🚀 go-pugleaf

bobball@emt-p.org wrote:
> 
> In a previous article,  Gerald Clough  <DONTSPAMclough@texas.net> writes:
> >medic13 wrote:
> >Run a search on Yahoo using keywords "prehospital thrombolytic".  You'll
> >find a number of studies and other reports, most demonstrating the value
> >of prehospital therapy.  One of the primary reasons the urban setting is
> >appropriate is the typical denial and delay in activating 9-1-1 or going
> >to the hospital.  We're shooting for the first hour or two after the
> >blockage, and the patients are consuming that and more in delaying
> >access.  Substantial efforts are being made in the area of public
> >awareness, but the unfortunate fact is that we are very often missing
> >the opportunity for the best outcome and are limiting the permanent
> >muscle damage, rather than preventing it
> <snip>
> 
> I don't know...In the urban area, if you're medics are doing appropriate
> diagnostics to determine potential lytics candidates, you can already be on
> the move to the ED, which in many urban areas is no more than 10 minutes
> away. As long as they know what you're coming in with, the door to drug time
> can be almost eliminated (<5 minutes for most of our suspected MI patients).
> And all this without increasing the patient's risk of doing something bad
> (like dying) due to reperfusion dysrhythmias.
> 
> Don't get me wrong. Prehospital thrombolytics are a great idea...but one that
> works best when you're not going to reach the hospital within the ideal
> window...regardless of how early EMS is accessed. This means suburban/rural
> is your ideal place for prehospital lytics, not the city. A BLS service I
> recently did a trauma lecture for has only a clinic in their town. Nearest
> hospital is 45-50 minutes away. When they have a suspected MI in progress,
> they call ahead...the PA arrives at the clinic to meet them. 12 lead EKG in
> the truck...if MI, the PA rides in with, beginning thrombolytics
> enroute...with good success.
> 
> Frankly in our urban area (and perhaps the people in Minneapolis are more
> enlightened), we either get called early (<1 hour) or very late (12-48
> hours), so we can reach the hospital for lytics easily, or they're not a
> candidate anyway.
> 
> Bob Ball, EMT-P
> HCMC EMS/Ambulance, Minneapolis MN www.hcmc.org/depts/em/ambulance

Your right, of course, in pointing up that there are real risks of
complication that are best faced in the hospital.  The original post
asked if thrombolytics in an urban setting was logical.  As always, the
logic has to include all the factors in each particular locale.  The
optimal urban setting has ready access to an ED that has become one of
those that has establish a chest pain emergency facility or equivilent
fast track to screen potential candidates.  Sometimes, the routine
delays in ED run the door to drug time too long.  It all comes back to
that "EMS system" we've always talked about, putting the appropriate
parts in place and using them properly.  The more correct response would
have been that, in an urban setting, 12-lead in the field often the
critical factor in starting therapy in good time at the hospital.  

What all this really points up is that all parts of the system in every
area need to do careful and realistic joint thinking about how the
appropriate intervention will be accomplished in their area, the kind of
thinking we have done in trauma.  

(We seem to have a fairly high hardhead ratio in the population around
here, and I'm working up ideas for a public chest pain awareness
effort.)
-- 

Gerald
----

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