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A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF MYOCARDIAL INFARCTION
Saturday 5 August 1967 A MOBILE INTENSIVE-CARE UNIT IN THE MANAGEMENT OF
MYOCARDIAL INFARCTION
J. F. PANTRIDGE M.C., M.D. Belf., F.R.C.P. PHYSICIAN-IN-CHARGE
J. S. GEDDES M.D., B.Sc. Belf. REGISTRAR
CARDIAC DEPARTMENT, ROYAL VICTORIA HOSPITAL, BELFAST 12
The risk of death from
myocardial infarcSummary tion is greatest in the twelve-hour period after the onset of symptoms. Despite this, the hospital admission of a large proportion of patients is delayed for more than twelve hours, and many die in transit to hospital. A scheme has been described involving the use
cardiac department. The only increase in the establishment obtained for the project was one registrar (J. S. G.). The signal from the general practitioner is given priority at the hospital telephone switchboard and immediately transmitted to the duty registrar or houseman and to ambulance control. The team proceeds with all possible speed to the patient. When the ambulance has arrived the patient is immediately under intensive care. Monitoring and therapy in the patient’s home may be required before a stable rhythm is established. When it is considered safe the patient is transferred to the ambulance and monitored continuously during transport to hospital. Haste or fuss during transit are carefully avoided. The mobile unit is available to a population of approximately half a million in the Belfast area. 100,000 live within a one-mile radius of the
hospital. The unit
Results was
were
admitted
FINAL
DIAGNOSIS
Introduction
THE evidence indicating the need for rapid initiation of intensive care in cases of myocardial infarction has been reviewed by Pantridge and Geddes (1966). Most deaths from myocardial infarction occur within twelve hours of the onset of symptoms and some 60% are within the first hour (Yater et al. 1948, Bainton and Peterson 1963). Despite this the hospital admission of a large proportion of patients is delayed for more than 12 hours (Mittra 1965, Lown et al. 1967), so that the patient comes under intensive care at a time when the greatest risk has passed. That the majority of deaths occur outside hospital was shown by Pemberton and McNeilly (1967) in a survey of deaths from myocardial infarction in Belfast in a one-year period starting in 1965. Of 901 individuals who had fatal coronary attacks, only 414 reached hospital, and of these 102 were dead on arrival. In an attempt to prevent deaths from cardiac arrest occurring soon after the onset of symptoms and in an attempt to ensure safe transport of the patient with myocardial infarction, a mobile intensive-care unit has been in operation from this hospital since January, 1966. We describe here the results obtained during the first fifteen months of the unit’s operation. Method The mobile intensive-care unit consists of an ambulance which carries routine monitoring and resuscitation equipment including a battery-operated D.c. defibrillator and bipolar pacing catheters. The personnel are found from the staff of the 7510
to IN
hospital 312
on 338 occasions. 312 patients with a suspected diagnosis of
PATIENTS
ADMITTED
WITH
SUSPECTED
MYOCARDIAL INFARCTION
of a highly mobile unit which enables intensive care to reach the patient when he is at most risk. The unit has been used in the transfer of patients to hospital. No death has occurred in transit in a fifteen-month period. Ten examples of successful resuscitation outside hospital are reported. 5 of these patients are now alive and well. Thus it has been shown perhaps for the first time that the correction of cardiac arrest outside hospital is a practicable proposition.
summoned
coronary thrombosis. In the first six months of the operation of the scheme 20% of the patients were reached within fifteen minutes. There has been a progressive improvement in performance and in a recent three-month period 7801 of patients were reached within fifteen minutes. It is well known that resuscitative methods may maintain adequate circulation for this period of time. The
after onset of symptoms: cumulative (all patients) and individual intervals for those in whom resuscitation was
Fig. I-Interval attempted.
