- Joined
- Mar 19, 2003
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One of the paramedic services near my house recently (two years ago) got permission to activate the cath lab from the back of the bus. Background on this service: They run 8 medic ambulances for a population of ~100,000 and do medic intercept for a much much larger area. There are only two hospitals in town, and the one with the cath lab is the hospital of choice for anyone who is "sick" anyway. The decision to give them the "power" to activate the cath lab was made because the MDs in charge of the cath lab did a big study and looked at their interperation of the clinical data at hand (12 leads et al) and found that the medics were "right" as often as the MDs in the ED.
There is no way that "study" was accurate. Look, where I trained as a resident we had the best door-to-balloon times in the country. We averaged in the 30-40 min range with no case in the previous year >60 minutes. Our residents were well drilled in 12 lead interpretation, with most of us trained by Dr. Hamilton who literally wrote the book. I'm telling you, as a former medic who still rides, I can't make the call accurately in the back of the bus. First off, to be accurate, the 12 lead has to be done in the house, not the bus. The frequency response range is simply too affected by baseline variation (such as a diesel engine) in the diagnostic mode. That delays the transport. But worse, if you rely on your EMS service to "call" 12 leads in the field, you are likely to miss aortic dissections (yeah, I'd love some IIb/IIIa inhibition for my type A that has dissected back to my coronaries), likely to call Brugada or LBBB as MIs, and you are unlikely to recognize new LBBBs (how can you without old ECGs) as MIs. But all of that leaves aside the other problem. If medics "call" MIs in the field, the system is likely to rely on them to do so. Patients transported in by EMS without cath lab activation will likely become seen as "cleared" and that is simply not true. The far better system is close medical control, where EMS calls and says "yeah, I'm really worried about this one". We can then have lab, X-ray, and ECG standing by on arrival. It works great - and it doesn't remove physician level judgement from the equation.
My basic point is this, EMS for a while (where I'm from) has been allowed to choose hospital destination based on how critical a trauma patient is. Why not let EMS (when trained well) choose hospital destination for critical medical patients. There is very little difference in my mind between activating a trauma team (done without complaints by EMS) and activating a cath lab.
Because that trauma selection system has never been proven in the literature. Look at the published figures on the number of "level 1" or "level 2" trauma patients that go to the OR within two hours of arrival. The number is roughly 10%. (look here as an example, I don't have time for a full lit search: http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum). The reality is that the availability of a surgeon has been the driving force behind these EMS guidelines. But that isn't even a realistic analogy. What you are advocating is a system whereby the EMS crew makes the decision to proceed directly to the OR with a trauma patient. No way, no how. Remember, cardiac cath is NOT a benign procedure. It requires physician level judgement, period.
- H