Conversations in Cardiology: How to Juggle Two STEMIs at the Same Time

Morton Kern, MD, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in cardiology.


Morton KernMorton Kern, MD, of VA Long Beach Healthcare System and University of California, Irvine, often engages his colleagues via email in brief, informal dialogue on clinically relevant topics in interventional cardiology. With permission from the participants, TCTMD presents their conversations for the benefit of the cardiology community. Your feedback is welcome—feel free to comment at the bottom of the page.

 

Ajay Kirtane, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), asks:

At your institutions how do you handle on-call coverage to account for the situation of two simultaneous emergencies? If people could please answer for cath lab staff especially, that would be great. For example: one on-call attending (with provisional backup by other local attendings) with one on-call staff team after 7 PM without formal backup structure.


Mitchell W. Krucoff, MD (Duke University Medical Center, Durham, NC), replies:

After hours, we do them one at a time . . . . I wish that was funny, but of course there is nothing more uncomfortable than being caught in that position.


Bonnie Weiner, MD (Saint Vincent Hospital, Worcester, MA), replies:

We do the same, although it is a rare occurrence. If we really think it will make a difference, would consider lytics for patient #2.


Christopher J. White, MD (Ochsner Medical Center, New Orleans, LA):

Hiring a second team comes down to the frequency of the occurrence. If it happened a couple of times a month, it would merit some consideration. In our experience, two or more simultaneous STEMIs is very rare, and therefore we plan to “triage” for these rare emergencies one at a time.

Having MDs and techs on contingency backup adds a lot of on-call time and can be expensive.


Steven R. Bailey, MD (LSU Health, Shreveport, LA), replies:

We have one call team (cath staff, faculty, and fellow) without a second backup team. While rare, we have also faced the situation of two simultaneous STEMIs.

In the event of two simultaneous STEMIs, our check off is:

  1. What is the time delay expected to start case 2?
  2. Can we use part of the team to finish STEMI 1 and the other part (including rapid response team) to start STEMI 2 in a different room (even with a slight door-to-balloon time delay)?
  3. If not possible and patient’s being transported by EMS, divert to different hospital.
  4. If not possible and patient’s on-site, we have a formal transfer agreement to an outside hospital (5 minutes away) to support primary PCI if our primary hospital can’t perform PCI.
  5. We do have a lytic pathway as well, but this is our last priority.

David Cohen, MD (Kansas City, MO), replies:

At Saint Luke’s Mid America Heart Institute, we covered four PCI centers off hours with two cath lab teams and two attendings (with each team/attending pair assigned to specific centers). If we had two simultaneous STEMIs at a single location (which almost never happened), we had the bandwidth to handle it. A little more common scenario was two simultaneous STEMIs at two different hospitals covered by the same “team.” In that case, the unoccupied team would just deploy to the second STEMI. I don’t recall any time when we had three simultaneous activations—that would have been impossible. 

All of this worked because all cath labs were set up identically (more or less) across the system, and the staff and interventionalists would rotate to different centers so the teams could work comfortably wherever needed. The only real difference is that fellows only covered one of the hospitals. 


Neal Kleiman, MD (Houston Methodist Hospital, TX), replies:

We have a backup team for weekends; during the week they usually scrape together a team and call an attending who can’t say no (me). That said, this happens in our place about once a year.


Carl Tommaso, MD (NorthShore University HealthSystem, Skokie, IL), replies:

We have a situation where we cover four hospitals, three with labs, and simultaneous STEMIs occur occasionally (last night). We have a primary IC and a “backup” IC and team. We have had a situation with three simultaneous STEMIs.


Herbert D. Aronow, MD (Lifespan Cardiovascular Institute, Providence, RI), replies:

We have two full teams, including two interventional fellows, four nurses, and two techs, on call every night. We cover two cath labs that are ~10 minutes apart by ambulance. When simultaneous STEMIs occur at the same hospital, we can divert one patient to the other hospital, if needed.


Malcolm R. Bell, MD (Mayo Clinic, Rochester, MN), replies:

At Mayo Rochester, while we have enough capacity to handle multiple STEMIs during daytime work hours, during afterhours we have only one team on call and we are the only cath lab in town. We have occasionally encountered concurrent STEMIs. Most of the time we just anticipate/accept a short delay and just deal with it. However, rarely, if the first case in the lab is going to be protracted (shock, difficult PCI, etc), we have utilized the pharmacoinvasive approach, especially if the second STEMI is an early presenter. This usually makes the ED nervous, but we take care of them in the CICU and a few hours later will proceed to the cath lab. The last one I recall—a patient needing ECMO and with a second STEMI who received lysis, followed by PCI—did well afterwards (and better than the first, sadly).


Pinak Bipin Shah, MD (Brigham and Women's Hospital, Boston, MA), replies:

The frequency of this happening is so rare at BWH (maybe 1-2/year) that it did not make financial or quality-of-life sense to have a full second team on call ready to go. But when it happens, it always raises concern with ED and administration.

We have worked out a plan where if the cath lab is occupied and an emergency case comes into the lab, the CCU attending is then called to take ownership of the case to decide whether to:

  1. Manage the case in ED until the cath lab is done based on attending estimate
  2. Administer lytic therapy
  3. Transfer to a nearby PCI facility (we have Beth Israel across the street)

We have been able to scrape up a second team in rare situations.


Kirk Garratt, MD, MSc (ChristianaCare, Newark, DE), replies:

We covered one hospital in Queens and one hospital in Manhattan when I worked at Lenox Hill. A primary team took a STEMI at either hospital. A backup team handled a simultaneous case, which basically never happened. We saw < 100 STEMIs each year between both hospitals. We had two fellows on call each night, and the backup fellow was told she/he couldn’t drink but that it was safe to buy theater tickets.

