A few points taken from a variety of postings:
> I don't think anyone should be allowed to kill people. I also
> use a chest xray to look at the mediastinum before
> administering thrombolytics. I can get this within a few
> minutes in my department. I interpret the xray myself and
> therefore do not have to wait for a radiologist
> interpretation.
Plain chest x-ray is pretty much worthless in these patients. It is unusual
to be able to get a good quality erect CXR (and even then, in my experience
it is less sensitive in picking up small effusions/ haemothorax than
practised clinical examination). Widened mediastinum is worse than useless
(most widened mediastina have nothing to do with aortic dissection; if it is
due to dissection, then there's a mediastinal haematoma rather than just a
dissection. In which case the patient's not going to make it with or without
thrombolysis)
> from these patients. I agree that experience is a valuable
> tool, but why
> can't paramedics gain that experience? I often have the crews
> coming and
> asking me about the ECG and the factors that made me discuss
> and deliver TNK
> to the patient they brought in. Is there any difference
> between this mode of
> learning and the education of new PRHO's and SHO's (apart
> from the obvious
> medical training issue) in this area?
1. Just because something's obvious doesn't mean it doesn't matter.
2. Individual paramedics have less experience than A and E staff (there are
more paramedics than A and E staff and the same number of patients with
MIs). If there's an experience issue, there's a prima facie case for
concentrating that experience in as few people as possible.
> Disagree that not enough cardiologists - if each major London hospital
> were on take for one night a week, London could have a primary
> angioplasty service. There are enough cardiologists, they are just
> spread between a range of hospitals. DGH cardiologists in our patch
> already do on-call rota for referral hospital with cath lab
Even Warwick is now up to 3 cardiologists- certainly enough to run a
service.
> I think the question should not be whether ECGs are done at
> the scene or not, but why are your paramedics not
> thrombolysing patients, based on their own clinical diagnosis
> of the 12 lead?
Because there's no evidence that it works. Paramedic initiated thrombolysis,
pre- hospital thrombolysis etc. is a nice idea. It does need resources,
which means some evidence of effectiveness would be useful. One could argue
it either way: 'Earlier thrombolysis- which we know that at least in the
early stages of a study can be provided by pre- hospital thrombolysis- saves
lives on a population basis' against 'If a patient's going to get sick,
they're better in hospital earlier' on an individual patient basis and
'Dilution of experience in A and E/ CCU will cause additional problems for
those not suitable for pre- hospital thrombolysis' on a population basis.
One or two studies purport to show survival benefits from pre- hospital
thrombolysis. However, there is usually a marked selection bias- patients
with MIs who are suitable for pre- hospital thrombolysis are a selected
group with a low mortality in any case (atypical MIs have a markedly higher
mortality). For example, re- analyse the GREAT study on an 'intention to
treat' as you can from their figures and there is no benefit.
Drawing parallels with moving thrombolysis from CCU to A and E has one key
problem: the big argument for moving thrombolysis from CCU to A and E is
that it means your thrombolysis is all in one place. Thus 'atypical'
patients get dealt with by experienced staff (my argument has always been
that all chest pains should go to the same place). Moving thrombolysis from
A and E to pre- hospital would have the opposite effect.
Jury is very much still out as to whether pre- hospital thrombolysis is
effective in terms of improved outcomes, let alone whether it would be
better to spend the money elsewhere.
Matt Dunn
Warwick
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