access to medical care, and (c) to increase the effectiveness and efficiency of the .... Does this mean that this approach to pre-hospital coronary care is futile?
EDITORIALS
tions and that black women are more likely to undergo surgical procedures that result in sterilization.5 Given that the health indices of the black population are less favorable than those of the rest of the population and that this state of affairs cannot be explained wholly as an outcome of poverty, it should not be assumed that the answer lies in improving the access of the black population to black physicians. It is more likely that medically underserved populations, black or white, will benefit less from policies aimed at correcting physician maldistribution than they will benefit from policies designed (a) to ensure that the preferences of consumers are respected, (b) to eliminate finacial barriers to access to medical care, and (c) to increase the effectiveness and efficiency of the care provided. The health of all communities will improve as the environment is protected and the quality of individual and family life enhanced. The collection of health manpower data by race should be justified only as a means of monitoring equality of access to education for health careers. As Dr. Gray points out, inequalities in health services for black or white people, in rural or urban areas, are not the problem of black physicians; like
other inequalities in our society, they are the problem of us all.
ALONZO S. YERBY, MD, MPH
Address reprint tequests to Dr. Alonzo S. Yerby, Professor of Health Services Administration, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115.
REFERENCES 1. Gray, L. The geographic and functional distribution of black physicians: some research and policy considerations. Am. J. Public Health, 67:519-526, 1977. 2. Elesh, D. and Schollaert, P. T. Race and urban medicine: factors affecting the distribution of physicians in Chicago. J. Health and Social Behavior, Vol. 13, September, 1972. 3. Yerby, A. S. The Disadvantaged and Health Care. Am. J. Public Health, 56:5-9, 1966. 4. Selected Vital and Health Statistics in Poverty and Nonpoverty Areas of 19 Large Cities, United States, 1969-71, Vital and Health Statistics Series 21, No. 26. DHEW Publication No. (HRA) 761904. 5. Davis, K. and Marshall, R. Primary Health Care Services for Medically Underserved Populations. Papers of the National Health Guidelines: The Priorities of Section 1502. DHEW Publication No. (HRA) 77-641.
Pre-hospital Coronary Care The two reports by Pozen, et al." 2 in this issue of the Journal describe the implementation and early results of a telemetry ambulance system designed to improve pre-hospital care of patients with acute ischemic heart disease in southeast Baltimore county. The results of their efforts are of obvious import. The vast majority of acute cardiac ischemic events occur outside the hospital as do the majority of sudden deaths due to ischemic heart disease. For these reasons, programs aimed at improving the pre-hospital phase of the treatment of ischemic heart disease are of vital importance. The essence of the pre-hospital phase of coronary care is to apply the principles learned in the coronary care unit to the treatment of acute ischemic heart disease earlier in its course. Experience in the coronary care unit has shown that although death due to coronary heart disease may be sudden, it is not unannounced.3 That is, the commonest mode of death, ventricular fibrillation, is usually preceded by ventricular ectopic activity. Recognition of this prelude permits effective therapy to prevent ventricular fibrillation. If prevention fails, early recognition and promnpt therapy of ventricular fibrillation permits survival. Many different models of pre-hospital coronary care have been proposed and implemented throughout the world. At one end of the spectrum is the mobile coronary care unit, manned by physicians.4 This is the most expensive system, and is not applicable to many areas in the U.S. 512
