> 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.

24 hour PTCA suggests resident interventional cardiologists. We're aiming
for one cardiologist/ 100k population. Allowing for some getting out of on
call by grandad clauses etc. and duties other than emergencies you're
probably talking about at least 15 to provide the cover. Suggests one per
1.5 million. In the major conurbations, might add 15- 20 minutes to transfer
time; but if you're talking about going to Birmingham from Hereford it could
easily add over an hour

> 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. 

Because (up to a point) time is important and transfer by helicopter over
distances under about 150- 250 miles (in areas served by decent roads)
generally takes considerably longer than transfer by road. Clearly, in most
parts of the UK, use of helicopters will introduce unacceptable delays. 

> Two thoughts on costs for helicopters. 
> 1. Is £1,000 for a helicopter trip that much more expensive 
> than £700-800 for single shot lytics when outcomes for 
> patients that we could include into the PTCA programme 
> probably far outweigh the numbers we could fit into 
> prehospital fibrinolytic programmes.
> 2. A bird on the ground, not being used is more costly than 
> one flying missions. I am sure it is easier to justify 
> helicopters if there is specific benefit to patient outcomes.

Remember, though that not every patient the helicopter responds for (unless
it is used for secondary transfer) will be suitable for PTCA. If say 1 in 10
is then it brings in a cost of 10k per PTCA.

> So. If a paramedic is able to rule out the majority of the 
> reasons for cardiac arrest -trauma, OD, hypothermia etc then 
> what remains is cardiac in origin - yes?

Minor error of logic. This is true only if every single possible non cardiac
cause of cardiac arrest has been ruled out, not if only the majority have.
One cause that is difficult to rule out quickly is of course intracerebral
haemorrhage. Pericardial effusion is another. I would note also the the 4 Hs
and 4 Ts refers not to causes of cardiac arrest but to treatable causes of
cardiac arrest. 

> Therefore why should we not consider fibrinolysis as part of 
> our treatment protocol for cardiac arrest? I know what you 
> are going to say - CPR and lysis - bad move, but is it?

Yes we should consider fibrinolysis as part of the treatment protocol.
Currently I'd probably still reject it pending more evidence. Basically the
problem is cost/ benefit (limited resources, and NICE has already rejected
treatments costing £30 k/ life saved). Bolus thrombolysis costs £700/ dose.
Patients in cardiac arrest not responding to initial defibrillation,
ensuring airway and ventilation including relief of tension pneumothorax and
pericardiocentesis as appropriate are highly unlikely to survive with
neurologically acceptable outcome (except in cases of hypothermia or certain
drug overdoses). My gut feeling is that the majority of your patients with
potential to survive would either have thrombolysis contraindicate or would
not benefit from it. However, as new evidence emerges we should continue to
reappraise this. At present it is an experimental technique.


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