272
final diagnosis of the 312 patients is shown in the table. was obtained in each of these patients. All developed 155 had proven myocardial infarction. 96 had prolonged ventricular fibrillation within four hours of the onset of chest pain without indubitable evidence of infarction, symptoms. Fig. 2 records the data of 4 patients who although the electrocardiogram was abnormal. 28 had developed ventricular fibrillation in the ambulance during prolonged chest pain with a normal electrocardiogram. transit. No patient died during transit. 1 elderly patient In only 3 % of cases was it thought that the call for the died, soon after admission, from pulmonary oedema. The mobile unit had been unjustified. other 3 were discharged from hospital. 105 (two-thirds) of the patients with proven myocardial Fig. 3 shows the data concerning 6 patients successfully infarction were male and the majority of these were under resuscitated in various situations soon after the onset of the age of 60. symptoms. 4 had cardiac arrest in their own homes, 1 in The time after the onset of symptoms at which the a dance hall, and 1 in her doctor’s surgery. 3 of these 155 patients with proven infarction came under intensive patients have survived. 6 of the patients shown in care and the incidence of ventricular fibrillation during figs. 2 and 3 were excluded from the analysis in fig. 1 the first three days is shown in fig. 1. 78 of the 155 (half either because the occurrence of cardiac arrest was the the patients) were under intensive care within two and a reason for the signal or because resuscitation occurred half hours, and two-thirds within four hours. Since the after March 31, 1967. majority of deaths occur soon after onset of symptoms it Case-reports might be expected that among patients seen early the Details of 10 patients successfully resuscitated outside incidence of ventricular fibrillation would be high. This hospital are given. proved to be so. 9 patients among the 101 seen within Case1 four hours developed ventricular fibrillation. Resuscitation A 79-year-old woman developed ventricular fibrillation was successful in 8 of these. during transfer to hospital. Defibrillation was achieved in the During the entire period in hospital 21 of the patients ambulance by the house-physician. Unfortunately pulmonary admitted by the mobile unit developed ventricular cedema became apparent soon after admission and the patient fibrillation. 15 of these were resuscitated, and of these 10 died one hour after resuscitation. survived to leave hospital. The mortality among patients Case 2 with definite infarction was 20%. There is little doubt A 55-year-old man developed chest pain while attending a that this heavy mortality was influenced by the tendency meeting. He went home and summoned his doctor. The of the general practitioner, particularly in the early stages mobile unit was called. Ventricular fibrillation developed of the project, to call for the mobile unit only when the immediately after the patient was transferred to the ambulance. was achieved by a registrar. His period in patient was considered to have a severe myocardial Defibrillation was uneventful and he was discharged on Dec. 6,1966, hospital infarction. and is now well. 10 patients have been resuscitated outside hospital. Electrocardiographic evidence of ventricular fibrillation Case 3
A 59-year-old man had chest pain for some three hours before calling his doctor. Transport to hospital by the mobile unit was arranged. Ventricular fibrillation occurred during transit. Defibrillation was achieved. Recovery from myocardial infarction was uneventful and he is now well.
Fig. 2-Details of 4 patients in whom ventricular fibrillation developed during transit.
Fig. 3-Details of 6 patients in whom ventricular fibrillation successfully removed shortly after onset of symptoms.
was
Case 4 A 41-year-old university professor was admitted to hospital because of an episode of chest pain. The electrocardiogram and serum-enzymes were normal. He insisted on leaving hospital three days after admission. Ten days later, whilst alone in his home, he was stricken with catastrophic chest pain but was able to telephone the cardiac ward. The mobile team got to him quickly. Cardiac arrest developed while the electrocardiographic electrodes were being connected. Ventricular fibrillation was removed by the house-physician. His four-week period in hospital was uneventful and although he had had an extensive myocardial infarction he was well at the time of discharge. He subsequently died after a further myocardial infarction. Case 5 The registrar in charge of the mobile unit on Nov. 21, 1966 (J. S. G.), was recording the electrocardiogram of a 49-year-old man in the patient’s home when ventricular fibrillation occurred. When the dysrhythmia was removed by D.c. shock, atrioventricular block was apparent. The systolic bloodpressure was 30 mm. Hg. A bipolar pacing catheter was inserted blindly into the right ventricle. When pacing was established, his condition rapidly improved and it was possible to move him to hospital. He was well on admission and normal atrioventricular conduction was soon resumed. Unfortunately, cardiac arrest occurred three weeks after admission and resuscitation was unsuccessful. Case 6 A 55-year-old man collapsed while dancing. A dance-hall attendant applied external cardiac massage until the arrival of
273 the mobile unit. Ventricular fibrillation was removed. Unfortunately, cerebral damage occurred and the patient died one week later. Case7 A general practitioner was called to a 45-year-old man who had collapsed in his bathroom. Although the patient’s home was some 4 miles from the hospital the mobile unit arrived in fourteen minutes. Cardiac arrest occurred as the team arrived. The practitioner maintained a circulation while the equipment was transferred from the ambulance to the patient’s home. Ventricular fibrillation was removed after some difficulty. One hour later the patient was transferred to hospital. Despite multiple rib fractures and a period of gross pulmonary congestion he recovered. He was discharged on April 23 and is now well.