The most prevalent system of pre-hospital coronary care in the U.S. today consists of ambulances manned by attendants who have taken the 81-hour Department of Transportation course for Emergency Medical Technicians (EMTs). EMTs are trained to perform cardio-pulmonary resuscitation (CPR) but are not trained to take EKGs, to defibrillate or to give drugs. Pozen's group elected to upgrade their Emergency Medical System (EMS) so as to allow the EMTs to provide definitive pre-hospital coronary care. They prepared 18 EMTs to become Cardiac Rescue Technicians (CRTs) by virtue of a 90hour advanced cardiac course. They were trained to identify patients who might have acute ischemic heart disease, and to institute EKG telemetry in these patients. They were also trained to recognize and treat (with telephone supervision by physicians) certain life-threatening complications of acute ischemic heart disease. These CRTs were then assigned to two ambulances that served a population of 125,000 people in Baltimore County. The ambulances were equipped with portable defibrillators and EKGs that were transmitted by telemetry to a teaching hospital. Two-way telephone contact between the ambulances and the base hospital was established. It was anticipated that this upgrading of the existent EMS would enhance the pre-hospital care of patients with acute ischemic heart disease in the population served by the system. When they evaluated the results of their first 22 months of operation, the results were quite disappointing. During that AJPH June, 1977, Vol. 67, No. 6
EDITORIALS
period of time, 7,654 patients were transported to hospitals by the two ambulances. However, when they looked at the number of patients who had pre-hospital interventions based on the findings of EKG telemetry, the number was incredibly small-only 22. Since only six of these 22 patients were alive three months later, the maximum number of patients who benefited from this upgrading of the EMS during a period of almost two years was six or less. One would have to conclude that the system was not cost-effective. Does this mean that this approach to pre-hospital coronary care is futile? Before we come to this conclusion, a closer look at their experience and a look at another community Emergency Medical System is in order. Although Pozen's system was designed to enhance the pre-hospital care of patients with acute ischemic heart disease, very few of their patients had this disease. In their second paper, they review 1,771 consecutive patients transported over a six-month period. The review of these cases by two cardiologists indicated that only 71 patients had acute ischemic heart disease. That is, only 4 per cent of the patients had the disease for which the system was specifically designed. We do not know the circumstances that led to emergency transportation of the remaining 96 per cent. There are several possible explanations for this very low percentage of patients with ischemic heart disease. It may be that many of the cases who were transported were in fact non-emergent. That is, the denominator, the total number of patients transported, may have been inappropriately high. On the other side of the coin, the numerator, that is the number of patients with acute ischemic heart disease seems to be unduly low. Sidel, et al.5 have estimated that one might expect 750 heart attacks per year in a "standard population" of 100,000. The fact that Pozen's group qnly transported 150 patients with acute ischemic heart disease per year certainly suggests that they may not have reached the majority of patients with acute ischemic heart disease in their population of 125,000. Some of their potential patients may have sought help via other systems, may have failed to ask for help, or may have died before help arrived. They excluded patients who were dead with a "straight line" by EKG when the ambulance arrived, but do not state how many patients fell into this category. It seems quite possible that the population that they served did not take full advantage of their EMS program. The number of patients with acute ischemic heart disease receiving pre-hospital care was further diminished by the fact that not all the patients with this disease were selected for telemetry. Their review indicated that one-third of the acute ischemic heart disease patients did not have telemetry. These individuals were more likely to have severe clinical presentations, and to have type III or IV myocardial infarction by the Killip classification.6 Discussion with the CRTs indicated that they were less likely to subject these patients to telemetry (and thus potential pre-hospital intervention) because of pressure by families and onlookers to forego on-site treatment and to rush the patient to the hospital. It would appear that the residents of the catchment area were not aware of the benefits of on-site stabilization and treatment of patients with ischemic heart disease. When one looks at the small subset of transported AJPH June, 1977, Vol. 67, No. 6
