For representational purposes only (Photo: Flickr)

The new STEMI programme has streamlined the treatment of heart-related conditions, allowing residents of even the remotest areas access to cardiologists at Hyderabad hospitals through a hub-and-spoke model.

Hyderabad, Telangana: Veeraswamy Goud is a 65-year-old tree climber from Yadadri, 65km from Hyderabad. The daily wager had been suffering from cardiac problems for five years. A couple of months ago, after he complained of breathlessness, he was rushed to the local public health centre (PHC) where doctors referred him to Osmania General Hospital in Hyderabad.

"They were upset when I took a local bus to the hospital instead of an ambulance, but I was scared because I didn’t have any money,” recalled Goud who had not forgotten how two years ago, he had to expend all his savings at a private hospital. But he needn't have worried. The ambulance, as well the treatment itself, would be free.

On April 13, his first stent was implanted, and since then, doctors from the hospital had been in touch with him regularly. “It’s a relief because I can connect with them directly if I have any problems,” he sighed. 

This is just one of the success stories of the Telangana government’s implementation of the ST-Elevation Myocardial Infarction (STEMI) programme. In fact, according to Dr Syed Imamuddin, Professor and Head of Cardiology at Osmania Medical College and Osmania General Hospital, sudden cardiac deaths in Telangana have dropped by 50% in rural areas since doctors implemented the system last year. The programme was finally operational in 2021, after the state completed setting up the required medical infrastructure such as digital diagnostics equipment, hub and spoke models, and catheterisation labs — commonly known as cath labs — at government hospitals, over four years. Cath labs are diagnostic centres where cardiac procedures are carried out with lower pain and risk involved and faster post-op recovery.

The hub and spoke model is an organisational system that arranges for healthcare services in a network of primary hospitals (hub) and multiple secondary establishments (spokes). Presently, Osmania General Hospital and Nizam’s Institute of Medical Sciences in Hyderabad and Mahatma Gandhi Memorial (MGM) Hospital in Warangal are the three government hospitals that act as hubs for patients from rural pockets and offer the STEMI programme. Another cath lab is in the process of being set up at Gandhi Medical Hospital in Secunderabad; it’s expected to be functional by end of June. 

Two years of saving lives and building data

According to Dr Raghu Kishore Galla, cardiologist and State Nodal Officer, STEMI-Telangana, as many as 2,000 cases have been attended to under the programme since 2021. Researchers are putting together data related to 350 patients for a paper, to be published in a medical journal, he added. 

This data procured from Dr Galla reveals that 2.8 lakh cases of acute coronary syndrome (ACS) are reported from Telangana’s rural areas every year, which translates to 240 cases for every one lakh individuals per year. These cases are evaluated at the hubs. So far, Osmania caters to about 170 to 200 cases per month, Nizam’s manages 100 cases per month, and MGM Hospital, 50 such cases.

In the 33 districts of the state, besides these three hospitals, the STEMI programme is operational at 46 spokes, such as public and community health centres (PHC and CHC) as well as area and district hospitals. Here, there are artificial intelligence-powered tele-electrocardiography (tele-ECG) machines that detect cardiac troubles. These telecommunications equipment can record and also transfer data from the spokes to the hubs, and at the latter, cardiologists inspect the reports and decide on the further course of treatment.  

The data, which is now collated on a daily basis, also reveals that 15 cases of heart attacks are handled in the STEMI network every day. A team of two MBBS doctors and two nurses handle these. A total of 65 such teams were trained for two days each in the past four years. PHCs have also been equipped with ventilators, defibrillator machines and other emergency equipment.

“Reports from the tele-ECG machines are uploaded on an app that’s installed in the mobile phones of the STEMI teams. Two doctors, two nurses and the head of the CHC are in the loop when such cases arrive,” explained Dr Bhavya Valli, MD, General Medicine, who works at the Gajwel CHC in Siddipet district and is trained in the programme.

