Helicopters are expensive, can you really justify carrying all these
?infarcts to the cath labs?? How much more effective is angioplasty in
the British system out of a trial. Remember there is such a thing as
advocate bias when enrolling patients in these trials. Why don't we
concentrate on spending money wisely instead of spending a lot of money
on saving 5-10 mins of jubious benefit. 10 minutes saved after 2 hours
of chest pain is not going to save much periinfarct tissue.
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Mike Bjarkoy
Sent: 18 October 2002 17:18
To: [log in to unmask]
Subject: Re: prehospital thrombolysis
Hi all
A few thoughts of my own - if you will allow...
I gave APSAC once back in 1990 and since then have fought to get lysis
on the road for us paramedics. So it may come as a bit of a surprise to
everyone, after fighting for this drug to be avaialbe to people such as
myself, to hear little 'ol me saying that I would prefer to see patients
not recieving prehospital fibrinolytics and bypassing local A&E depts in
favour of the cath labs.I have seen how they work the system in Seattle
and they go straight to cath labs. The only people they do not lyse are
those too big to get into the cath labs.
The number of patients who will be eligible for prehospital thrombolysis
will be minimal. I have been applying the questionnaire that JRCALC has
put forward in one form or another since the late 1980's (pre-JRCALC
recommendations) and this year only 2 people have been eligible.
Door to needle times in some hospitals are still not wonderful. To my
knowledge (anecdotal) the local hospital I run into still has door to
needle times in excess of 30 - 45 minutes unless the patient is
fortunate enough to be met by Doc who are switched on. The wasted time
(if you could call it that) could possibly be better spent delivering
the patient to definive mechaincal care - cath labs.
I believe the way forward should be...
All patient to go to central unit with cardiac specialties (PTCA). If
the patient fits the paramedic format for lysis and is out in the
sticks, then Reteplase would be administered as this doesn't preclude
the patient from mechanical interventions.
If they are outside the scope for PHT by paramedics i.e. recent surgery,
known active bleed etc then I believe it is an even greater indication
to take the patient to cardiac specialties.
If most of the MI patients go to one very good unit instead of many
mediocre units then there will be the volume of patients required to
justify 24/7 PTCA.
There is obviously one very big down side to all of this. If in the
extra 15 - 20 minute running time suggests that the patients condition
will dramatically deteriorate en-route then bypassing the local A&E unit
may not be the best course of action.
The other possibility is helicopter transport in. I know we only use
these birds to get trauma in but is there any negative evidence to
suggest why they cannot be used for AMIs. Theoretically it will increase
stress - or will it??
just the rantings of a senile paramedic
Mike
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