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East End emergency cardiac care: Where do you want to be if you have a heart attack?

2012 0920 heart attack

It was a lovely fall afternoon, a Saturday. Fred, a 65-year-old retired bank executive, had just returned from a round of golf, recalls his widow Ellen.* He had taken his bag out of the trunk to stow in the garage.

“That’s where I found him,” she said.

She’d heard the garage door open and when he didn’t come inside after a while, she looked out the kitchen window and saw the trunk of his car was open. That seemed odd, so she went out to check. He was on the garage floor, sitting on his haunches, one hand resting on the wall, the other holding his chest. He was having trouble breathing and couldn’t speak.

She raced inside and called 911. The ambulance was there within minutes, she said. After that, everything is a blur.

“It all happened so fast,” Ellen recalled. “I remember being confused when the EMTs said they were taking him to Stony Brook,” she said. The couple was new to Riverhead, having moved from their home in Nassau to an upscale condo complex in Riverhead just six months before. “I wasn’t even sure exactly where that was or how long it would take to get there.”

Within an hour of her arrival at Stony Brook’s emergency department, a grim-faced young doctor gave her the worst news of her life: Her husband of 36 years was gone.

Retirement heaven: Golf, shopping and state-of-the-art hospital

Riverhead’s golf courses, beaches and shopping had attracted them. But the community asset that sealed the deal for the recent retirees was the state-of-the-art hospital facility less than two miles from their new home.

“In your golden years, you want to make sure you live near a good hospital, and we were impressed with Peconic Bay,” Ellen recalled this week. “We’d both been blessed with good health, but once you reach a certain age,” she said, “you never know.”

2012 0919 PBMCThey didn’t know that the newly renovated hospital with its gleaming new pavilion located minutes from their home wouldn’t be able to provide the treatment Fred needed when he was struck with the most deadly type of heart attack: an ST-elevated myocardial infarction, known as a STEMI.

Saving the life of someone suffering a STEMI requires rapid diagnosis and treatment. The preferred treatment is known as PCI — for percutaneous coronary intervention — according to the American College of Cardiology and the American Heart Association. It’s also known as a balloon angioplasty, usually accompanied by the implantation of a stent in the affected artery.

But none of the three East End hospitals is certified for PCI. The nearest PCI-capable hospital is University Hospital in Stony Brook.

Protocol requires EMTs to transport a heart attack patient to Stony Brook if an EKG taken in the ambulance indicates a STEMI, Riverhead Volunteer Ambulance Corps president Kim Pokorny said in an interview. But even with sirens blaring and lights flashing, the trip can take upwards of 45 minutes to an hour, depending on traffic, Pokorny said.

‘Time is muscle. Time is survival.’

Cardiology practice guidelines call for commencement of the PCI within 120 minutes of first contact with EMTs or within 90 minutes of coming through the emergency room doors.

Every 30-minute delay in commencement of PCI increases the risk of mortality, according to the American College of Cardiology.

“A person’s condition could deteriorate rapidly,” Pokorny said.

There are two strategies for a STEMI patient, according to Dr. Gray Ellrodt, chairman of the American Heart Association’s Mission:Lifeline national task force.

The preferred strategy is prompt PCI, which usually requires direct transport to a PCI-capable facility if one is within reach, Ellrodt said in a phone interview this month.

The other strategy is to make sure patients are receiving thrombolysis — the use of clot-busting drugs — within 30 minutes of arrival at the hospital. The drugs are not for everyone. They can cause dangerous, even deadly, hemorrhaging. And for many STEMI patients, the drugs are a stop-gap measure, Ellrodt said. ER doctors use a “drip and ship” protocol. They start an IV of the drug and do an immediate transfer to a PCI-capable hospital, Ellrodt said.

“We don’t even wait to see if it works, because if it doesn’t, we need to do the PCI right away,” he said. “Time is muscle,” Ellrodt said. “Time is survival.”

Does the East End need a PCI cardiac cath lab?

Ambulance corps president Pokorny said from an EMS standpoint, a PCI facility is needed on the East End. Riverhead, she notes, is “a heck of a lot closer to Stony Brook than Orient [62 miles away] and East Hampton [63 miles away] are.”

2012 0920 rvac ambulance
In addition to improving patient outcomes, a local PCI facility would allow RVAC to keep its rigs and personnel in-district. “Every time we transport to Stony Brook, we have a crew and a rig out of service for at least two hours,” Pokorny said. “That puts the district in a bad position.”

Pokorny’s sentiments were echoed by more than a dozen EMS companies that wrote letters of support for a proposed PCI lab at Brookhaven Memorial Hospital in Patchogue. Brookhaven’s application to the state health department for a “certificate of need” or CON — a special kind of permit — was approved by the state health department in late July. The new lab will be operated in partnership with Winthrop University Hospital.

Brookhaven will become the easternmost PCI facility in Suffolk and will be “a primary resource for the residents of the county’s East End — an area covering 346 square miles with approximately 136,000 residents,” the Patchogue hospital wrote in its CON application, which RiverheadLOCAL obtained by a freedom of information law request. The summer population increase is huge, bringing the East End total population to approximately 650,000, according to the document.

Eastern Suffolk STEMI patients are often first transported to one of the community hospitals and then require “time-consuming and potentially dangerous secondary transfer…for definitive therapy,” according to the Brookhaven CON application.

Brookhaven Memorial by itself transferred 989 patients for PCI in 2010. Four hundred ninety-five were transferred to Stony Brook, with 204, or 41 percent, classified as emergency cases and another 287 considered urgent, according to the CON application. The rest of the transfers went to other hospitals, with the bulk of the balance going to St. Francis in Roslyn.

