Hi Matt,

"Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR" wrote:
>
> Seems like a good idea, Anton. I hadn't thought of it as a way of 'triaging'
> how fast to drive, but it makes a lot of sense. On a similar note, have you
> thought of fingerprick testing for troponins? (Should pick up your acute
> coronary syndromes with or without chest pain- elevated troponins would mean
> driving faster and possibly alerting the hospital- even starting to arrange
> a be for admission after initial resuscitation). There's a lot of these
> little sticks coming out for doing various tests at the moment.

Yes, have trialed several makes, and were very popular with the
paramedics.  First problem is the cost, at some £8-12 per strip -
estimated annual cost for us was in the region £100,000 (population of 1
million).

Second problem is False Negative in early MI - myoglobin seems to peak
earlier but will also miss an MI in the first hour.

> However, on MIs, I wouldn't thromobolyse on ECG in the absence of a good
> history (to give time of onset of ischaemia),

Absolutely agree - I think the Trops best role is to identify the high
risk unstable angina patients, as you have said.

> so I think the reasoning
> behind prehospital ECGs in elderly patients with LVF etc is a little
> different to that in patients with chest pain.

Absolutely correct - it is to try and get them on to an acute coronary
syndrome care pathway rather than COPD/CCF exacerbation/acute
breathlessness care pathway.

> Are you doing 12 lead ECGs in your elderly patients with collapse as well?
> Could pick up MIs and help risk stratification.

Not explicitly propounded, but perhaps should be given the evidence.

> What do you do if you find ST depression?

Oxygen, GTN, aspirin, opiate, generally do not run in on blues.  Had a
discussion at paramedic steering committee about intravenous
beta-blockers and decided against it, wisely in my opinion.  ST
depression patients will invariably receive repeat ECG on arrival at A&E
to see current ST segment status.

> (Indeed, a general worry-
> initially paramedics were trained to recognise the signs of thrombolysable
> MI in patients with a good history. This seems to be moving more to general
> ECG interpretation. Are they risking being held by a court as able to
> interpret ECGs in general- and thus negligent if a mistake is made. Relevant
> case law is R v Bateman (1925)- basically a practitioner claiming a certain
> expertise is liable if they fail to provide that level of expertise
> regardless of whether it is an accepted standard for their post or level of
> training. An example could be not using blues, but failing to recognise QT
> prolongation).

Very good point.  Paramedics do not at present interpret 12 leads - the
ECGs are transmitted and medical direction given to crew (thrombolyse or
not, blues or not) - more of a US style of medical direction than was
previously traditional in the UK.  Paramedics would be expected to
interpret a 3 lead in accordance with their training.

Anton
Staffs