Pre-hospital care in the ambulance for a heart attack

‘A suspected heart attack is treated as an emergency because of the possible damage to your heart, and the risk of death. Early treatment can save your life and can limit the amount of damage to your heart muscle.’ [British Heart Foundation – heart attack leaflet 2014]
The people we talked to accessed pre-hospital care in various ways; by calling 999, by phoning NHS Direct or via their GP. They remembered being asked various questions, mostly about symptoms, such as ‘are you having chest pain,” or “did you pass out?” – this type of information was passed to the responding ambulance crew.

John lives in the countryside and an air ambulance was sent by NHS Direct to take him to hospital…

Age at interview 67

Gender Male

Age at diagnosis 67

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We took the dogs for a walk and coming back I started to feel a bit out of breath and I also felt slight pains, just on the side of my chest and started coughing a bit but thought no more about it. And especially two days after that I was talking to my sister on the telephone and she happened to mention she’d had this terrible cough which she couldn’t shake off. Described the symptoms and it sounded very similar to what I was going through so I assumed that’s what it was.

On the Monday, I spoke to her on the Sunday, on the Monday I went up to my study to go and do my 2011 self-employed tax assessment. Not that it was that stressful but it just struck me as ironic that it was then. And as I sat down at the desk I had pains, these pains came back in the side of my chest and I had sort of down the sides of my throat and to some extent like a pain in the forearm but not terribly intense. So I sat there thinking, It will pass off’ but already slightly suspicious then it might be heart. I then went downstairs to my wife who was sitting in the kitchen and I said, I think you’d better call NHS Direct because I’ve got these pains and see what they think.

So she phoned NHS Direct which looking back was a mistake because NHS Direct weren’t really geared up to deal with this sort of thing. Spoke to a lay person. Went all through the thing with her. She then said, I am going to get a nurse to talk to you. The nurse then went through it and said, It sounds like it might be heart. Where is your nearest hospital?’ so my wife told her and she said, Well you could drive him there. Which, of course, everybody else I spoke to after that said, That was the worst possible thing you could have done.

Or he said, We can get you an ambulance. So my wife elected to get an ambulance. We were phoned back I guess about 10 minutes, quarter of an hour later to say there was no ambulance available in the area but they had alerted HeliMed and they would be there fairly quickly but they’d got to come from [Town].

So it’s really weird because the symptoms weren’t that chronic for me. They were, they seemed quite ok but I did accept that it was a heart problem at that stage. They actually came into this room and sat in the armchair you are sitting in now and while I was there I saw a helicopter going around looking for somewhere to land and they had difficulty finding somewhere but they actually went up the hill the other side of the church into a farmer’s field. So they came chasing down and came in. They put an ECG on but the stickers that they had, you know, they said were new. They were one-use-only stickers and they didn’t work properly and they were complaining about how the old ones were much better. And while they were trying to do that they couldn’t get an output, not because I’d stopped, you know, heart beating but because they were just saying, This is really frustrating.

Anyway a few minutes later a land ambulance arrived. They came in with the old fashioned stickers and put it on and said, Yes it was definitely a heart attack. They then debated whether it was best to take me by air or by land ambulance. So they decided they’d decide that when they got me to the helicopter. So they drove the ambulance up the road to the helicopter. There was some discussion about whether to go. The pilot eventually said that he thought there was nothing in it in terms of time because they would have to take about 10 minutes to load me onto the ambulance this end and ten minutes to unload me the other end and it’s about a 40 minute drive to the hospital anyway. So li

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Stanley was alone at home when he started to feel unwell and called 999 and went to wait for the…

Age at interview 59

Gender Male

Age at diagnosis 59

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Well I’d had no symptoms in the past until, you know, the 15th till the day it happened. I’ve never had any pain or anything.

And what happened on the 15th?

