The Ambulance Services have a critical role in the management of acute myocardial infarction. Originally The NHS Plan¹ set out the commitment to prehospital thrombolysis. The National Service Framework for Coronary Heart Disease and Reforming Emergency Care² has reinforced the commitment to prehospital thrombolysis (PHT) within the golden hour. The Department of Health has published a review of the CHD National Service Framework thrombolysis targets.³ This document has encouraged extending the paramedic role in the management of acute myocardial infarction (AMI) by prehospital 12 lead ECG monitoring and interpretation. In addition, prehospital thrombolysis when call-to-door times for AMI are greater than 30 minutes has been supported. The proposed models of care are autonomous paramedic PHT or telemedicine link with a physician authorising PHT on a named patent basis. To our knowledge there has been no research carried out questioning individual paramedics to ascertain their views of paramedic delivered PHT.

PARTICIPANTS, METHODS, AND RESULTS

West Yorkshire Metropolitan Ambulance Service Trust (WYMAS) provides ambulance services for a predominantly urban population of 2.2 million people. We conducted a questionnaire study of paramedics in WYMAS who had been trained to perform and interpret a 12 lead ECG. Approximately 250 paramedics had been trained at the time of the study and were eligible to participate. We compiled a postal questionnaire, which assessed the knowledge of risks and benefits of AMI treatments. The paramedics had not received any prior evidence based information regarding these drugs. We also included questions asking for their views on the ability of paramedics to carry out PHT and to express an opinion regarding this future role.

A total of 193 paramedics replied to the questionnaire, a response rate of 77%. The results are shown in table 1.

The majority (83%) of paramedics questioned felt paramedics would be capable to deliver PHT, 67% felt thrombolysis was safe for use by paramedics, and only 12% felt that paramedics should not carry out PHT at all.

When questioned about the preferred model of paramedic delivered thrombolysis, there was a similar preference towards autonomous PHT (42%) and telemetry with physician directed PHT (46%).

A majority (71%) felt they saw enough patients to carry out PHT, with a high level of confidence, after training, to perform a 12 lead ECG (89%) and interpret it (83%).

In addition there was a strong preference for the inclusion of a hospital based training programme (80%), and a nationally recognised thrombolysis training certificate for paramedics (96%).

In the comments section this was reinforced, as many expressed a preference for specialist in-hospital training.

There were concerns regarding the risks of AMI treatment including thrombolysis. This was confirmed by the questionnaire responses in which there were underestimates of the benefits of aspirin treatment, and overestimates of the benefits of thrombolysis. They also greatly overestimated the risks of thrombolysis in terms of extra deaths (71%), and bleeding (90%).

Virtually all (95%) felt there should be additional pay for the extra responsibility; some felt that thrombolysis training should be optional. There was also apprehension expressed about fear of litigation, personal liability for clinical incidents, and support systems.

COMMENT

The majority of paramedics in WYMAS responding to this questionnaire support the principle of PHT, although have some specific concerns. These clearly arise from a perception of the risks of thrombolytic treatment, concerns about training and the medico-legal implications for them as individual paramedics. We have identified potential educational needs; the training for this role should therefore include evidenced based medicine education, in-hospital training, and reassurance regarding medico-legal issues. Models for paramedic thrombolysis for each ambulance service should include the views of paramedics.