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Thanks for the excellent scenario, Dave. A few points to add about POC troponin and STEMI / NSTEMI care: * Troponins can take a long time to bump, so a single negative troponin is not an effective cardiac rule-out * Conversely, most NSTEMI patients don't require emergent catheterisation * The presence of absence of STEMI indicates the need for emergent reperfusion therapy. If there's a STEMI pattern, they need to either be lysed or cathed, depending on their risk factors, comorbidities, the availability of cathlab, and the age of their MI. * In the first 2 hours, field fibrinolysis may actually outperform PCI (*Unless your site is basically always ready to go, and has an open suite 24-7, it is extremtly hard to actually cath someone in the first 60-90 mins of an MI -- a paramedic team can have someone lysed in 25 minutes, sometimes quicker), and has at least comparable benefit in carefully selected patients. Re: TXA * CRASH-2 is a great study because it shows that even in a broad, poorly differentiated population, there was no real increase in thromboembolic events. No one really infarcted or stroked out. The only patients who did badly were those with non-recent injuries. * MATTERS is another good study to look at; this was performed by the military, so it used predominantly younger and baseline-healthier individuals, but they were also much more severely injured. It showed a much greater mortality benefit, suggesting that some of the benefit of TXA may have been masked in CRASH-2 by a subgroup of less severely injured patients who were at little risk of dying, and little risk of benefiting from the TXA, making the effect seem smaller. * It's a very safe drug, with a pretty large benefit. More places should be using it.

The benefit of having a trop Istat in the field would be huge for every service that has more than a 30 minute transport to a cardiac center. Think of the needless transports (medics best judgement on non-elevated troponins for transport to a cardiac center) that would not be made initially. I for one know that some of the patients that I did send to the cardiac center 60 minutes away who did not have elevated troponins might have been served better in a local smaller ER but I also know that those that I erred on the side of no ekg changes and only a gut feeling along with a elevated troponin that I elected to send to the local ER would have been better served at the cardiac center. Having this tool would be one more tool and I say TOOL to help us direct the right patients to the right center. Having ready use of a helicopter near by sometimes made me send patients who would have done just as well at our small ER but due to presentation or other symptoms, I elected to fly them to the cardiac center. Think of the decreased health care bills for these patients.

Only speaking from my personal experience Dwayne: But here in the Northeast you will not even be considered without 5-10 years under your belt in a busy system and plenty of education to go along with it. Most have advanced care/Critical Care Paramedic and some are dual Paramedic /RN's at time of hire. Maybe in other parts of the country where there are helicopters based in every other town and competition is stiff to drum up business the standards are lower for the quality of flight Medics. Those are the kind of services that have a high rate of aircraft incidents .