Pulmonary embolism patient Katy Sauls and her mother, Erin Sauls, talk about Katy's emergency surgery at Heart Hospital DMC, using a pioneering technique developed by DMC's Dr. Mahir Elder.
There’s a good chance that 22-year-old Katy Sauls would have died on Christmas Day last year if she hadn’t been at the right hospital at the right time.
The Oakland Community College student from Highland had a massive pulmonary embolism, a large blood clot in the lung so lethal that fewer than 50 percent of such patients nationally survive.
Fortunately for Sauls, her condition was quickly diagnosed and treated following the procedures of a new model for pulmonary embolism care that took root at the Detroit Medical Center (DMC) and is spreading across the country.
A group of experts from the hospital’s Pulmonary Embolism Response Team, or PERT, was on duty at DMC Heart Hospital that night. They rushed Sauls into a cardiac catheterization lab, where a tube was inserted into her lungs to deliver medication, and tools and sound waves were used to blast the clot apart before safely flushing it out of her body.
“I asked the doctor flat out, ‘Am I going to die?’ And he said, ‘We’re not sure,’ ” Sauls said she was told at a suburban emergency room before being rushed to the Detroit hospital.
Sauls was one of about 300,000 Americans annually who develop a pulmonary embolism, according to estimates. The condition affects all ages regardless of health status and can lead to sudden death for some. For those lucky enough to make it to a hospital, the condition often is mistaken for a heart attack, asthma or a range of other conditions. As a result, pulmonary embolism often is under-treated, meaning patients die who could have been saved.
The PERT program at Heart Hospital was the brainchild of Dr. Mahir D. Elder, medical director of the cardiac critical care unit at the hospital. It was the first such dedicated program in Michigan and one of the first in the world. Team members passionately call themselves the “Clotbusters.”
The “epiphany” came in 2011, Elder said, after he was called to the emergency department to treat a patient diagnosed with a heart attack. The patient, however, had suffered a massive pulmonary embolism. Elder diagnosed the problem and took aggressive measures that saved the man’s life.
Something had to be done, Elder decided, to spread the word about the condition, to improve diagnosis and to speed patients into treatment.
Elder put together a multidisciplinary team of specialists — ranging from emergency physicians to orthopedic surgeons, anesthesiologists and critical care nurses — from throughout the seven-hospital DMC health system. The team is on duty 24 hours a day every day of the year and has saved more than 300 lives so far, he said.
Elder collaborated with doctors at Massachusetts General Hospital in Boston to form a national PERT Consortium to spread the concept to doctors in the United States and around the world. So far, 87 hospitals nationwide have established treatment teams or have one in development, he said.
“Pulmonary embolism overall is like a great masquerader because the signs are so subtle,” Elder said. “Because it mimics other illnesses, it usually goes under-diagnosed, and when it gets to the stage of massive (embolism), they’re really under-treated.”
Many pulmonary embolisms are small and can be dissolved with medication. But massive clots can require surgery or other aggressive procedures.
Elder said hospitals, from Port Huron to Toledo, now rush pulmonary embolism patients to DMC Heart Hospital for treatment, and several Metro Detroit hospitals have started PERT programs of their own, including the University of Michigan Health System. Henry Ford Health System launched its program last spring.
Dr. Mahir Elder, director of the cardiac care unit at DMC Heart Hospital, talks about treating pulmonary embolisms.
Another local system, Beaumont Health, launched its first program Aug. 1 at Beaumont Hospital-Royal Oak, said Dr. Terry Bowers, medical director for cardiovascular medicine at Beaumont hospitals in Royal Oak and Troy. Another team is set to start next year at Beaumont Hospital-Troy.
‘I was so scared’
Katy Sauls was wearing an orthopedic boot over the holidays last year because a doctor had diagnosed the pain in her calf as a muscle tear.
In fact, she had a thromboembolism, Elder said. That’s a blood clot that forms in a blood vessel, breaks loose and is carried by the blood stream until it blocks another vessel. If it lodges in the brain, it can cause a stroke. If it moves to the lungs, it can cause a pulmonary embolism.
“My symptoms started about two weeks before, when my calf muscles started hurting real bad,” Sauls recalled. “It got to the point where I could hardly walk on it.”
On the way to her grandparents house on Christmas Day, the young woman became short of breath and her chest started to hurt. Her heart was pounding.
“I just laid on the couch, and that’s when my mom started to get worried,” Sauls said. “I thought, ‘Am I having a heart attack?’ That can’t be.”
That night, her parents took her to Huron Valley-Sinai Hospital in Commerce Township where doctors had been trained to look for pulmonary embolism. After a blood test showed Sauls had inflammation in her body, the doctors investigated further.
“Once they found that pulmonary embolism, they said we are taking her by ambulance, lights and sirens blaring, down to Heart Hospital,” Erin Sauls, Katy’s mother, recalled. “I was so scared.
“The surgeon (Elder) told us after the surgery that if we had not taken her to the hospital that night she would not have survived the night.”
‘Lack of attention’
Approximately 900,000 cases of thromboembolism occur annually in the United States, according to the federal Centers for Disease Control and Prevention. Elder said about a third of those result in pulmonary embolism. Causes of the condition can range from genetics to the after-effects of surgery or an injury, to something as simple as sitting too long on an airplane.
Pulmonary embolism causes between 180,000 and 200,000 U.S. deaths a year, and is the most common cause of in-hospital cardiovascular death, said Dr. Kenny Rosenfield, section head for vascular medicine and intervention with the Division of Cardiology at Massachusetts General Hospital and president of the PERT Consortium.
“There has been a lack of recognition of the magnitude of this problem, and lack of attention to it,” Rosenfield said. “This is the third leading cardiovascular cause of death, right behind stroke and heart attack, so it’s very common.”
“... And yet where we’ve reduced the mortality for heart attack and stroke some 30 percent or more over the last couple of decades, we have not made virtually any impact on pulmonary embolism.”
The lack of focus on pulmonary embolism is particularly discouraging in light of it being one of the most preventable and treatable cardiovascular diseases, Rosenfield noted. But awareness in increasing as the PERT Consortium has attracted doctors from as far away as China, Argentina, Uganda and the Netherlands, he added.
Elder has pioneered development of several new technologies for treatment of pulmonary embolism, Rosenfield noted. Innovative cardiac catheterization procedures, such as the one used on Katy Sauls, are saving patients considered too unstable to survive surgery.
In Sauls’ case, Elder used an ultrasound machine called an Ekos to pulse clot-busting medications into the pulmonary embolism. While clot-dissolving medications can cause bleeding in other parts of the body, placing the patient at risk of a stroke, the Ekos allowed Elder to deliver a fraction of the usual dose exactly where it needed to go, reducing the risk of that complication.
Elder talked about saving the life of a 12-year-old boy recently. Because of heightened awareness of pulmonary embolism, doctors at DMC Children’s Hospital diagnosed the condition quickly and called PERT for help.
“He had a condition, sickle cell, which is common in the city of Detroit, and that progressed to a clot that he developed and went to his lungs,” Elder said. “Hats off to Children’s Hospital, they were very good at catching it, and catching it early.”