I enjoyed “Sixteen diseases not to miss in the office,” by Dr Ian L. Mitchell in the March issue of the BCMJ (2006;48:84-85). Point number 7, regarding myocardial infarction, struck a chord with me as a practising emergency physician (EP). I absolutely agree with Dr Mitchell’s description and inclusion and wanted to add a point on the means of transportation to the local emergency department.
My colleagues and I frequently receive notice from family doctors’ offices or clinics (those courteous enough to call ahead and/or fax in a note) with patients that they’d like to send in to the emergency department (ED). Many of us advise that an ambulance should be called to transport patients to us for assessment when there is a suspicion of acute coronary syndrome (ACS).* As often as not though, patients have already left the office and are either driving themselves or are being driven in by a relative. Neither of these options is ideal.
Paramedics come with the ability to do a 12-lead ECG on scene (not available in all offices), establish IV access, and initiate some early therapy. Importantly, they can also bypass a local hospital in favor of a cardiac centre with a cath lab if need be. Additionally, the EMS system, through dispatch, has a good feel for the waiting times in their regional EDs and, in some cases, can arrange transport to a facility that will optimize patient care by accessing an available bed.
From the primary care setting to the paramedics working under medical control to a direct handover to the emergency RNs and EPs, the chain of care is better than the alternative of showing up in the waiting room, checking in at triage, and waiting in the waiting room for an ever-elusive bed to materialize.
Although most of the time a transport by private vehicle will be uneventful, the possibility of dysrhythmia, sudden cardiac death, or a motor vehicle collision due to pain, distraction, etc., exists. Such a complication occurring between the primary care setting and the ED would be difficult to defend.
—Adam Lund, MD
Royal Columbian/Eagle Ridge/
BC Children’s Hospitals
* ACS = Acute coronary syndrome—unstable angina (any new symptoms or change in pattern/threshold), non-ST elevation MI, acute ST elevation MI.
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