MrJones
Iconoclast
- 652
- 168
- 43
That might be true. Can you ask him which specific studies he has read that promote this view? I would really be interested in them.
I don't know Handsome Robb's medical director so sorry, no.
That might be true. Can you ask him which specific studies he has read that promote this view? I would really be interested in them.
What contraindications are you using before infusing UFH?
That option simply isn't available in many systems. I cannot even believe people think PCI is so readily available that other options do not even need to be discussed.Primary PCI (pPCI) is the treatment of choice for STEMI, so take the STEMI to the cath lab. I cannot even believe we are having this discussion.
Thrombolysis is reserved for those patients who cannot receive PCI within a reasonable time frame (varies a little bit internationally - but approximately two hours from symptom onset).
That option simply isn't available in many systems. I cannot even believe people think PCI is so readily available that other options do not even need to be discussed.
How do you reconcile your opinion with the study I cited in the original post which says that in fact a STEMI should go to a community ED first to receive antiplatelet and anticoagulant therapy and then go for facilitated PCI?Regardless of how far the cath lab is, the patient should go to the cath lab first time (regardless of whether it's by road or air (either plane or helicopter)) unless it is not physically possible because the aircraft cannot fly or ambulance cannot drive.
The Royal Flying Doctor Service, Scottish Ambulance Service, Ambulance Service of New South Wales and similar services' (particularly in Australia) and New Zealand get people directly to the cath lab despite great distances, in the case of Australia, often thousands of kilometers.
This includes transfers for pPCI and urgent transfers post-thrombolysis.
Essentially, if your jurisdiction does not have a formalised system to get the patient to the cath lab as fast as possible or thrombolyse them en-route to a cath lab, well, that is, pragmatically, unacceptable, because it means the patient is receiving sub-optimal care.
Welcome to 80% of America.I think his point is that if your system doesn't have the capability of getting a patient to a Cath Lab in a reasonable timeframe, the system sucks.
Sent from my iPhone using Tapatalk
Citation?Welcome to 80% of America.
Welcome to 80% of America.
How do you reconcile your opinion with the study I cited in the original post which says that in fact a STEMI should go to a community ED first to receive antiplatelet and anticoagulant therapy and then go for facilitated PCI?
Citation?
By using data from the American Hospital Association survey, they found that the proportion of US hospitals providing PCI increased from 25.5% in 2001 (1176 of 4609) to 36.2% in 2006 (1695 of 4673), a 44% relative increase in the proportion of hospitals with PCI.11 Despite the addition of >500 new PCI programs, geographic access for patients improved little during the period of study. In particular, the percentage of the US population residing within 60 minutes of a PCI-capable hospital increased by a mere 0.9% (79.0% in 2001; 79.9% in 2006). Moreover, the average driving time and total elapsed time from 9–1-1 call to hospital arrival decreased by 48 and 30 seconds, respectively, suggesting that most new PCI programs have opened in areas with preexisting PCI hospitals. Although the improvement in geographic access from new PCI programs appears to have been small, the costs of these new programs are likely substantial. The fixed costs of setting up a new cardiac catheterization laboratory (construction and equipment) have been estimated at $3.1 million, without including the cost of physicians, nurses, and technologist staffing.12 Thus, the capital costs of the new PCI laboratories that have opened in this 5-year period are likely to have exceeded $1.5 billion Souce: http://circoutcomes.ahajournals.org/content/5/1/9.full
Easy. Carry ticagrelor and LMWH as part of your "STEMI bundle". This might not be necessary in an urban area with fast access to pPCI but certainly in rural areas is practical, maybe not on every ground ambulance but on the helicopter certainty.
Sounds like the focus needs to be public education for symptoms of STEMI and benefits of early detection... If someone chooses to live in a rural area, odds are they are not the type to call 911 very often; it's likely ignorance and stubbornness are the confounding factors.
Sent from my iPhone using Tapatalk
Amen. If you live in the sticks, you can't expect instant care at a fully equipped medical facility.
Rest assure I'm not trying to be a pain, that number just seemed way high.Good point and I really need to take my own advice before offering up an opinion. I did some research and it's clear that the numer is not as high as 80% of America lives outside a 60 minute drive directly to a PCI-center. In fact it seems nearly 80% does live within a 60 minute transport directly to a PCI center. The problem is that STEMI patients aren't getting to those centers within 60 minutes of activating 911 for several reasons, one of which is the PCI-center is outside the service area of the EMS geographical service area. It also appears many patients simply self-present to the ER of non-PCI hospitals when experiencing STEMI symptoms .