Case8 A 42-year-old woman called her doctor because of chest pain. Cardiac arrest occurred while she was attempting to describe her complaint. The practitioner initiated resuscitation. Defibrillation was achieved by J. S. G. in the patient’s home. One hour later it was thought safe to transfer her to hospital. Unfortunately she died one week later from cerebral damage. Case9 A 61-year-old man had chest pain while visiting a relative. Cardiac arrest occurred immediately after the arrival of the practitioner who maintained a circulation. Relatives called the mobile unit. Defibrillation was achieved. The patient was moved to hospital and discharged four weeks later. He is now well. Case 10
A 51-year-old woman went to see her general practitioner because of chest pain. Cardiac arrest occurred in the doctor’s surgery. The doctor maintained a circulation until arrival of the team. Ventricular fibrillation was removed. She was admitted to hospital and discharged five weeks later. She is now well. Discussion
Most deaths from myocardial infarction occur soon after the onset of symptoms. It is less generally recognised that the delay in hospital admission is on average nearly twelve hours (Mittra 1965). Many factors are concerned in this delay. The patient may not immediately seek medical help; the practitioner may not be aware of the high risk of sudden and preventable death; the ambulance service may not be able to deal with the call immediately; the patient may have to wait his turn with other ill patients in the casualty department. With provision of a mobile resuscitation unit and a general-practitioner training programme, all but the first of these factors may be removed. Patient-delay in seeking medical help will diminish with increasing public awareness of the problem. Analysis of the incidence of ventricular fibrillation among the patients in this series indicates that the risk of developing this dysrhythmia during the first four hours may be 15 times greater than the risk of its appearance between the fourth and twelfth hours, and 25 times greater than the risk between the twelfth and twenty-fourth hours. It seems likely that at least half of the deaths from myocardial infarction result from rhythm disturbance (Mower et al. 1964). A large proportion of the early deaths might be prevented if the patients come under intensive care at the time of greatest risk. In this series 15 patients developed ventricular fibrillation within four hours of onset of symptoms, and of these 9 survived to leave hospital. An even higher incidence of ventricular fibrillation would have occurred but for the liberal use of the antiarrhythmic drugs lignocaine and potassium.
or houseman in charge of the mobile monitor the patient in his own home for a period during which lignocaine is given if required to abolish evidence of ventricular irritability. Among patients reached soon after the onset of infarction the ominous QRs-on-T pattern (Smirk and Palmer 1960) is sometimes seen. No attempt is made to transfer the patient to the ambulance until this or other evidence of ventricular irritability had been dealt with by anti-
The
registrar
team may
arrhythmic drugs. The mobile intensive-care unit removes the risks of transport to hospital. Of 312 patients in a fifteen-month period no patient died in transit, whereas in a study of coronary deaths in a one-year period starting in 1965, 102 of 414 patients brought to hospital were dead on arrival (Pemberton and McNeilly 1967). The general adoption of units of the type described will mean an increase in the number of patients admitted to hospital. The bed problem created may in part be solved by earlier discharge. There is evidence that half the patients with coronary thrombosis may be safely discharged in less than eighteen days (Adgey 1967). This project was supported by the British Heart Foundation. We thank the registrars and house-physicians of the cardiac unit for their unstinted help and the general practitioners for their cooperation. The mobile unit would not operate without the enthusiastic support of Dr. A. A. J. Adgey, Dr. J. M. K. Ekue, Dr. H. C. Mulholland, Dr. M. E. Scott, and Dr. D. K. Wiley. REFERENCES
Adgey, A. A. J. (1967) Unpublished. Bainton, C. R., Peterson, D. R. (1963) New Engl. J. Med. 268, 569. Lown, B., Fakhro, A. M., Hood, W. B., Thorn, G. W. (1967) J. Am. med. Ass. 199, 188. Mittra, B. (1965) Lancet, ii, 607. Mower, M. M., Miller, D. I., Nachlas, M. M. (1964) Am. Heart J. 67, 437. Partridge, J. F., Geddes, J. S. (1966) Lancet, i, 807. Pemberton, J., McNeilly, R. H. (1967) Unpublished. Smirk, F. H., Palmer, D. G. (1960) Am. J. Cardiol. 6, 620. Yater, W. M., Traum, A. H., Brown, W. G., Fitzgerald, R. P., Geisler, M. A., Wilcox, B. B. (1948) Am. Heart J. 36, 334, 481, 683.
