2. Pre-hospital Thrombolysis in the UK - looking ahead Richard Vincent Royal Sussex County Hospital, Brighton

3. Pre-hospital thrombolysis Why attempt it? Why attempt it? What are the possibilities? What are the possibilities? Where are we now? Where are we now? What of the future? What of the future?

4. Pre-hospital thrombolysis Why attempt it? Why attempt it?

5. Pre-hospital thrombolysis The argument of natural history The argument of natural history Why attempt it?

6. Pre-hospital thrombolysis The argument of natural history The argument of natural history Persuasive clinical trials Persuasive clinical trials Why attempt it?

7. Pre-hospital thrombolysis 0 - 1 hr65 1 - 2 hrs37 2 - 3 hrs26 3 - 6 hrs 29 Lives saved per 1000 patients treated of those with ST  or LBBB Boersma, Lancet 1996

8. Pre-hospital thrombolysis Reducing delay early after the onset of symptoms (A) gives greater benefit than reducing delay later (B)

9. Pre-hospital thrombolysis The argument of natural history The argument of natural history Persuasive clinical trials Persuasive clinical trials The enthusiasm of a few The enthusiasm of a few Why attempt it?

10. Pre-hospital thrombolysis The argument of natural history The argument of natural history Persuasive clinical trials Persuasive clinical trials The enthusiasm of a few The enthusiasm of a few Improved practicality Improved practicality Why attempt it?

11. Pre-hospital thrombolysis The argument of natural history The argument of natural history Persuasive clinical trials Persuasive clinical trials The enthusiasm of a few The enthusiasm of a few Improved practicality Improved practicality The NHS plan and others The NHS plan and others Why attempt it?

12. Pre-hospital thrombolysis Why attempt it? Why attempt it? What are the possibilities? What are the possibilities?

13. Pre-hospital thrombolysis Report clinical and ECG data to hospital Report clinical and ECG data to hospital What are the possibilities? recognise clinical AMI then:

14. Pre-hospital thrombolysis Report clinical and ECG data to hospital Report clinical and ECG data to hospital Report AMI and transmit ECG to hospital Report AMI and transmit ECG to hospital What are the possibilities? recognise clinical AMI then:

15. Pre-hospital thrombolysis Report clinical and ECG data to hospital Report clinical and ECG data to hospital Report AMI and transmit ECG to hospital Report AMI and transmit ECG to hospital Seek authorisation for on-site thrombolysis Seek authorisation for on-site thrombolysis What are the possibilities? recognise clinical AMI then:

16. Pre-hospital thrombolysis Report clinical and ECG data to hospital Report clinical and ECG data to hospital Report AMI and transmit ECG to hospital Report AMI and transmit ECG to hospital Seek authorisation for on-site thrombolysis Seek authorisation for on-site thrombolysis Liaise with GP on site Liaise with GP on site What are the possibilities? recognise clinical AMI then:

17. Pre-hospital thrombolysis Report clinical and ECG data to hospital Report clinical and ECG data to hospital Report AMI and transmit ECG to hospital Report AMI and transmit ECG to hospital Seek authorisation for on-site thrombolysis Seek authorisation for on-site thrombolysis Liaise with GP on site Liaise with GP on site Decide and treat without outside advice Decide and treat without outside advice What are the possibilities? recognise clinical AMI then:

18. Pre-hospital thrombolysis Why attempt it? Why attempt it? What are the possibilities? What are the possibilities? Where are we now? Where are we now?

19. Pre-hospital thrombolysis A growing level of interest A growing level of interest Where are we now?

20. Pre-hospital thrombolysis A growing level of interest A growing level of interest A growing level of consultation A growing level of consultation Where are we now?

21. Pre-hospital thrombolysis A growing level of interest A growing level of interest A growing level of consultation A growing level of consultation A new level of trust A new level of trust Where are we now?

22. Pre-hospital thrombolysis A growing level of interest A growing level of interest A growing level of consultation A growing level of consultation A new level of trust A new level of trust Greater permission to use drugs Greater permission to use drugs Where are we now?

23. Pre-hospital thrombolysis A growing level of interest A growing level of interest A growing level of consultation A growing level of consultation A new level of trust A new level of trust Greater permission to use drugs Greater permission to use drugs On-going technical development (equipment and drugs) On-going technical development (equipment and drugs) Where are we now?

24. Pre-hospital thrombolysis Reporting clinical and ECG data to hospital27 Reporting AMI and transmitting ECG to hospital24 Seeking authorisation for on-site thrombolysis27 Liasing with GP on site17 Deciding and treating without outside advice21 Ambulance trusts with an interest JRCALC, Summer 2000

25. Pre-hospital thrombolysis Why attempt it? Why attempt it? What are the possibilities? What are the possibilities? Where are we now? Where are we now? What of the future? What of the future?

26. Pre-hospital thrombolysis Continued technical development Continued technical development The future?

27. Pre-hospital thrombolysis Continued technical development Continued technical development Increasing determination to make pre-hospital successful including the use of thrombolytics Increasing determination to make pre-hospital successful including the use of thrombolytics The future?

28. Pre-hospital thrombolysis Continued technical development Continued technical development Increasing determination to make pre-hospital successful including the use of thrombolytics Increasing determination to make pre-hospital successful including the use of thrombolytics A hard look at some challenging questions…. A hard look at some challenging questions…. The future?

29. Pre-hospital thrombolysis MISTAKES The future will also contain

30. Pre-hospital thrombolysis Organisation? Organisation? Challenging questions

31. Pre-hospital thrombolysis Organisation? Organisation? Ownership? Ownership? Challenging questions

32. Pre-hospital thrombolysis Organisation? Organisation? Ownership? Ownership? Competence? Competence? Challenging questions

33. Pre-hospital thrombolysis Organisation? Organisation? Ownership? Ownership? Competence? Competence? Training? Training? Challenging questions

34. Pre-hospital thrombolysis Organisation? Organisation? Ownership? Ownership? Competence? Competence? Training? Training? Psychology? Psychology? Challenging questions

35. Pre-hospital thrombolysis Diagnose death + appropriate ECG Diagnose death + appropriate ECG Four observations + gross ECG changes Four observations + gross ECG changes No contra-indications No contra-indications Immediate, visible benefit Immediate, visible benefit Patient can’t get worse Patient can’t get worse Treating VF with a shock

36. Pre-hospital thrombolysis Diagnose death + appropriate ECG Diagnose death + appropriate ECG Four observations + gross ECG changes Four observations + gross ECG changes No contra-indications No contra-indications Immediate, visible benefit Immediate, visible benefit Patient can’t get worse Patient can’t get worse Treating VF with a shock Treating AMI with thrombolysis Diagnose MI + appropriate ECG Diagnose MI + appropriate ECG Twenty observations + subtle ECG changes Twenty observations + subtle ECG changes Important contra-indications Important contra-indications Delayed, invisible benefit Delayed, invisible benefit Patient will sometimes get worse - early or late Patient will sometimes get worse - early or late

37. Pre-hospital thrombolysis Organisation? Organisation? Ownership? Ownership? Competence? Competence? Training? Training? Psychology? Psychology? Audit? Audit? Challenging questions

38. Pre-hospital thrombolysis Keep discussing Keep discussing Pray for wisdom Pray for wisdom So now…..