“We have a code system: an emergency case gets everyone on the team on high alert. All operations are smooth during the day, but when cases arrive post-midnight, we need the guidance of our seniors on occasion,” she added, recounting the time when Dr Raghu had guided the team on a video call at 2 am when they were unsure about the course of action. “It’s helped us gain people’s confidence and also spread a positive word about the programme among those who travel to the centres from distant villages.”

Since the ECG machine was installed at the Gajwel CHC in 2021, patients complaining of a burning sensation in their chest, breathlessness, and pain in their arms and back are first monitored for high blood pressure and glucose and then taken for an ECG. Nurse V Ramaiah of the health centre said this is the standard procedure before patients are prescribed drugs. 

“It’s challenging at night because families prefer to consult with a doctor first. Villagers are calmed by their presence. Luckily, there are doctors on call within 2km in case of emergencies,” she added.

Such spoke-level emergency care offers higher chances of survival for patients from the state’s remotest villages than at the hub level, as explained by Dr Imamuddin. 

“STEMI has helped to provide emergency care at the remotest level,” he said. “Physicians and nursing staff at spokes are trained to handle cases of sudden cardiac arrests, starting with administering the thrombolysis injection and stabilising the patient. New medical and infrastructural advancements have also given us a window of 20 to 24 hours to transport a patient to a high-end facility."

Stacking the odds in favour of time and money

Under the STEMI programme, diagnostics centres, government CHCs and PHCs are connected via high-tech systems to the main hub, facilitating access to cardiologists in Hyderabad who can evaluate ECG reports and instruct doctors at spokes on emergency care. Next, the nursing teams at both the hub and tertiary centre remain in constant contact, with the doctors evaluating patients on an hourly or daily basis, based on the severity of the case.

The patients, too, can connect with their specialists directly. Though the primary concern that crops up during these follow-ups is that they often don’t have the money required to purchase the medicines necessary to continue treatment. While it is free at public hospitals and health centres, for example, the thrombolysis injection costs Rs 40,000 in private hospitals. In the 20 private hospitals which take up STEMI patients, however, the stabilising injection is available at no cost for those covered by the state health insurance scheme, Aarogyasri.

In the meantime, the case of Eswaramma, a 55-year-old farm labourer, brought to light another crucial circumstance. When the Jangaon resident travelled by bus to the Shadnagar PHC after feeling breathless and uncomfortable, a prompt ECG detected a mild heart attack. 

“This patient arrived breathing heavily. He could hardly speak. His blood pressure was at a whopping 180/100. An ECG showed he was having a mild attack,” said Dr S Srinivas from the Shadnagar health centre. “We spoke to cardiologists at Osmania, who asked for Eswaramma to be sent to the hospital immediately because he had reached the centre with time in hand for treatment.”

The doctors had found three blockages and implanted two stents. Eswaramma recalled being quite terrified in the moment, but at least he “wouldn’t have to worry about exorbitant bills at the government hospital”. 

This instance highlighted that when patients arrive with time in hand, without letting their conditions deteriorate, they witness the best results under the STEMI programme. However, in 15% of cardiac cases, symptoms are atypical and often go undetected or misdiagnosed, according to the American Heart Association Journal. This is when there’s no chest pain or breathlessness, and patients neither feel pain in their back nor their jaw. Such complicated situations are often dubbed ‘brought dead’ cases.

Moreover, with cath labs only in Hyderabad, the burden of all such cardiac patients falls on the capital alone for two primary reasons: these are established at a great expense, and the cardiologists required to ensure smooth operations are mostly centred in Hyderabad and its outskirts.

There are plans to develop similar such hubs in Siddipet, Nizamabad, Karimnagar and Mahaboobnagar. It’s set to develop cath labs at these locations and depute trained cardiologists for emergency and elective care.

This story is part of our series on ‘Rural Diagnostics’ that attempts to highlight the availability of such medical services in rural India. Read another article Quacks, quackery and their popularity in Rajasthan in the absence of doctors published under this series.