Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Again?
- David Syme (5 July 2003)
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Unreliable Imagery
- Jeffrey J Clarke (7 July 2003)
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Prehospital thrombolysis in "floating ambulance"
- David Rawlings (12 July 2003)
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Kettering's experience of accelerated management of AMI
- Jonathan A West (16 July 2003)
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Prehospital Thrombolysis For All??
- Michael O Coupe, Nadia Sunni (19 July 2003)
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Re: Again?
- Brian G McAleer, MPS Varma - Consultant cardiologist (9 August 2003)
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David Syme, GP Killin
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I'm genuinely surprised that we're still faffing about on this one when the GREAT trial reported ten years ago! Surely by now, all patients should have access to thrombolysis provided by GPs or paramedics and we should be actually achieving this, not discussing how it might be done! Refs:1.GREAT Group. Feasibility, safety and efficacy of domiciliary thrombolysis by general practitioners: Grampian region anistreplase trial: BMJ 1992;305: 548-53.[ISI][Medline] P.S. Where is the glen in the picture. Accuracy requires more detail than "Scottish Viewpoint" Competing interests: None declared |
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Jeffrey J Clarke, Consultant Psychiatrist for the Elderly Bootham Park Hospital, York, YO30 7BY
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The cover illustration of the printed BMJ this week is entitled "Scottish Viewpoint". The headline illustrated by the image refers to the paper from Scotland highlighting the benefits of the earliest possible therapeutic intervention in myocardial infarction and the related editorial. This image appears to show an ambulance travelling through classically beautiful Scottish countryside, perhaps with a paramedic crew on board administering thrombolysis in a timely and life-saving fashion. The image is however quite clearly a poorly assembled composite of two separate images. The front of an ambulance has been rather carelessly pasted onto the narrow country lane at an impossible angle. Even if the rear of the vehicle were there (which it visibly is not) the patient and crew would be entangled in the trees and fence making thrombolysis or progress to hospital extremely difficult. In this digital age we know that the camera can lie and the manipulation of photographs has become a tool whereby the truth can be distorted to suit the purpose of the publisher. Although it may seem a trivial accusation to make I believe that the BMJ does a disservice to the authors of this paper and undermines it's own position as a scientific journal by using such an image. I do not suspect that there were sinister motives for manufacturing this particular image on this occasion. We are meant to think of skilled paramedics at work in rural Scotland and there is no reason to doubt that paramedic ambulances do drive down Scottish lanes. The fact that they are almost certainly too busy to pause for photographs is not the fault of the editorial department of the BMJ. The serious question which arises, now that we know that we cannot trust everything we see on the cover of the BMJ, is how can we be certain in future that we are not ourselves being deliberately and less benignly deceived by digitally manipulated imagery? Competing interests: None declared |
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David Rawlings, consultant radiologist crosshouse hospital, kilmarnock, ka2 0be
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I read with interest the editorial and papers on prehospital thrombolysis but note with interest the acompanying photograph titled as "Scottish Viewpoint" which adorns the front page of the BMJ. The ambulance looks like it is floating above the ground and has clearly been rather poorly superimposed onto a background image. While the image is that of some beautiful Scottish scenery, is it impossible to find a picture of a real Scottish ambulance rushing through the countryside or are rural ambulances too thin on the ground. Competing interests: None declared |
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Jonathan A West, Cardiac Suite Manager Kettering General Hospital NHS Trust, Rothwell Road, Kettering, Northants NN16 8UZ
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Dear Editor Re: Accelerated management of acute myocardial infarction Further to Prendergast ‘s editorial on Prehospital thrombolysis I agree that there are difficulties in delivering an effective and timely treatment for acute myocardial infarction as detailed in the National Service Framework.1,2 In addition to a ‘call to needle’ time, the NSF has revised targets on ‘door to needle’ times from 30 minutes to 20 minutes stressing the importance of speed of care in thrombolysis. The recent report from MINAP (June 2003) assesses the current success of hospitals in the UK reaching those targets. It shows that a door to needle time of 30 minutes has been achieved by 95% of participating hospitals.3 Meeting the target of 20 minutes door to needle time, however, presents hospitals with an even tougher target to reach. As Prendergast highlights, prehospital thrombolysis has a vital role to play in reaching these targets, but so too is the introduction of bolus injection thrombolysis administered either in-hospital or prehospital. At Kettering Hospital we are within 25% of the 20 minute DTN time for all eligible AMI patients - an achievement which has been helped largely by a switch to bolus injection thrombolysis. Time of preparation is no longer a concerning issue, anxieties over weight adjustment are not a consideration with bolus injection and this improvement can also assist paramedics with prehospital administration. In order for other hospitals to meet the revised NSF targets and improve cardiac care for patients, this sort of approach to hospital and prehospital thrombolysis will be essential. Jonathan West, Cardiac Suite Manager, Kettering Hospital 1. Pendergast, BD. Prehospital thrombolysis. BMJ 2003; 327:1-2 (5 July) 2. Department of Health. National service framework for coronary heart disease. 2000. www.doh.gov.uk/nsf/coronary.htm (accessed 30 Jun 2003). 3. MINAP. Second Public Report of the Myocardial Infarction National Audit Project, June 2003 Competing interests: None declared |
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Michael O Coupe, Consultant Cardiologist Royal Oldham Hospital OL1 2JH, Nadia Sunni
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Editor, The article by Pedley et al on prehospital thrombolysis is a welcome addition to the debate about prehospital thrombolysis. However it exemplifies the danger of unblinded studies. Thrombolysis delivered by interested recently trained paramedics from the Scottish Ambulance service was compared with standard therapy in an accident and emergency department. The standard therapy in the accident and emergency department, as far as one can say, gave a median door to needle time of 30 minutes, with a mean of 39 minutes. This falls well short of the NSF standards. This view is re-enforced when one understands that the time for assessment by the paramedics on the scene,was less than the time for assessment in the accident and emergency department, (29 minutes against 39 minutes). Intervention by paramedics in the community should be compared with the best practice, not substandard practice. Strident calls for out of hospital thrombolysis throughout the UK, which have been heard,should be resisted,until it is demonstrated that cost benefit ratio against best practice remains superior, and we personally believe that in an urban environment it never will. Competing interests: None declared |
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Brian G McAleer, Staff physician Erne Hospital, Enniskillen BT74 6AY, MPS Varma - Consultant cardiologist
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Following the editorial by Prendergast on prehospital thrombolysis(1), we agree with Syme that this debate about feasibility should have moved on. We have been using prehospital thrombolysis in Enniskillen since 1986. The service was delivered by a Mobile Coronary Care Unit (MCCU) staffed by a doctor and nurse. Within the last 2 years, because of changes in junior doctor hours of work, the staffing has changed to 2 cardiac trained nurses with senior transtelephonic ECG interpretation back up. We have demonstrated similar time gains (2) to those of Pedley et al (3) and improvement in longterm survival. Whatever the mode of delivery of prehospital thrombolysis, this treatment is feasible and should be the standard form of thrombolysis in rural areas. (1)Prendergast B. Prehospital thrombolysis. BMJ 2003;327:1-2 (2)McAleer B,Varma MPS. Prehospital thrombolysis: longterm survival. Journal of Cardiovasc Drugs 1992;6:369-72 (3)Pedley DK, Bisset K, Connolly E et al. Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics. BMJ 2003;327:22-6 Competing interests: None declared |
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