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A Hospital Too Far

March 31, 2014

Involuntary Manslaughter: Manslaughter resulting from the failure to perform a legal duty expressly required to safeguard human life, from the commission of an unlawful act not constituting a felony, or from the commission of a lawful act in a negligent or improper manner.

After shoveling snow, a 50 year-old man struggles for breath and tells his wife that it feels as if someone is “sitting on his chest.” Although it is cool inside his home, he is drenched in perspiration. His wife calls 911, and within the hour, the artery–which had abruptly closed due to a blockage, starving his heart of oxygenated blood–is being opened by a cardiologist who has inserted a fine, metallic stent into his coronary artery.

This is an example of the best cardiovascular care in America, on which consumers spent approximately $444,000,000 in 2010–almost one dollar for every six dollars spent overall on health care.

While there are not a lot of absolute “facts” in the practice of medicine, or processes with only one “best” solution, when it comes to a patient having a heart attack following an artery’s closing, we do know that the method most likely to save the patient’s life is to get the artery open as soon as possible.

Time is of the essence, for as the minutes pass, more of the heart muscle dies and cannot be repaired. Scarring will subsequently occur. A heart with a large scar is a far weaker heart. Patients who incur such damage will experience symptoms of heart failure. Additionally, large scars also cause short circuits in the heart’s intricate electrical wiring which may lead to lethal arrhythmias and sudden death.

In actuality, a few minutes between the time a heart attack occurs and the time a patient is treated, may mean the difference between life and death. We know that patients who get to a cath lab quickly and have their artery opened promptly are more likely to survive the event, are less likely to experience heart failure, and are more likely to live longer.

For me, personally, the event is akin to caring for the victim of a gunshot wound to the chest. In that scenario it is essential that the victim be transported to the nearest hospital that can save his or her life. There is no other option here.

That is why the current guidelines for the management of patients having had heart attacks caused by an acutely closed artery, published jointly by The American Heart Association and American College of Cardiology, states that “transport time to the hospital is variable from case to case, but that the goal is to keep total ischemic time within 120 minutes,” which means that the total time for the heart to be starved of blood flow and hence, oxygen, should be less than the aforementioned figure. The most trusted and senior cardiologists developed the rule for such an event, intending to emphasize to every healthcare worker the importance of getting a closed artery opened as quickly as possible.

Now, to digress. Imagine that a large, university hospital made an agreement with the administrators of a small, community hospital (a hospital not equipped to administer care to this patient) to ship that gunshot victim to THEIR hospital, regardless of the fact that the patient was bleeding to death and another university hospital, their competition, was closer as well as capable of treating this patient. And suppose the victim died due to this arrangement? Would this, then, be considered involuntary manslaughter?

In New York State–and I suspect all around the country–some large University hospitals have, in fact, entered into “affiliations” with small hospitals that do not have cardiac labs and are not capable of opening these closed arteries with balloons and stents. Perhaps prior to this arrangement that smaller hospital sent their patients to the closest hospital capable of saving the patient’s life. But now, with this new arrangement doctors and hospital administrators are expected to “feed” their affiliated University hospital (hospital A) these heart attack patients, even though hospital B, C or D might be much closer.

I sat down today; a Saturday in March of 2014; a day where traffic is light, and nothing near as slow as a weekday, especially during a rush hour. I looked at Google Maps at around 1 PM and at the estimated drive times from the two Community Hospitals in Yonkers New York (Saint Joseph Hospital and Saint John’s Hospital) to four major medical centers, one in the same county as Westchester, the other in the Bronx of New York City, and two others in Manhattan. These are the estimated transport times:

From Saint John’s Riverside Hospital:

18 Minutes to Montefiore in the Bronx

23 Minutes to Westchester Medical Center

38 Minutes to Mount Sinai Medical Center in NYC

39 Minutes to NYU Medical Center in NYC

From Saint Joseph’s Hospital:

20 minutes to Montefiore Medical Center

25 Minutes to Westchester Medical Center

39 Minutes to Mount Sinai Medical Center

45 Minutes to NYU Medical Center in NYC

Again, these are estimated times for a car, not an ambulance, and on a weekend day. These times also do not take into account the time it may take for the ambulance to come to the community hospital after they are called for transport. Nevertheless, you can understand now the importance of getting a patient with a heart attack to the NEAREST hospital and question why someone in a hospital in Yonkers would be transported to a hospital almost 40 minutes away when it would take almost half the time to transport the patient to the closer hospital.

It appears that in an effort to capture business, a patient may be taken an extra 20 minutes or more from where they can get equal care far sooner. Damned if valuable treatment time may be lost in transit–whether for the gunshot victim, or the person having suffered the heart attack. In the latter case, millions of heart cells may have died in the process; the patient might incur a larger scar; or even die a few years earlier than if he had been promptly treated.

The basic rule that patients with a STEMI (ST ELEVATION MI — the heart attack often caused by sudden blockage), be taken to the nearest hospital, is being ignored, and as I review the names of the physicians on the committee who wrote the rules for the treatment of a STEMI myocardial infarction–a rule almost as powerful as any law–I recognize that some of the hospitals of which they are in charge, may be violating the very rule they so judiciously demand of others.

This is yet another symptom of our sick healthcare system, concerned with plumping egos as well as pockets, and turning a blind-eye to the administering of honest patient care. The tragedy is that no one seems to be policing it. If a physician, who wrote the rules, knowingly violates those rules, is he not responsible? If one single patient dies because of these actions, is that not a crime? Is that not involuntary manslaughter?

About the author: Evan S. Levine, MD FACC, is Director of the Cardiovascular Center at Saint Joseph’s Hospital and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You”. He lives in Connecticut with his wife and children.


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