I just re-read this, and realised that I come across a little strongly in places. Please don't interpret this as disrespect, as I value your opinion highly, and recognise that you have much greater training and education in this area than I do. However, I'm quite passionate about this area, so please forgive me where my passion comes across too strongly -- I don't mean to cause offence.
Educating and training paramedics to provide increased interventions.
I think the cost of this depends on how many paramedics you have, and what background they're starting with. If they already have a degree of familiarity with 12-lead, it may be a case of refreshing that knowledge and talking a little about STE mimics, and contraindications to fibrinolysis, and a little about reperfusion arrhythmias.
Equipment, you need some way to transmit, something to transmit to.
Yeah. The cost of this is going to vary by setting. An urban environment with a functioning 3G network is going to present different challenges to a rural environment with no functioning cellular coverage, as people have pointed out. A well-funded urban/suburban system may already have data transport capabilities.
At it's simplest, most monitors can simply be plugged into a phone line and used as a fax. This could then be evaluated by a remote physician.
Collaborative patient registration, sure, the technology exists, who buys the toys?
If a system has purchased monitors that aren't telemetry / fax capable, then there's going to be a cost. I would guess that many systems have purchased this capability but aren't using it.
All these costs have to be viewed against what a PCI procedure costs, the cost of a unit dose of thrombolytics (which is likely going to be given in the hospital if it hasn't been given in the field, in the right population). The cost savings may be in ICU time, cardiac rehab, etc.
You do end up in a situation where you may be asking a municipal entity, or a private company to pay for equipment where the cost saving is going to be for the treating hospital. This is probably much simpler to organise in a public health care system.
You are going to screen every patient for a STEMI or even every at risk patient for a STEMI? You couldn't possibly limit it to classic textbook presentation.
I think it's negligent of any paramedic not to perform a 12-lead on anyone with syncope, chest pain, abd pain above the navel, unexplained upper back pain, weakness, syncope, presyncope, etc. We should be doing this already.
Given the relatively small number of things that we have good evidence for, spending a few minutes to 12-lead a high percentage of our patients seems like a worthwhile effort.
I think what you do have to do, to reduce costs, is to train the paramedics to read 12-lead properly, and accept that the physician is going to get some false notifications. You don't want to have the individual provider scared to fax / transmit an ECG, but you also don't need to see 300 left bundle branch blocks, or clear BER.
Resources, if you have every patient who thinks they might be having a stemi call 911, you will probably need a few more unitson the road.
I think you're going to increase scene times. For negative ECGs, this is going to be a minimal increase. But for positive ECGs, if you're giving thrombolytics you're going to want 3 or 4 providers on scene, with preferably at least 2 of them being paramedics. And the scene times may be a little longer here.
That being said, this is sort of time well-spent. If you pull a second ALS unit to thrombolyse a STEMI, what are the chances that that unit is going to really be more useful somewhere else? That rare time-sensitive ALS call could come in, but how many situations really benefit from early ALS? The STEMI is clearly one.
What is the plan for the patients where the EKG fails to pick up the pathology?
Repeat ECGs, standard therapy, ER transport. Possibly field evaluation for cardiac markers for NSTEMI. The scene delay is probably not important for most of these patients.
Istats are a great tool, but not really practical prehospital, daily controls, refrigerated cartriges, etc.
I agree, but there are other solutions available that are more paramedic-friendly, even if you may lose some sensitivity. We're now talking NSTEMI management anyway. As I'm sure you're aware, enzymes aren't required to decide what form of reperfusion therapy should be used in STEMI.
TpA from a protocol? I could think of a dozen ways that could go wrong.
I think this is why you need the physician oversight. While well-trained paramedics can probably recognise STEMI quite well, you can catch the occasional mistake. If you have a good set of inclusion criteria, you can defer a subset of high-risk patients for further inhospital evaluation.
We don't have to replicate the inhospital process, just produce a system that works prehospitally with a low error rate and a net benefit.
In particular, I think you need the physicians for the fibrinolysis versus PCI decision.
What happens when you have a 65 y/o male patient complaining of chest or abd pain, history of CAD, uncontrolled HTN, and no stemi detected?
Transport to the ER. No STEMI = no 'lytics, no cathlab.
