Using Fibrinolytics in the Remote Setting

GilaRRT · Sep 12, 2008

Thought I would throw this out for consideration by other providers.

The current situation:

I am currently working in a small remote medical clinic. We provide care for several thousand clients. Our resources and diagnostic abilities are quite limited. Labs and tests beyond XII leads, BGL's, Urine dip and HCG, and rapid hepatitis and malaria tests are subcontracted out to a couple of local hospitals and may take 1-3 days for any kind of result.

We are currently discussing the possibility of providing fibrinolytic therapy for patient presenting with STEMI. Obviously, the diagnosis would be based on clinical findings and XII lead evidence with the exception of patients already admitted to a local facility.

However, we need to consider the pitfalls of implementing such a program.

1) We do not have access to definitive cardiac care. No cath lab, no open heart, no heart/lung bypass.

2) We do not have access to reversal therapy and subspecialty resources if complications develop. No neurological resources, no cryoprecipitates for reversal, no readily available blood bank.

3) Prolonged evac times. A flight to Dubai would take at least four hours on a good day. If we are talking about a national with no passport, visa, or ID, then, several days. In addition, no flying at night and aircraft availability must be considered.

At this point, we are trying to figure out if the potential benefits outweigh the risks of administering fibrinolytics. If you guys know of any literature that specifically deals with these type of situations, I would appreciate the link.

Unfortunately, I cannot use much of the pre-hospital material, because in many cases, the patient is delivered to a definitive care facility by the EMS crew. This would not be the case in our situation.