Addendum
patients who developed ventricular fibrillation outside hospital have been resuscitated. Both survive. 2 further
PROGNOSIS AFTER RECOVERY FROM VENTRICULAR FIBRILLATION COMPLICATING ISCHÆMIC HEART-DISEASE A. A. J. ADGEY J. S. GEDDES M.D., B.Sc. Belf.
M.B.
Belf., M.R.C.P. REGISTRAR
REGISTRAR
J. F. PANTRIDGE M.C., M.D. Belf., F.R.C.P. PHYSICIAN-IN-CHARGE
CARDIAC ROYAL VICTORIA
DEPARTMENT, HOSPITAL, BELFAST 12
Data are presented concerning the followup of fifty patients who survived ventricular fibrillation complicating ischaemic heart-disease. In thirty-one patients (62%) ventricular fibrillation complicated a clinically mild coronary attack. In these patients the long-term prognosis regarding survival seemed similar to that of patients whose myocardial infarction was not complicated by ventricular fibrillation. Residual disability among the survivors of ventricular fibrillation would not appear to be significantly greater than among those patients whose myocardial infarction was not so
Summary
MYOCARDIAL INFARCTION
J. F. PANTRIDGE M.C., M.D. Belf., F.R.C.P. PHYSICIAN-IN-CHARGE
J. S. GEDDES M.D., B.Sc. Belf. REGISTRAR
CARDIAC DEPARTMENT, ROYAL VICTORIA HOSPITAL, BELFAST 12
The risk of death from
myocardial infarcSummary tion is greatest in the twelve-hour period after the onset of symptoms. Despite this, the hospital admission of a large proportion of patients is delayed for more than twelve hours, and many die in transit to hospital. A scheme has been described involving the use
cardiac department. The only increase in the establishment obtained for the project was one registrar (J. S. G.). The signal from the general practitioner is given priority at the hospital telephone switchboard and immediately transmitted to the duty registrar or houseman and to ambulance control. The team proceeds with all possible speed to the patient. When the ambulance has arrived the patient is immediately under intensive care. Monitoring and therapy in the patient’s home may be required before a stable rhythm is established. When it is considered safe the patient is transferred to the ambulance and monitored continuously during transport to hospital. Haste or fuss during transit are carefully avoided. The mobile unit is available to a population of approximately half a million in the Belfast area. 100,000 live within a one-mile radius of the
hospital. The unit
Results was
were
admitted
FINAL
DIAGNOSIS
Introduction
THE evidence indicating the need for rapid initiation of intensive care in cases of myocardial infarction has been reviewed by Pantridge and Geddes (1966). Most deaths from myocardial infarction occur within twelve hours of the onset of symptoms and some 60% are within the first hour (Yater et al. 1948, Bainton and Peterson 1963). Despite this the hospital admission of a large proportion of patients is delayed for more than 12 hours (Mittra 1965, Lown et al. 1967), so that the patient comes under intensive care at a time when the greatest risk has passed. That the majority of deaths occur outside hospital was shown by Pemberton and McNeilly (1967) in a survey of deaths from myocardial infarction in Belfast in a one-year period starting in 1965. Of 901 individuals who had fatal coronary attacks, only 414 reached hospital, and of these 102 were dead on arrival. In an attempt to prevent deaths from cardiac arrest occurring soon after the onset of symptoms and in an attempt to ensure safe transport of the patient with myocardial infarction, a mobile intensive-care unit has been in operation from this hospital since January, 1966. We describe here the results obtained during the first fifteen months of the unit’s operation. Method The mobile intensive-care unit consists of an ambulance which carries routine monitoring and resuscitation equipment including a battery-operated D.c. defibrillator and bipolar pacing catheters. The personnel are found from the staff of the 7510
to IN
hospital 312
on 338 occasions. 312 patients with a suspected diagnosis of
PATIENTS
ADMITTED
WITH
SUSPECTED
MYOCARDIAL INFARCTION
of a highly mobile unit which enables intensive care to reach the patient when he is at most risk. The unit has been used in the transfer of patients to hospital. No death has occurred in transit in a fifteen-month period. Ten examples of successful resuscitation outside hospital are reported. 5 of these patients are now alive and well. Thus it has been shown perhaps for the first time that the correction of cardiac arrest outside hospital is a practicable proposition.
summoned
coronary thrombosis. In the first six months of the operation of the scheme 20% of the patients were reached within fifteen minutes. There has been a progressive improvement in performance and in a recent three-month period 7801 of patients were reached within fifteen minutes. It is well known that resuscitative methods may maintain adequate circulation for this period of time. The
after onset of symptoms: cumulative (all patients) and individual intervals for those in whom resuscitation was
Fig. I-Interval attempted.
