On a busy workday in Bangalore, India, cars, busses, taxis, and bikes squeeze onto narrow streets, progressing so slowly at times, it can seem like they aren’t moving at all. The traffic may be a daily source of frustration for workers in the “Silicon Valley of India,” but for paramedics trying to reach a patient in need, it can be a matter of life or death.
From 2011 to 2017, the city’s population grew 45%, but its infrastructure — including its emergency response system — hasn’t been able to keep pace with this rapid growth. Adding to the challenge, heart problems like sudden cardiac arrest and heart attack are on the rise in India. The rate of cardiovascular disease (CVD) deaths in India has doubled in the past two decades, and CVD now claims 4 to 5 million lives a year. Often, lives are lost because patients simply can’t get the treatment they need quickly enough.
So leading health experts have come together to improve acute CVD care in India through a global program called HeartRescue. With support from the Medtronic Foundation, the goal of the program is to engage underserved communities to understand signs and symptoms of acute CVD events, decrease call time to intervention, and increase survival of patients. The program focuses on resource-constrained settings, where patients experience disproportionately poor health outcomes.
"Emergency medicine in India is still in the development phase,” said Dr. Aruna Chala Ramesh, head of emergency medicine and trauma at M.S. Ramaiah Medical College and Memorial Hospital in Bangalore, India. “I like to say it’s like an iceberg. What you see on the outside might not show the entire depth."
Cardiovascular care, she said, is often too slow. People may not be aware of the symptoms of CVD and they may not call for help quickly when symptoms like chest pain occur. When they do call, narrow streets and heavy traffic make it difficult for ambulances to reach CVD patients. And hospitals may not have the systems in place or necessary equipment to treat patients as soon as they arrive — such as antiplatelet medicines in the field or catheterization (cath) labs within hospitals to perform angioplasty for heart attack patients and restore blood flow to the heart. All of these delays add up to lost minutes when a patient is suffering a heart attack or cardiac arrest, putting people at a greater risk of death.
If an ambulance can’t get there, “patients may be transported in the nearest available vehicle instead of an ambulance,” Dr. Ramesh said. “They may be taken to the closest hospital, which may not be the best one for cardiovascular care.”
To address the challenge of reaching patients quickly, dispatch centers deploy trained first responders on scooters — one of the program’s innovations developed specifically for India — who can navigate the busy and narrow streets faster than an ambulance, to reach patients quickly. Each first responder carries an electrocardiogram machine (ECG), a tablet, and an automated external defibrillator (AED).
When the first responder arrives, he or she can give the patient an ECG and transmit the results to the hospital to determine whether the patient is having a heart attack. If they are, the first responder can give aspirin, which helps thin the blood. If the patient is having cardiac arrest, they can be treated on the scene with the AED. The goal is to provide life-saving care rapidly and treat the patient until an ambulance arrives.
Once the ambulance arrives, patients are transported to the next stage of care at a hospital. The HeartRescue India program helps strengthen the existing health system, which is arranged in a hub-and-spoke model. “Hub” hospitals have full capabilities to care for heart attack patients, including cath labs where angioplasty is performed. “Spoke” hospitals can stabilize patients, provide blood thinners, and transfer those who need angioplasty to a hub center. Data collection and quality improvement efforts provide continuous feedback to improve care.
“The HeartRescue project is successful because we cover the entire spectrum of care,” said Roopa KP, an emergency physician and chair of HeartRescue India. “It starts by involving the community and creating awareness. Then we address pre-hospital and in-hospital care. We involve emergency care and cardiology, as well as post-discharge care.”
Importantly, the program empowers people to live a healthier lifestyle and seek care if they need it as soon as possible, Dr. KP said. It’s also helping close the gap in what people know about heart disease, including the many symptoms that can occur beyond just chest pain.
To date, HeartRescue India has trained more than 500 physicians and hospital staff and established CPR programs at 10 community schools. At least 569 patients with STEMI have received better care and improved outcomes.
And HeartRescue India leaders are seeing signs that more people are paying attention to symptoms of CVD. A few months ago, a HeartRescue India volunteer told Dr. Ramesh that just six months earlier, he experienced chest pain. Because of his work with the program, he knew he should seek medical care right away. At the hospital, he was diagnosed with a heart attack and treated with angioplasty.
“He was so happy to be part of the program and tell his story,” Dr. Ramesh said. “It is a real joy to have people come back and tell us our systems are working.”