Are you going to give him the TpA prior to determining if he has a ruptured aneurysm?
This gets to be more of a concern if the patient has a proximal dissections that causes coronary artery occlusion, and produces ECG changes suggestive of STEMI. Then, I think you have to hope you get lucky, and that the patient's history or presentation causes the paramedics and physician to withhold the tPA.
While it's insensitive, a decent protocol would consider bilateral blood pressures prior to lysis. I'm not sure that a CXR is going to be routinely done in the ER prior to tPA, and that risk of thrombolysing a TAA that's missed on CXR and doesn't get further evaluation remains there.
I accept that it's a real risk, and that having evaluation by a physician in an ER environment is going to mitigate that risk. But any risk to a rare subset of patients with TAA has to be balanced against benefit to a more common group of patients with acute STEMI presenting in an environment where timely reperfusion therapy can only be provided by paramedics.
How about a untreated or subclinical GI bleed?
Remains a risk in the ER. How long does stat bloodwork take to come back? How anemic can they be before the ER will decide to withhold tPA?
Granted, the options to treat this complication in an ambulance are extremely limited, and it would be better to avoid this in the first place --- something a physician examination is more likely to do. But it's the same risk / benefit. Is the additional risk of inadvertent tPA to a small group of patients with subclinical GI bleed and STEMI in the prehospital environment versus the ER outweighed by the benefit of early tPA?
Same problem, though, right? You would know better than me, but I can't think the the ER is going to routinely do contrast CT before giving 'lytics or punting to cathlab.
If the patient sits on an EMS stretcher, that unit is out of service. You once again need more units. At the very least more stretchers.
But at least the unit is out of service for a good reason. And I think it's a more reasonable use of healthcare resources to have a crew sitting with a stretcher outside the cathlab doing their best impression of critical care nursing, than having the delays associated with an ER admit, or trying to develop some sort of equivalent system in the cathlab.
As you point out earlier, there's definitely potential issues with who's going to pay here.
Who pays for the helo rides? how much?
I don't think the helo rides are a good idea, unless the patient is in cardiogenic shock, and even then, I'm not convinced.
Also, I don't think that this is that many patients. I think the number of patient presenting to most EMS systems with acute STEMI is tiny compared to the number presenting with major trauma, for example.
Why should a doc or hospital lose time or take an operating theatre (cath lab) out of service for it with associated cost?
They're getting the patient anyway. Or at least someone is. I would assume the goal here isn't to take large numbers of patients who would otherwise receive tPA and send them to PCI. All we're doing is getting them to the cathlab faster, and saving ER time / dollars.
The inconvenience for the cathlab is going to be in false-positive activations, which should be partially mitigated by physician oversight. Or in the patients who code after activation and don't make it to angio. Otherwise they were going to have to move around electives for a primary PCI anyway.
How much over triage/treatment is acceptable?
Depends, I think. This isn't a trivial system to organise. I mean, you have to have 24-hour physician availability for ECG analysis. So someone has to have the pager and a laptop, and be prepared to spend maybe 20 minutes talking with EMS, quickly interpreting ECGs, starting the wheels in motion for cathlab / lytics, and is going to be tied up in some way. The better you train your paramedics to actually read ECGs, the more likely you get sent fewer ECGs with a greater PPV. If they just send everything that the LP12 balks at, then the requirement for physician involvement is going to increase near-exponentially.
The physician is there to limit the amount of unnecessary cathlab activation, and to limit the administration of tPA in at-risk patients. I think this is a major expense. Would PCI use increase? Maybe, but I'd almost expect the opposite --- if we catch the patients earlier in the pathology, we'll get a higher proportion of people in the first couple of hours where the benefit from thrombolysis is much higher. So we may end up using a therapy that might not be desirable at a later timepoint, instead of angio.
Is there a cost to the EMS system? Absolutely, in terms of training, oversight, and potentially equipment. Not to mention that the cost of a unit dose of TNK might exceed a billable transport. Those issues have to be addressed. But it's not like the EMS system is running around making people sick. These patients were having MIs to start with, and someone was going to have to give the TNK or do PCI at some point anyway. If we increase survival, perhaps we have associated costs there, but this is probably a good thing. And may be balanced by decreased costs from reduced morbidity.
It all costs money.[/QUOTE]