Data on transfers of patients from Southampton, ELIH and Peconic Bay for PCI at Stony Brook or other hospitals were not made available by the East End hospitals in response to requests by RiverheadLOCAL.

Data on the number of STEMI patients seen by the East End hospitals, also requested by RiverheadLOCAL, were likewise not made available.


View PCI-cardiac cath labs on Long Island in a larger map

10 PCI facilities on L.I. but none east of Stony Brook

The three East End hospitals were mandated by the state to form the East End Health Alliance, which was born in 2008. The alliance hospitals are formally affiliated with Stony Brook University Hospital.

Stony Brook is currently one of five PCI-capable hospitals in Suffolk, an area of 2,373 square miles inhabited by 1.5 million people. The others are Southside Hospital in Bay Shore, Good Samaritan Hospital in West Islip, St. Catherine of Siena in Smithtown and Huntington Hospital.

There are five PCI-capable hospitals in Nassau County, an area of 453 square miles and home to 1.3 million people.

Suffolk County, in addition to its far-flung geography, has an aging population, particularly on the East End, and is home to a significant minority population that’s traditionally underserved by the health care system.

Cardiac mortality rate in Suffolk among worst in the nation

Suffolk also has a higher cardiac mortality rate than Nassau, according to data provided by the American Heart Association.

In fact, surviving a heart attack in Suffolk County is far less likely than almost anywhere in the country, former Suffolk Regional Emergency Medical Services Council chairman Edward Stapleton testified before the Suffolk County Legislature last year.

Survival is better in the western parts of the county, he said.

“Where do you want to be if you’re having a heart attack? You want to be somewhere where you can get a cardiac catheterization and a stent, that’s where you want to be,” Stapleton told members of the legislature’s public safety committee.

‘People are not keeling over dead with coronaries in our communities’

Peconic Bay Medical Center president and CEO Andrew Mitchell referred questions about cardiac care on the East End to his counterpart at Southampton Hospital, Robert Chaloner, who is the current spokesman for the East End Health Alliance.

Chaloner said in an interview the alliance is not convinced a PCI lab is needed on the East End. It’s a very expensive facility to build and also to staff, Chaloner said. (Brookhaven’s project cost estimates are about $4 million, according to its CON application.)

“It’s certainly been studied for a long time,” Chaloner said. “Any one of us is too small to support a program financially or clinically,” he said, referring to the three East End hospitals. “You need to be a certain size. On the aggregate, we probably have the numbers, but individually we don’t,” he said. “So how do you pick a location?”

Chaloner denied that rivalries among the three hospitals of the EEHA have gotten in the way of picking a location and moving forward with establishing a PCI-capable cath lab for the East End.

“There are no turf battles,” he said.

But some members of the PBMC board see things differently. They would not speak on the record, citing the sensitive nature of the the topic and lack of authorization to speak for the hospital.

“Peconic Bay has been pursuing a cardiac cath lab, but the health department won’t approve it unless the other members of the East End Health Alliance consent,” said one board member, speaking on the condition of anonymity. “And that’s something we haven’t been able to get.”

EEHA has a cardiac care committee that is studying the issue, Chaloner said.

“I don’t think it’s off the table at some point in the future,” he said. “There’s a lot of debate swirling around about timing and how we coordinate it,” he said. The East End hospitals would have to partner with a hospital that does heart surgery. The likely partner would be its tertiary-level affiliate in Stony Brook.

Stony Brook University Hospital refused to directly answer questions about whether it planned to seek a CON for a PCI lab on the East End or to provide any data on STEMI patients transferred to Stony Brook from the EEHA hospitals. Instead, it issued a written statement saying it would continue to work to improve the healthcare of all the communities served by the hospital. The Stony Brook spokesman declined a subsequent request for a phone interview.

The Southampton Hospital president said, speaking just for his own hospital, he would need to make sure the PCI lab is worth the investment. “If you put your money into one area, you may forgo other opportunities,” Chaloner said.

“We get them in the ER and get them transported,” Chaloner said. “Our mortality rates are pretty good. People are not keeling over dead with coronaries in our communities.”

Chaloner said he’d “like to see the debate play out, rather than rush into something we’re not ready for.”

State policy pointing in another direction?

“There are also a lot of questions about the long-term future of cath labs. There is new technology evolving, new imaging capabilities, and I think that’s the area the alliance is going to focus on,” Chaloner said.

Both Chaloner and State Senator Ken LaValle said the state health department is not enthusiastic about approving new PCI labs.

“The problem is the health department,” LaValle said in a phone interview. “They’re not doing them,” he said.

“The numbers are not as high as you think. How many cases do you have? How many had to go to Stony Brook? The health department looks at it and says there’s not a need,” LaValle said.

A spokesman for the state health department said data at that level of specificity is kept by the individual hospitals and would have to be obtained from them. Neither the hospitals nor the East End Health Alliance made the data available in response to requests by RiverheadLOCAL.

“The CON process involves meeting three main criteria,” said health department spokesman Jeffrey Hammond. “They are community need, fiscal stability, and character and competence of the entity that’s applying.”

Hammond declined to answer questions about whether the state agency has a policy against approving CONs for new PCI labs.

“Any facility, regardless of location, if they want the services, they should follow the CON process. If they asked us, we’d tell them to file an application.”

* Editor’s note: “Ellen” agreed to speak to a reporter for this story if we concealed her true identity.

Tom Burke contributed reporting for this story.

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