In Delaware, we see about 350 STEMIs each year (including transfers = maybe 20% of work) in one hospital with four cath labs. We just looked at our incidence of simultaneous STEMI cases. It happened four times in 2019, seven times in 2018, and four times in 2017. Roughly half happened during regular hours, and those patients were just directed to an open room. That leaves two to three events happening each year after hours or on weekends. With this low frequency, we don’t keep two technical/nursing teams on call. We do have two physician teams, but this is to address the realities of having both employed and independent cardiologists work here.

When two events happen simultaneously, we do what everybody else is doing: keep the patient as stable as we can and get the first case done as quickly as we can. We have on very rare occasions called in the second MD team and made pleading calls to techs/nurses to open a second lab at night—the hourly workers don’t mind as emergency pay makes up for the unexpected pain and it’s still much less costly than keeping a second team on call every night.


James Blankenship, MD (University of New Mexico, Albuquerque), replies:

My prior institution was a moderate-volume program (800-900 PCIs/year) with two daytime labs. All five operators lived within 15 minutes of the hospital. Many of the techs lived within minutes of the hospital. On the rare occasion when SimulSTEMIs occurred we would delay the second by 15-30 minutes to finish the first and “bounce” to the other cath room. If it was going to be longer than that we usually were able to call in a second doc and enough cath techs (they are a committed, patient-first bunch) to do two cases simultaneously. Our general and interventional fellows are very good, and sometimes we would have them start the second STEMI and supervise both cases simultaneously. We talked about the additional alternatives of lytic therapy or flying the patient to our sister hospital 40 miles away, but I do not recall ever having to do that. What made this approach feasible was being in a small town where everyone is just 15 minutes (usually less) from the hospital, and having great partners and cath staff that are so patient-oriented that they will come to the hospital for an emergency without thinking twice about it.

For a while we covered two hospitals. Each hospital had a cath lab staff on call. Our plan for SimulSTEMI care, where a STEMI shows up at both hospitals simultaneously, was to call a partner to come in emergently. The alternative was to fly the patient from one hospital to the other where the doc was working, with the expectation that the 30 minutes transport time would be adequate for the doc to finish the first case before the second arrived. Or fly the doc to the other hospital after he/she finished the first patient. Or fly the second doc to the other hospital. Or give lytics. I don’t recall ever going beyond Plan A.

My current institution has one doc covering two hospitals, each with its own cath staff. One is a VA; STEMIs there are very rare. In one case where STEMI patients showed up at both simultaneously, a second doc (not on call) came in to cover the other case.


Alan C. Yeung, MD (Stanford Cardiovascular Health, CA), replies:

We have three cath labs teams on call each night/weekend at Stanford: one for cardiac (IC and EP), one neuro, and one vascular. If two STEMI comes in at the same time, we activate the cardiac team and then piece together a second cardiac team by taking appropriate nurse and tech from the other two. There is usually one IC fellow on call and one attending. Typically we can finish one before the other. If necessary, we will call in a second attending who can do the STEMI by himself/herself with the tech. More often than the two STEMIs scenario is when EP would like to do an emergent pacemaker over the weekend and we need to proactively put a backup cardiac team together before letting EP do the pacer. Hope this is helpful.


Cohen replies:

So far, the most interesting thing by far about the responses is how unique each one is to the specific environment (number of hospitals, number of STEMIs, local geography). There is definitely no “one-size-fits-all” approach here.


Weiner replies:

Agree. One thing seems to be true, though, and that is that seeing this phenomenon is infrequent across the board but is more likely in multiple hospital coverage environments.

Comments

1

Joshua Krasnow

6 months ago
Just want to add our experience. Here at Huntsville Hospital we are basically the regional STEMI center. We do in the vicinity of 700 STEMIs/yr. As you can imagine, this comes up, while not frequently, not rarely. We cover this (at the moment) with 10 ICs, but have done with as few as 7. We keep a "late" team which stays in the lab to cover late cases or STEMIs until 9pm. There is also a "call" team, whose call starts at the end of the second-to-last case (the "late" team will cover the last case). After that time, and on the weekend (when we do 4 scheduled cases on Saturday, plus urgent/emergent) it is formally just the call team, but there is a list of people as a sort of 'super secret backup' who are willing to be called in. This list is large enough that in the rare instance we really truly need two teams at once, have always been able to get enough. In fact I recall one time we had 3 at once. With the number of ICs, we can always call around and find someone. We also have lower level staff equivalent to anesthesia techs, that originally started out as transporters, but are now trained to set up labs, and ferry equipment and personnel, who we have take call as well which adds flexibility at a less prohibitive cost. More importantly, what we have experience with is managing with what we have. It is really rare to have two truly simultaneous cases. In the off-hours, when you think of it, the usual 30-40 minutes it would take to get the team in and patient to the lab etc, is enough to at least get the emergent issue dealt with. We're creative with splitting teams to have an RN stay with the pt in the lab until CCU can come help transport while the rest of the team is getting going with the second case in another lab. I personally have certainly opened an artery to reestablish flow, realized definitive PCI would require a bifurcation approach, started the patient on heparin/IIbIIIa, left the sheath in (radial of course), did the second case, then brought the first patient back for completion PCI. The key is to be aware of the timing (getting accurate ETA's from EMS is shockingly difficult!) and what your resources are, and being creative. It's certainly difficult and stressful, but it's exceedingly rare that a patient's care is delayed more than the expected delay if the team weren't already in house. The key is to be creative and utilize your