I’d taken my partner to workand which is only like five minutes away and it was when I drove back and it was you know when I entered the flat. I just started, you know, I got like a fluttering feeling in my chest, no pain but it made me feel a bit drained, you know, like blood had drained from my head and I started to sweat a bit but other than that no real pain just a fluttering and it didn’t get any better and I was starting to get light headed so I phoned for a 999.

You called 999 yourself?

Yeah

OK. So you were alone?

Yeah I was on my own yeah.

OK and how long it took for an ambulance to arrive and what happened when the paramedics arrived.

It took about ten minutes for the ambulance to arrive although it seemed longer. But by this time I had made my way out of the flat and I was waiting out on the road for the ambulance and you know I was getting a lot dizzier.

Where you standing up, sitting on the pavement?

No I was standing up but I was starting to get a lot more light headed. Then the ambulance arrived and they got me in the ambulance and shaved my chest and cut my t-shirt off and put their
Electrodes?

heir electrodes on and by this time I’d phoned my partner. She was on her way back from work and they let her in the ambulance and I don’t really remember much after that.

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James had a stroke a year before and was retired at the time of his heart attack. He said that he didn’t have what he described as the ‘classical’ heart attack symptoms and therefore waited a whole weekend before seeking medical attention.

James’ GP did an ECG and sent for an ambulance. The ambulance crew also did an ECG which was sent…

Age at interview 63

Gender Male

Age at diagnosis 62

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I had a stroke in February 2010. This had meant that I’d given up work and at the time of my heart attack I was retired. I find, the thing I find amazing with my heart attack was the fact that I never had any chest pain or any arm stiffness, tingling, nothing at all. The only pain I felt was a very strong stomach, like a cramp which came and went and also a tingling down my neck and in my chin. These were with me for the night and I rang in the morning to see the doctor who asked for me to come down.I went to the doctor and he looked at me and said, "You don’t look too well." By then I was sweating, I was also trembling. He immediately put me on an ECG and also gave me some pain relieving drugs for my stomach, I assumed stomach cramps. Once he saw the results of the ECG he then rang the hospital and an ambulance arrived within fifteen minutes. The ambulance also took an ECG and that ECG was sent through to the hospital. This, this ECG was probably the most important because the doctors that were going to operate on me later were able to see the information of what my heart was doing at the time I entered the ambulance. Thirty minutes later I was laid in the emergency room at the [Hospital name]. They were very good, everyone was there, I had a specialist, there were doctors and there were nurses. They explained to me the problem with my heart and the fact that they wanted to do an antiplasty
Angioplasty?

Angioplasty as soon as possible as this would then not damage the heart any more than it had been damaged by my heart attack.

The ambulance also took an ECG and that ECG was sent through to the hospital. This ECG was probably the most important because the doctors that were going to operate on me later were able to see the information of what my heart was doing at the time I entered the ambulance. Thirty minutes later I was laid in the emergency room at the [Hospital name]. They were very good, everyone was there, I had a specialist, there were doctors and there were nurses. They explained to me the problem with my heart and the fact that they wanted to do an antiplasty
Angioplasty?

Angioplasty as soon as possible as this would then not damage the heart any more than it had been damaged by my heart attack.

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Once the ambulance crew arrive, the diagnosing process continues. Paramedics usually do an electrocardiogram (ECG) to check the heart’s rhythm and find out if the symptoms are due to a heart attack. Depending on what the rhythm looks like, and the symptoms described by the patient, paramedics may make a preliminary diagnosis of a heart attack. While the final diagnosis rests in the hands of doctors, that preliminary diagnosis is important because it allows paramedics to begin treatment immediately (often while still in the patient’s home).
If people have a low level of oxygen in their blood, ambulance staff may give them oxygen. To relieve pain they may administer morphine intravenously (through a vein), glyceryl trinitrate (GTN) – as a tablet under the tongue or as a spray and an aspirin to chew to thin the blood.

Mervyn describes the treatments he received in the ambulance on his way to the hospital.

