Fionola Meredith visits Belfast’s Royal Victoria Hospital to witness an emergency cardiac procedure where ‘time is muscle’ and every second counts.
THE CALL to the emergency cardiac team at Belfast’s Royal Victoria Hospital goes out just before 4am on a stormy night in the middle of November. Twenty-five miles away in Portavogie, a small town on the Ards Peninsula, a woman is having a heart attack. As the ambulance bringing her in rushes along the dark country roads, waves from the nearby lough lashing the sides of the vehicle, the cardiac team leap from their beds, throwing on clothes, grabbing the car keys. There can’t be any delay.
As they say in the world of cardiology, “time is muscle”. Every minute that passes is doing irreparable damage to the muscle of the woman’s heart: the strength of the heart, and its ability to keep on beating, diminishes moment by moment. The circumstances couldn’t be more serious – it’s a life or death situation.
The traditional treatment for heart attack victims is the use of clot-busting drugs. But the gold standard emergency treatment is a primary percutaneous coronary intervention (PCI), or balloon angioplasty: a tiny balloon is inflated in the coronary artery in order to clear away the clot that’s cutting off blood supply to the heart. And it’s this rapid and highly skilled treatment, offered around the clock under a pilot scheme at the Royal, that the Portavogie woman will receive.
It’s 4.20am, and Mary McGeough, primary PCI co-ordinator at the Royal, is waiting for the ambulance and watching the clock. The period from when the 999 call is made until the culprit clot is cleared is known as “call-to-balloon” time, and ideally it should take less than 150 minutes. The shorter the duration, the better the outcome for the patient.
While the time frame sounds quite generous, the minutes slip away very quickly. Even getting the patient loaded into the ambulance takes time. As McGeough says, “Before you know it, that’s 10 minutes gone”. Only certain types of heart attack are suitable for treatment by primary PCI, but the ambulance team have transmitted the woman’s heart trace to the coronary care unit, and she qualifies for the procedure. The team at the Royal treat an average of 16 such cases a month.
Blue lights flashing, the ambulance pulls up and the crew quickly unload the patient. Swaddled in blankets, and holding an oxygen mask to her face, she looks utterly bewildered.
McGeough is instantly by her side: it’s her job to meet the patient, reassure her and explain what’s happening, and to get her consent for the procedure. And then everything happens very quickly: there’s a sense of carefully controlled urgency as the emergency crew whisk the patient along a strip-lit corridor in the otherwise dark and silent hospital.
“We need to go as fast as the ambulance staff can push,” says McGeough, and that turns out to be very fast indeed. The patient’s eyes are large and fearful above the oxygen mask. It’s likely that she is in excruciating pain. She’s wired up to a portable cardiac monitor, which a crew member carries alongside her suitcase-style, recording her vital signs. The minutes are still ticking by.
It’s a highly choreographed operation: once the crew reaches the catheterisation laboratory, or the cath lab as it’s known, the surgical team are scrubbed up and waiting: Dr Niall Herity, consultant cardiologist; radiographer Andrea Bonnar; Ruth Kirkpatrick, the clinical physiologist; and nurse Gaye Medenilla. Each person has their own vital part to play.
This is the second emergency they have dealt with tonight: they only got home from the first one at 1.30am and, less than three hours later, they’re back at the hospital.
As the patient is wheeled in, she’s immediately surrounded by the team and there’s a flurry of activity as they manoeuvre her on to a narrow table. Seconds later, a catheter – a long, thin, flexible tube – is inserted into the patient’s radial artery in her wrist, and is guided all the way up her arm and into her heart.
A radio-opaque dye is pumped into the coronary artery, and the grainy black and white X-ray image appears on a screen. The patient’s ribs and spine are visible, while the heart itself appears as an ghostly grey mass, its intricate network of blood vessels lit up as the dye pulses through.
Working in his heavy lead-lined coat, Herity is looking for the blood clot that is causing the heart attack. Suddenly there it is, obvious to even the untrained eye: a dark thickening, after which the coronary artery appears to abruptly stop – no blood is getting through to this part of the heart at all.
Herity clears the blockage, and the X-ray screen shows the instantaneous result: life-giving blood flows through the patient’s heart, relieving the intense pain she has been experiencing. Herity completes the procedure by inserting a stent – an expandable wire mesh tube – in the previously blocked artery, to ensure that it remains fully open.
The patient, who has been awake throughout, stirs uncomfortably under her blanket as the stent goes in. But the operation has been a success, and the danger has been averted. Moments later, she’s sitting up on a trolley. She looks drained, and her lips are a bad colour, but all the pain, trauma and fear have vanished from her face. The whole procedure has taken one hour.
Watching the cardiologist at work, it’s hard to believe that the small movements he makes as he manipulates the catheters and wires in the woman’s wrist – guided only by the X-ray images – translate into heart surgery of such extraordinary skill and finesse. The calmness and accuracy with which he works are all the more impressive given that those vital minutes are constantly slipping away.
Sipping a cup of tea afterwards, Herity says that, while this case was straightforward, complexities can arise.
“Some patients have very low blood pressure, some have heart rhythm disturbances, and sometimes you have difficulty getting into the artery. Some people have arteries that are calcified like bone: you can get 99 per cent calcification, and just a little clot.”
He says that while the disease process in the heart can develop over months if not years, the clot itself can develop within minutes.
McGeough says that no one should be complacent about the risks of heart disease. “We’ve had 36-year-olds on this table, right up to 80- and 90-year-olds.”
It’s 6am, and the patient is wheeled off to the recovery ward. Outside, the storm has passed and the city is beginning to wake up, oblivious to the drama that played out at the hospital in the early hours of the morning.
A life has been saved. To the team, it’s their regular work. But I feel I’ve been witness to an everyday miracle.
