Should Heart Attack Care be More Like Trauma Care?

[WelshMedic]

Hi all,

Here's my spin on the subject:

No, you can't set up a runny nose center for all patients with a rhinitis. But what about oncology centers for cancer patients, they're a good thing, aren't they? Yes, we'd all agree. Here's the thing, Cancer is the number two killer in the western world. Coronary Heart Disease is still number one. We need tertiary centers that specialize in angioplasty, but they also need the facilities to perform by-pass surgery, should it be necessary. The alternative is to put unstable patients on Intra Aortic Balloon Pumps and tranport to a facility that caters for open heart surgery. Not a particularly good prospect all in all, really.

Here in the Netherlands we've reached a fairly workable compromise where we give tenecteplase to patients at home with an MI below a certain total sum of ST elevations, the rest ( the big MI's ) go directly for primary angioplasty. Our transport times never exceed an hour in total, irrespective of traffic conditions (that's the advantage of being a country about the size of New Hampshire).

Greetings to all you folks from the other side of the big pond,

Carl.

[flight-lp]

Anybody out there using thrombolytics in the pre-hospital environment?

A service near by uses Retavase pre-hospital. I think it is pointless though, considering this county service has 6 cath labs available less than 20 minutes away!

[WelshMedic]

[A service near by uses Retavase pre-hospital. I think it is pointless though, considering this county service has 6 cath labs available less than 20 minutes away!

It all depends on what criteria the cath labs have for primary referal....

WM

[Nate]

A service near by uses Retavase pre-hospital. I think it is pointless though, considering this county service has 6 cath labs available less than 20 minutes away!

Thats got to be either ESD or Montgomery...in which case if it is Montgomer I wouldn't be surprised if one day they have the freaking cath lab in the back of the truck.

Seems to me that we are over-specializing our "emergency" care.

Trauma to a trauma center

Cardiac to a cardiac center

Stroke to a stroke center

COPD to a respiratory center?

Diabetics to an endocrinology center?

Sickle cell patients to a hematology center?

I can accept the fact that the facilities that specialize, or deal with a specific problem are going to be better at it, but to what end? Pretty soon we will end up needing multiple "centers" for the complaints that we see every day.

Here in Houston, with the expection of a few hospitals...they can handle just about any kind of medical emergency, now trauma is a different story. We have two Level 1's (three if you count Galveston) and we have several Level 2's and 3's. Most are working their way up to Level 2. The ones who can't handle most medical emergencies are usually Level IV or unranked.

We have two children's ER's, they are dedicated to only children...however everyone forgets about one. They all want to go to Texas Children's, but they forget that Hermann has one that is just as good (and hella quicker) as TCH. This is how it breaks down for trips into the Texas Medical Center.

Most trauma goes to Ben Tuab or Hermann with Hermann getting all children's trauma. Neuro, stroke, and cardiac is usually split between St. Lukes, Methodist, and Hermann. If you have someone who wants to just be in the medical center, but wants quick service...then St. Joesph's is our "hidden ace" because almost everyone forgets it is there. We have one hospital called Park Plaza...I wouldn't take Bin Laden to that hospital.

[Ridryder 911]

The problem is taking care of them and then being able to stabilize. Can every hospital afford a vascular neurosurgeon and his/her team ?..no... can every facility afford a cath team with a chest-cutter present 24 hr a day ? In which you have to have... most of EMS only sees the back doors of the hospital... there is a lot more that is required than an ER. So yes specialties are going to increase as competition and to decrease services that are able to make the hospital grow.

There is no reason to have multiple specialties... that is why 40% of Trauma Centers goes out of business within 5 years.. Trauma does not pay..(most GSW does not have Blue Cross & Blue Shield in their pocket)

R/R 911

[HFD23]

I think Cath labs are the way to go. But it's not just about the specialty centers, and their capabilities. We have to take into consideration our capabilities. A patient presenting with an AMI, get a 12-Lead, Elevation present? Recip depression present? My service is particpating in the PATCAR study, and its turning up really good results. You run and 12-Lead, and see elevation, you send the 12-lead by cell phone to the hospital participating in study, they confirm, you push retavase, plavix (they eat it), and heparin, seeing the patient meets the check list. Once you have this pushed, then you get on the road, the Cath Lab team is waiting on the Docks of the ambulance bays, and the pt. never sees the ER. I think Monkey County just north of us is in the study. So far this combination of a specialty hospital, and EMS using it's capabilites seems to be working very well. Now I know not everyone has a fancy zoll, or LP 12, but you still have your MCL's on a three lead. That way you have a better idea. But after seeing this system work in the field, I think its more important to look not just at going straight to these specialties centers, but Paramedics working with these centers to provide quicker treat.

[Nate]

Liberty County eh?

[flight-lp]

"Monkey County" - That pretty well sums it up it a nutshell LOL!!!!!!

O.k. I think it is nice to have advanced treatments such as Retavase available, but they serve no advantageous purpose in an urban environment. Thrombo's are a temporary solution to a permanent problem. Angioplasty is the definitive treatment, so why not just get them to the cath lab? I cannot offer an educated assertation to other areas of the country, but around here, most Interventional Radiologists and Cardiologists will not touch a thrombolytic patient for 24 - 48 hours, thus increasing the time to corrective therapy. I say fix what is broke................

While on the subject of specialty centers, I just wanted to point out an interesting statistic that Houstonian's have dealt with for years. We are severly underserved for trauma care. I know, it's all about the money, but..........

Houston, Tx. pop. 2 million +

2 adult level 1 trauma centers

2 pedi level 1 trauma centers

0 regional level 1 trauma centers (outlying trauma centers)

0 level 2 trauma centers

0 regional level 2 trauma centers

Chicago, Ill. pop. 2.8 million

4 adult level 1 trauma centers

4 pedi level 1 trauma centers

4 regional level 1 trauma centers

26 regional level 2 trauma centers!!!!!!!

St. Louis Mo. pop. 350000

3 adult level 1 trauma centers

2 pedi level 1 trauma centers

4 regional level 2 trauma centers

Just a statistic that I thought I would share...............................

[rat115]

Nate...you mentioned pediatric trauma and I thought of Hermann not Texas Children's. It's been a few years since I've been down there. Unfortunatly, with what flight-lp said, not much has changed since I left there in 1992.

Here we have one hospital. No choices. If the pt needs cath, we usually fly them to Denver or CO Springs.

[Nate]

Nate...you mentioned pediatric trauma and I thought of Hermann not Texas Children's.

Thats what I said, pediatric trauma goes to Hermann. The only thing we take to TCH is medical, and I have yet to find to many people who have transported to Ben Taub with a pediatric patient (even though they have a pedi ER).

Houston, Tx. pop. 2 million +

2 adult level 1 trauma centers

2 pedi level 1 trauma centers

0 regional level 1 trauma centers (outlying trauma centers)

0 level 2 trauma centers

0 regional level 2 trauma centers

I thought Conroe was nearing Level 2 status. I know that the new Katy Hermann is suppose to be a Level 3 and there was a rumor that a Level 2 hospital was going to be built around Highway 3/Beltway 8/I-45 to service Pasadena, South Houston, and Clear Lake. Is Mainland even ranked?