Age at interview 76

Gender Male

Age at diagnosis 73

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Mervyn’ So I rang NHS Direct and they said that. They asked me what was wrong and different things and then they said, Well we’ll talk to the doctor and he’ll probably, he will get back to you very shortly and he will tell you then what to do. So I waited and the doctor rang me and I again I gave him all the symptoms and he said, I think what we’ll do is

I’ll ring the hospital for you and they will send paramedics down to check you over. The paramedics arrived I would imagine 15 minutes, 15 to 20 minutes later and they checked me over and they then decided that they would take me up to my local hospital. And they, whilst I was in the ambulance I believe they put the spray under my tongue and they also
Did an ECG?

Mervyn’ Yeah I think they did an, yeah they did an ECG and they also. What did they give me?

Mervyn’s wife’ Took some blood.

Mervyn’ Oh yeah they took some blood. On the way in the ambulance up to the hospital I felt violently sick. And we arrived at the hospital and I can’t remember much what happened then. Everything was very vague so I’d probably been given something that probably dulled me a bit.

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Ambulance crews also provide emotional support by reassuring and comforting those who feel distressed or worried about their situation.

Alan remembers one of the paramedics reassuring him and telling him that he was going to be in…

Age at interview 62

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Age at diagnosis 62

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And how long did it take the ambulance to arrive to your mother-in-law’s house?

Well I mean, you know, to be honest I don’t really know, probably 5, 10 minutes I would have thought but I mean I don’t know. It could have been less. It could have been a little bit more like, you know, because I was, well leaning back in the chair and the paramedic man was trying to calm me down a bit like because I was worrying what was going off. And I was no sooner there and they put me in the ambulance, sorted me out and we had the alarm going and [laugh] away we went. They chucked me off.

In the ambulance what happened? How did they manage you?

They stood up, they watched it on me, checking me but I mean apart from that I was normal really. I mean they just sat beside of me because I was trying to talk to ask, you know, what was going on. You know, What’s going to happen to me?’ And she was trying to calm me down like because I was withering about it and the next thing we were there.

She was explaining to you?

Yeah she was explaining what was going to happen. She said, Like I’ve seen it hundreds of time, don’t worry about it. it’s, you know, you will be in good hands. Which I was obviously, you know, I was very impressed.

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People we talked to found it reassuring being in the ambulance and receiving treatment even before they arrived in hospital. Some had an ECG done in the ambulance which was then transmitted electronically to the Coronary Care unit in the hospital, enabling healthcare staff to plan treatment before the person arrived at the hospital (see ‘Diagnosing a heart attack’).
Primary angioplasty is performed in some, but not all, hospitals. This is another reason to do an ECG in the ambulance: to establish if the person is having a heart attack in order to take him/her to the most appropriate hospital.

Once it was established that John was having a heart attack, it was agreed that he should be…

Age at interview 67

Gender Male

Age at diagnosis 67

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So in the land ambulance they connected me to the ECG. I was feeling not terribly well at that stage but not in huge pain still and they confirmed that it was, again confirmed that it was, the ECG was showing something, they kept referring to as ST which I didn’t understand at the time but now obviously realise it’s part of the heart pattern. And they said, We’ll give you some GNT. Just so GTN isn’t it. So, you know, I can’t remember was it TNG, trinitroglycerine and they actually sprayed some under my tongue which I knew was designed to dilate the arteries but the reality was. It was awful because the. I just suddenly said, I feel very, very faint. So they put my head down and they had previously put an injection into the arm. So they said, We are going to push some saline into you now because your blood pressure is dropping through the floor. So that was going on while they were actually driving off. As they drove off they were in touch with the [Hopsital name] in [City] and because this is [County], [Hospital name] was asking them to send telemetry of the ECG outputs but they couldn’t because [Town] don’t carry telemetry for it. So there was a lot of debate between the [Hospital name] and the ambulance as to whether it was ST but once they knew that it was, the [Hospital name] said, Yes we are happy to admit him. So we just proceeded and I drove feeling more uncomfortable because of the angle I was at more than anything else but not, not too. I mean in the whole scheme of things it’s pretty small.

