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Prehospital management of myocardial infarction was evaluated in two differently structured Emergency Medical Service (EMS) systems in Southern Finland: a physician directed EMS with on-site physician involvement (physician EMS) and an EMS without operational physician involvement with paramedics only (non-physician EMS). The management of 641 consecutive acute ST-elevation myocardial infarction (STEMI) patients between 1997 and 1999 (263 patients in the physician EMS group and 378 patients in non-physician EMS group) were studied. Patients treated in the physician EMS received all necessary medical care including thrombolytic therapy at the scene whereas patients in the non-physician EMS were transported to hospital for definitive treatment after initial care. There were no differences in the demographics of the patients. The delays from onset of pain to initiation of thrombolysis were shorter in the physician EMS-group (124+/-101 min (25-723) versus 196+/-150 min (12-835), p<0.001). In 2% of the patients in the physician EMS group the pain to therapy-time was unknown compared to 27% in the non-physician EMS group (p<0.001). Fifty-two patients (20%) in the physician EMS received thrombolytic therapy after cardiopulmonary resuscitation compared to two patients in the non-physician EMS (p<0.001). Of the resuscitated patients in the physician directed EMS group 60% were discharged from the hospital, and 44% of these had a good neurological recovery. We conclude that a physician directed EMS is able to reduce the pain to therapy delays significantly in STEMI patients and may offer thrombolytic therapy to a wider patient group compared to an EMS without operational medical involvement.

We studied the long-term outcome and quality of life of elderly patients after prehospital thrombolysis to treat acute ST-elevation myocardial infarction. Data of 218 patients after prehospital thrombolytic therapy given by two physician staffed Helicopter Emergency Medical Service (HEMS) units were collected prospectively. Physical and mental status was evaluated at 4--6 months after discharge, and 1-year mortality was determined. Patients older than 65 years were compared with those younger than 65 years. There were 112 elderly and 106 younger patients. The elderly patients had more previous coronary events and more medications. Pain to therapy times between the two groups were equal (<65 years: 108+/-93 min (range 27--500 min) versus >65 years: 108+/-70 min (20-357 min)). After 4--6 months, the Barthel Daily Living Index or the Beck Depression Inventory (BDI) (depression, if BDI >/=10) showed no differences between the two groups (<65 years: 99+/-5 (range 65--100) versus >65 years: 98+/-12 (10--100); BDI>/=10, 18% versus 9%). One-year survival was lower among the elderly (79% versus 93%; p=0.001). No differences in the frequency of arrhythmias, haemodynamic problems during thrombolysis or complications such as intracranial haemorrhage after thrombolysis were detected. We concluded that elderly patients treated with prehospital thrombolysis for acute ST-elevation myocardial infarction recover mentally and physically as well as younger patients.

Prehospital thrombolysis for acute ST-elevation myocardial infarction (STEMI) has been shown to improve recovery from myocardial function. We describe prehospital thrombolytic treatment in two patients suffering from STEMI complicated by ventricular fibrillation (VF) on a passenger ship. The importance of a functioning Emergency Medical Service (EMS) system providing guidance for paramedical personnel is discussed briefly. Both our patients survived and returned back to normal life. It is concluded that EMS physician guided prehospital thrombolytic treatment may offer an important therapeutic option for nurses or paramedics in locations out of reach of ordinary EMS services.

The occurrence of arrhythmias and haemodynamic changes was studied prospectively in 226 consecutive patients who received prehospital thrombolysis for acute ST-elevation myocardial infarction (STEMI) in two Helicopter Emergency Medical Service (HEMS) systems in Southern Finland. Of the 226 patients, 129 were classified as receiving early (pain to treatment-time <90 min) and 97 as late (pain to treatment-time >90 min) treatment. Data on all arrhythmias and haemodynamic disturbances during the prehospital phase were collected. Arrhythmias occurred in 39% of all patients (40% in the early and 38% in the late group). A third of the patients received treatment for their arrhythmia (38% in the early group and 24% in the late group, P = NS). The most common arrhythmia was ventricular extrasystoles, which did not require any treatment in the majority of patients. On arrival of the EMS crew, 14% of all patients were hypotensive (14% in the early and 13% in the late group). After thrombolytic treatment, 7% of all patients became hypotensive (7% of the patients in both groups). The most common treatment for hypotension was fluid administration. Of the 15 patients who received thrombolysis after cardiopulmonary resuscitation (CPR), four patients suffered from arrhythmias and six patients developed hypotension after initiation of thrombolytic treatment. Although arrhythmias and haemodynamic changes were frequent in the prehospital setting after initiation of thrombolytic therapy, severe adverse events were rare. Those requiring therapeutic measures responded well to treatment. The occurrence of events was not related to the timing of thrombolysis in relation to the duration of pain.