Heart attack study looking at whether giving clot-buster in ambulance is best

Photo credit: The Canadian Press

A recent story from the Canadian Press talks about the international STREAM study (Strategic Reperfusion Early After Myocardial Infarction).

"It's widely recognized that the faster you treat a heart attack, the better the outcomes," says Dr. Warren Cantor, a cardiologist at Southlake. "You can preserve heart muscle and increase a patient's chance of survival by opening the artery quicker."

"Furthermore, we now realize you can save approximately one hour if you diagnose the heart attack in the ambulance as opposed to in an emergency department."

I certainly can't disagree with that.

So far, more than 400 patients worldwide have been included in the STREAM protocol, which compares two treatment strategies.

The first involves giving a clot-busting medication in the ambulance, followed by artery-opening balloon angioplasty within 24 hours, while the second has a patient undergoing angioplasty within three hours, without a prior clot-dissolving drug.

This study will not resolve the question as to whether or not primary PCI with prolonged transfer times is superior to fibrinolytic therapy followed immediately by PCI.

Now the really interesting quote.

"So what we're looking at is whether patients may benefit by getting the clot-busting medication in the ambulance," explains Cantor. "And in order to do that, you can't rely on a paramedic interpreting the ECG. A physician really has to confirm the heart attack."
The obvious question is, why can't you rely on a paramedic interpreting the ECG?


Adam Thompson, EMT-P said...

Because 12-leads are taught in maybe one or two lectures in paramedic school and some systems never touch on it again. Paramedics are also known for erring on the side of caution which means more non STEMIs are probably called than STEMIs being missed. Not such a bad thing for the patients, but that means wasted time and $$$$ on the hospital side.

Tom B said...

Okay, so how do we turn it around?


Adam Thompson, EMT-P said...

Better training, QI/QA, and improved accuracy.

Medic 97 said...

Well, if you notice this article is coming from Canada. Our good friends to the north don't exactly go through the same training curriculum as we do. another fact is there skepticism of Paramedics resembles what we had/have (depending on state) when the program was first introduced. They haven't learned how to respect the field yet...

Tom B said...

Medic 97 -

Our friends to the north actually go through more education and training than we do.


Jim D said...

There are a few studies of paramedic interpretation of 12ld ECGs. A British study found the paramedics were virtually the same as the hospital ER residents (SHOs). Another study in the US found the ER physicians were about 25% more accurate than paramedics. So, in that respect the jury is still out.

COULD paramedics be as good as physicians? I think so, given the right training. Canadian paramedics are very highly trained. ECG analysis is not an esoteric skill requiring specialization and years of training, such as reading MRIs or CTs.

The physician exposes his own unscientific bias by making such a blanket statement without factual support to back it up.

paramedimark said...

I totally agree Jim D - i have just finished a 2 day course on 12 leads, and the use of thrombolytic drugs here in Northern Ireland. Our studies showed paramedic accuracy in diagnosing STEMI's as 92% - just as high as an ED doctors.
12 lead ecg's are not so difficult to interpret and identify a STEMI, maybe for the finer details one might have to look at them for years. But with the advent of telemetry, any ECG diagnosis can be confirmed with the receiving department before administering drugs.
i sometimes wonder is it more a political decision to try and prevent other medics from stealing their thunder, as it were? 'no, they cant thrombylise, thats our baby!' we find the same here with a lot of anaesthetists who are not at all happy that we intubate patients, as it's their domain. In my opinion, we are all in the same business, and it's the patient that comes first - not politics or ego!