272
final diagnosis of the 312 patients is shown in the table. was obtained in each of these patients. All developed 155 had proven myocardial infarction. 96 had prolonged ventricular fibrillation within four hours of the onset of chest pain without indubitable evidence of infarction, symptoms. Fig. 2 records the data of 4 patients who although the electrocardiogram was abnormal. 28 had developed ventricular fibrillation in the ambulance during prolonged chest pain with a normal electrocardiogram. transit. No patient died during transit. 1 elderly patient In only 3 % of cases was it thought that the call for the died, soon after admission, from pulmonary oedema. The mobile unit had been unjustified. other 3 were discharged from hospital. 105 (two-thirds) of the patients with proven myocardial Fig. 3 shows the data concerning 6 patients successfully infarction were male and the majority of these were under resuscitated in various situations soon after the onset of the age of 60. symptoms. 4 had cardiac arrest in their own homes, 1 in The time after the onset of symptoms at which the a dance hall, and 1 in her doctor’s surgery. 3 of these 155 patients with proven infarction came under intensive patients have survived. 6 of the patients shown in care and the incidence of ventricular fibrillation during figs. 2 and 3 were excluded from the analysis in fig. 1 the first three days is shown in fig. 1. 78 of the 155 (half either because the occurrence of cardiac arrest was the the patients) were under intensive care within two and a reason for the signal or because resuscitation occurred half hours, and two-thirds within four hours. Since the after March 31, 1967. majority of deaths occur soon after onset of symptoms it Case-reports might be expected that among patients seen early the Details of 10 patients successfully resuscitated outside incidence of ventricular fibrillation would be high. This hospital are given. proved to be so. 9 patients among the 101 seen within Case1 four hours developed ventricular fibrillation. Resuscitation A 79-year-old woman developed ventricular fibrillation was successful in 8 of these. during transfer to hospital. Defibrillation was achieved in the During the entire period in hospital 21 of the patients ambulance by the house-physician. Unfortunately pulmonary admitted by the mobile unit developed ventricular cedema became apparent soon after admission and the patient fibrillation. 15 of these were resuscitated, and of these 10 died one hour after resuscitation. survived to leave hospital. The mortality among patients Case 2 with definite infarction was 20%. There is little doubt A 55-year-old man developed chest pain while attending a that this heavy mortality was influenced by the tendency meeting. He went home and summoned his doctor. The of the general practitioner, particularly in the early stages mobile unit was called. Ventricular fibrillation developed of the project, to call for the mobile unit only when the immediately after the patient was transferred to the ambulance. was achieved by a registrar. His period in patient was considered to have a severe myocardial Defibrillation was uneventful and he was discharged on Dec. 6,1966, hospital infarction. and is now well. 10 patients have been resuscitated outside hospital. Electrocardiographic evidence of ventricular fibrillation Case 3
A 59-year-old man had chest pain for some three hours before calling his doctor. Transport to hospital by the mobile unit was arranged. Ventricular fibrillation occurred during transit. Defibrillation was achieved. Recovery from myocardial infarction was uneventful and he is now well.
Fig. 2-Details of 4 patients in whom ventricular fibrillation developed during transit.
Fig. 3-Details of 6 patients in whom ventricular fibrillation successfully removed shortly after onset of symptoms.
was
Case 4 A 41-year-old university professor was admitted to hospital because of an episode of chest pain. The electrocardiogram and serum-enzymes were normal. He insisted on leaving hospital three days after admission. Ten days later, whilst alone in his home, he was stricken with catastrophic chest pain but was able to telephone the cardiac ward. The mobile team got to him quickly. Cardiac arrest developed while the electrocardiographic electrodes were being connected. Ventricular fibrillation was removed by the house-physician. His four-week period in hospital was uneventful and although he had had an extensive myocardial infarction he was well at the time of discharge. He subsequently died after a further myocardial infarction. Case 5 The registrar in charge of the mobile unit on Nov. 21, 1966 (J. S. G.), was recording the electrocardiogram of a 49-year-old man in the patient’s home when ventricular fibrillation occurred. When the dysrhythmia was removed by D.c. shock, atrioventricular block was apparent. The systolic bloodpressure was 30 mm. Hg. A bipolar pacing catheter was inserted blindly into the right ventricle. When pacing was established, his condition rapidly improved and it was possible to move him to hospital. He was well on admission and normal atrioventricular conduction was soon resumed. Unfortunately, cardiac arrest occurred three weeks after admission and resuscitation was unsuccessful. Case 6 A 55-year-old man collapsed while dancing. A dance-hall attendant applied external cardiac massage until the arrival of
273 the mobile unit. Ventricular fibrillation was removed. Unfortunately, cerebral damage occurred and the patient died one week later. Case7 A general practitioner was called to a 45-year-old man who had collapsed in his bathroom. Although the patient’s home was some 4 miles from the hospital the mobile unit arrived in fourteen minutes. Cardiac arrest occurred as the team arrived. The practitioner maintained a circulation while the equipment was transferred from the ambulance to the patient’s home. Ventricular fibrillation was removed after some difficulty. One hour later the patient was transferred to hospital. Despite multiple rib fractures and a period of gross pulmonary congestion he recovered. He was discharged on April 23 and is now well.