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During a heart attack there is also the risk of having a cardiac arrest. This is when the heart stops pumping blood and normal breathing stops. The paramedics or ambulance staff have a defibrillator with them. One or more electrical shocks from the defibrillator can restore a normal heart rhythm and save the person’s life.

Stanley suffered three cardiac arrests in the ambulance on his way to the hospital and another…

Age at interview 59

Gender Male

Age at diagnosis 59

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Yeah I had three cardiac arrests in the ambulance. And then I had another one when I was in theatre but I don’t remember any of them. I must have had one as soon as my partner got into the ambulance, I think I had one then. I can remember speaking to her and I had one then and then I don’t remember anything then. Although when I first got in the ambulance the paramedics sprayed under my tongue and made me chew half an aspirin but I don’t remember anything after that.

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Everyone we talked to praised the ambulance crew for their help, their prompt arrival and the care provided. Looking back, John said that the whole experience would have been less anxious for his wife if she had travelled in the ambulance with him, instead of by car with their daughter.

Alan and his wife were very impressed’ by the service provided by the cardiac care unit and the…

Age at interview 62

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Age at diagnosis 62

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Alan’s wife’ We were very impressed with the service.

Alan’ it’s when they said what they were going to do in the ambulance and I thought, well tomorrow or the day after. And she said, Oh no as soon as you get there like. You know because I thought I would be in my bed then they’d come up and fetch me like, you know, but it was straight in and in then.

Alan’s wife’ And when I got there it was all over.

Alan’ Over and done with yeah that’s the amazing part to me especially not feeling anything either. I mean I’m not a one for
Exactly

Alan’ aving operations. I mean it’s not the best thing I like you know, I mean but
Alan’s wife’ It didn’t help because my mum, bless her heart she is 89, jumped in the ambulance with him and when it came and she left a note on the back door that said, Gone to [Hopsital name]’ which is obviously the other hospital. So my daughter came here and we sped off in the car and we went to [Hopsital name] and we parked and then we went to see if we could find him and he was at [Hopsital name]. So then [laugh] we had to obviously go and reclaim the car and go to [Hopsital name] and by the time we got there it was all over. He had been done but he wasn’t up in the ward. But the lady on the reception just said, don’t worry he’s had his op. You know everything is fine. He’ll be coming back here soon. And we just sat there and waited but we couldn’t believe that it had been done when we got there after taking a slight diversion into the other hospital.

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John said that his wife arrived to hospital anxious and fearing the worse.

Age at interview 67

Gender Male

Age at diagnosis 67

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Now in retrospect my wife says she should have come in the ambulance and I can see that would have made sense. But that would have left my daughter to drive on her own over to the [Hospital name] which she doesn’t know the way or anything like that. So they drove there. When they got there they couldn’t remember what they’d been told by the ambulance crew to go to the Cath Lab so they couldn’t, neither of them under the stress could remember where they had been told to go. So they found their way up to the Cardiac Care Unit, knocked on the door of, I assume it was the sister in her office outside and said, Could they, could she tell them where I was. And she said she felt as though she had interrupted her in doing something. So sister went off, came back, was much more consolatory and said, Would you like to come into this room?’

Well of course they then feared the worst. So my daughter was in floods of tears and she [the sister] said, No it’s ok. He is in the lab, sorry, in the ward. You can go through and see him. But by not being there in the ambulance they missed out on that bit so some unnecessary anxiety was raised because they weren’t there. And I think that’s true all the way through the thing.

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The experiences of the people we talked to showed that on average they waited for about 10 to 20 minutes for ambulance crews to arrive and a bit more if they lived in rural areas. People who have had a heart attack need to be treated within two hours to make primary angioplasty effective and to avoid further damage to the heart muscle.

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Initial treatments for heart attacks

The initial treatment of a heart attack at the time of these interviews (2004 and 2011) included pain relief, thrombolysis (clot busting) and other blood...