or stroke symptoms.
For a heart attack, those symptoms include shortness of breath; pressure, squeezing, fullness or pain in the chest; pain in the arms, back, neck, jaw or stomach; and other signs such as nausea, a cold sweat or a rapid or irregular heartbeat. Stroke warning signs include face drooping, arm weakness, difficulty speaking or walking, confusion and severe headache. The American Heart Association recommends calling 911 if any of these symptoms develop, or if a person experiences a sudden loss of responsiveness or can’t breathe normally, which are signs of cardiac arrest.
Haamid, who also is an assistant professor of emergency medicine at University of Chicago Medicine, said she also has seen families arrive at the hospital with someone whose heart stopped beating on the drive there. “And now we’re doing CPR because they’re in cardiac arrest.”
So, the emergency specialists’ advice is clear: Call 911. But for those who still might hesitate, here are some of the reasons why doctors think that way.
Connect with care more quickly
It might seem faster to get somebody with relatively mild symptoms to the hospital yourself, Isaacs said. But that doesn’t account for the things that can go wrong on the way there. Mild symptoms can quickly worsen. A heart can start beating irregularly or stop; people can lose consciousness and loved ones may not even notice because of agonal breathing, which are reflex breaths that occur when a person is in cardiac arrest.
If you put someone in a car yourself, thinking the hospital is only 15 minutes away, that’s 15 minutes without breathing, or 15 minutes without a pulse, Isaacs said. “That means that they’re going to be dead when you arrive.”
An ambulance crew is trained to handle such problems and recognize when a person’s condition suddenly changes. They can administer medications, perform CPR or shock a heart back into a correct rhythm if necessary. Powell said the ambulance, in some ways, brings the hospital to your home, and a well-trained paramedic can do nearly all the things a hospital will do for you in cardiac arrest.
It puts you at the front of the line
When you call 911, the hospital can be ready to evaluate you immediately on arrival, Powell said.
Calling 911 speeds things in other ways, too.
“Even if you live a block away from the hospital, you still need to find a place to park,” Isaacs said. “You then have to walk from the parking area to the hospital for the emergency department.” There might be a line to check in, and you might have to wait before a nurse can evaluate you.
“Time is ticking,” Isaacs said.
Haamid spelled out why that matters. “Both a heart attack and a stroke are time-sensitive diagnoses,” she said. During a heart attack, blood flow is blocked to the heart muscle. In the most common type of stroke, blood flow is blocked to part of the brain.
The longer there is little or no blood flow to the tissue, the greater the likelihood of irreversible damage to the heart or the brain. “That can result in permanent deficits like paralysis, not being able to speak again, or symptoms that are so severe that they can be fatal,” she said.
It gets you to the best care
Emergency medical responders are experts in knowing where the best care happens, Haamid said, and this can be a matter of life or death.
Understanding their role in selecting a hospital is especially important in rural areas, said Dr. Stephen Powell, an assistant professor of emergency medicine at Wake Forest School of Medicine in Winston-Salem, North Carolina.
Someone who lives far from a large city might be tempted to deliver themselves to the nearest clinic, he said. But that is not always the best choice.
“You might think, ‘Oh, I live 5 minutes from this hospital. That’s where I need to go if I’m having a stroke,'” said Powell, who also serves as medical director for a rural North Carolina county. But your local hospital might not be able to provide the advanced treatments you need, depending on your type of stroke.
Powell said an EMS team can assess you and say, “‘Whoa! Your symptoms are the symptoms of a large brain vessel that’s occluded! You actually need to bypass the hospital that’s in town and go 30 miles to the right hospital.’ And then, boom, you get the intervention you need as quickly as possible, as opposed to a delay.” Local hospitals and larger, tertiary referral hospitals often have agreements in place to make sure “the community gets the right care at the right place,” he said.
People in extremely remote areas, Powell said, should be aware of what resources are available ahead of time. “I do think common sense plays a role” in any emergency, he said, referring to making the decision of when and when not to call an ambulance. EMS is facing a nationwide crisis in staffing, and this can affect response times. “If you feel that based on where you live and how remote this is that it’s better to drive to the hospital, then that might be the right call for the minority of people in those situations.”
But even as a physician, Powell said he’d call 911 to help a loved one he suspected was having a heart attack. “I would much rather my wife be transported by a fully stocked ambulance with a trained EMS team than transported with just me who is simultaneously driving and emotionally compromised.”
Faster diagnosis and treatment
Calling 911 doesn’t just summon an ambulance, Haamid said. It sets hospital staff in motion, so the right specialists are standing by when you arrive. “If you arrived with a heart attack in the middle of the night, we would actually call people at home to quickly drive into the hospital to treat you,” she said.
In the ambulance, emergency specialists can begin to evaluate you and even transmit electrocardiogram readings for a doctor to analyze. If you are indeed having a heart attack, the catheterization lab can be on standby, ready to perform procedures that restore blood flow to your heart. If they suspect a stroke, you can be taken straight for a scan to determine what kind and whether clot-busting medication can be given.
Nobody will judge you if you’re wrong
“If you’re worried,” Powell said, “that’s what the hospital is for – to make sure that you’re OK.”
Haamid agreed. “There’s no such thing as being embarrassed about any symptom you present with in the emergency department,” she said.
And yet, people often ignore symptoms. Haamid said she sees it every day. People say, “I think I had a stroke, maybe two or three days ago,” but they sat at home with the symptoms, she said. At that point, they’ve missed out on time-sensitive treatments that could have helped them.
Powell said he has seen the same with people who had a transient ischemic attack, commonly referred to as a “mini-stroke,” but dismissed it as a fluke, when it was a harbinger of a full-blown stroke yet to come.
“It’s better to be cautious, and it’s better to be evaluated,” he said.
Isaacs said he understands the pressures people face when making the decision to call 911. Some of them may be practical, such as concerns about the cost. “But of course, I would err on the side of caution, because that’s what I do.”
Emergency department staff, he said, go into work each day knowing that many of the patients with chest pain aren’t having a heart attack and will be sent home. “And not to be dramatic, but I will be dramatic: I would rather send you home reassured that it’s not something serious than having you be dead or disabled.”
Instead, Isaacs said, “I would rather educate you and reassure you in that situation. And that’s what we do for most people.”