patients with acute ischemic heart disease who did have telemetry, it is apparent that a sizeable proportion (32 per cent) had significant arrhythmias. In fact, 28 of 179 such patients (16 per cent) had complications that required defibrillation or drug therapy, prior to arrival at the hospital. The need for, and the efficacy of pre-hospital intervention in patients with acute ischemic heart disease, has been documented in other cities. The EMS in Seattle serves a population of 500,000.7 It responds to 18,000 requests for medical assistance per year. About one-third of the requests relate to patients with acute cardiovascular disease. Requests for help are answered within 2 to 5 minutes by an aid car manned by EMTs dispatched by the fire department. If the dispatcher deterinines that a life-threatening emergency is likely, a mobile ICU manned by paramedics (with 1,000 hours training) is also dispatched. The number of patients who require prehospital intervention is quite different from that reported by Pozen. In 1975 a total of 297 patients were treated for ventricular fibrillation outside the hospital. Sixty-eight (24 per cent) were long term survivors. During the 22 months of Pozen's experience only 15 patients were treated for ventricular fibrillation, and two survived. Pozen, et al. refer to the unique circumstances of having 90,000 citizens trained i;{ cardiopulmonary resuscitation in Seattle. This unique circumstance may well be related to the differences in the results of pre-hospital coronary care in Seattle and in Baltimore County. The importance of citizen involvement in pre-hospital coronary care in Seattle is indicated by the fact that in 37 cases of ventricular fibrillation where a citizen was administering CPR when the paramedics arrived, 45 per cent were long term survivors. In 68 cases where CPR was not being given, only 18 per cent survived.8 In addition to being trained to administer CPR in the event of cardiac arrest, the citizens of Seattle are aware bf the signs of acute ischemic heart disease and the need to summon help quickly. This may account for the much higher utilization of the EMS by patients with acute ischemic heart disease in Seattle. One might conclude that citizen involvement is vital if an EMS aimed at providing pre-hospital care for citizens with acute ischemic heart disease is to be successful.
JAMESE. DALEN, MD, MSPH Address reprint requests to Dr. James E. Dalen, Department of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, MA 01605.
REFERENCES
1. Pozen, M., et al. Studies of ambulance patients with ischemic heart disease I. The outcome of pre-hospital life-threatening arrythmias in patients receiving electrocardiographic telemetry/ therapeutic interventions. Am. J. Public Health 67:527-531, 1977. 2. Pozen, M., et al. Studies of ambulance patients with ischemic heart disease II. Selection of patients for ambulance telemetry. Am. J . Public Health 67:532-535, 1977. 3. Lown, B., Fakhro, A., Hood, W., et al. The coronary care unit. JAMA 199:3, 156-166, 1967. 4. Pantridge, J. F., and Geddes, J. S. A mobile intensive care unit in the management of myocardial infarction. Lancet, 2:271-273, 1967. 513
EDITORIALS 5. Sidel, V., et al. Models for the evaluation of pre-hospital coronary care. Am. J. Cardiology. 24:674-688, 1969. 6. Wolk, M. J., Scheidt, S., Killip, T. Heart failure complicating acute myocardial infarction. Circ. 45:1125-1126, 1972. 7. Cobb, L., et al. A rapid response system for out-of-hospital car-
I
diac emergencies. Medical Clinics of No. America. 60:283-290, 1976. 8. Cobb, L. A. Pre-hospital coronary care. Presented at the 16th Annual Meeting of the Association of University Cardiologists, Phoenix, Arizona, January 1977.
Emergency Medicine Symposium Set for Fall 1977
The Johns Hopkins Medical Institutions Division of Emergency Medicine, in cooperation with the Office of Continuing Education, University of California at San Diego, and Emergency Medical Associates, is sponsoring Emergency Medicine-Symposium 11: Trauma and Surgical Emergencies, to be held in Baltimore, Maryland October 3 1-November 4, 1977. This postgraduate symposium offers an in-depth review of practical diagnostic and therapeutic principles applied to trauma and surgical problems seen in the Emergency Department. The course is directed at practicing emergency and primary care physicians. Presentations will consist of formal lectures with question periods, videotapes, and demonstrations of technical procedures. Small group sessions in the animal laboratory will allow registrants to improve their skills in performing procedures useful in the management of trauma and other surgical emergencies. The program is approved for 40 hours of credit in Category I toward the Physician's Recognition Award of the American Medical Association. Fee is $300. For further information contact the Program Coordinator, Office of Continuing Education, Turner Auditorium Room 17, 720 Rutland Avenue, Baltimore, MD 21205, telephone (301) 955-5880.
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