Case8 A 42-year-old woman called her doctor because of chest pain. Cardiac arrest occurred while she was attempting to describe her complaint. The practitioner initiated resuscitation. Defibrillation was achieved by J. S. G. in the patient’s home. One hour later it was thought safe to transfer her to hospital. Unfortunately she died one week later from cerebral damage. Case9 A 61-year-old man had chest pain while visiting a relative. Cardiac arrest occurred immediately after the arrival of the practitioner who maintained a circulation. Relatives called the mobile unit. Defibrillation was achieved. The patient was moved to hospital and discharged four weeks later. He is now well. Case 10
A 51-year-old woman went to see her general practitioner because of chest pain. Cardiac arrest occurred in the doctor’s surgery. The doctor maintained a circulation until arrival of the team. Ventricular fibrillation was removed. She was admitted to hospital and discharged five weeks later. She is now well. Discussion
Most deaths from myocardial infarction occur soon after the onset of symptoms. It is less generally recognised that the delay in hospital admission is on average nearly twelve hours (Mittra 1965). Many factors are concerned in this delay. The patient may not immediately seek medical help; the practitioner may not be aware of the high risk of sudden and preventable death; the ambulance service may not be able to deal with the call immediately; the patient may have to wait his turn with other ill patients in the casualty department. With provision of a mobile resuscitation unit and a general-practitioner training programme, all but the first of these factors may be removed. Patient-delay in seeking medical help will diminish with increasing public awareness of the problem. Analysis of the incidence of ventricular fibrillation among the patients in this series indicates that the risk of developing this dysrhythmia during the first four hours may be 15 times greater than the risk of its appearance between the fourth and twelfth hours, and 25 times greater than the risk between the twelfth and twenty-fourth hours. It seems likely that at least half of the deaths from myocardial infarction result from rhythm disturbance (Mower et al. 1964). A large proportion of the early deaths might be prevented if the patients come under intensive care at the time of greatest risk. In this series 15 patients developed ventricular fibrillation within four hours of onset of symptoms, and of these 9 survived to leave hospital. An even higher incidence of ventricular fibrillation would have occurred but for the liberal use of the antiarrhythmic drugs lignocaine and potassium.
or houseman in charge of the mobile monitor the patient in his own home for a period during which lignocaine is given if required to abolish evidence of ventricular irritability. Among patients reached soon after the onset of infarction the ominous QRs-on-T pattern (Smirk and Palmer 1960) is sometimes seen. No attempt is made to transfer the patient to the ambulance until this or other evidence of ventricular irritability had been dealt with by anti-
The
registrar
team may
arrhythmic drugs. The mobile intensive-care unit removes the risks of transport to hospital. Of 312 patients in a fifteen-month period no patient died in transit, whereas in a study of coronary deaths in a one-year period starting in 1965, 102 of 414 patients brought to hospital were dead on arrival (Pemberton and McNeilly 1967). The general adoption of units of the type described will mean an increase in the number of patients admitted to hospital. The bed problem created may in part be solved by earlier discharge. There is evidence that half the patients with coronary thrombosis may be safely discharged in less than eighteen days (Adgey 1967). This project was supported by the British Heart Foundation. We thank the registrars and house-physicians of the cardiac unit for their unstinted help and the general practitioners for their cooperation. The mobile unit would not operate without the enthusiastic support of Dr. A. A. J. Adgey, Dr. J. M. K. Ekue, Dr. H. C. Mulholland, Dr. M. E. Scott, and Dr. D. K. Wiley. REFERENCES
Adgey, A. A. J. (1967) Unpublished. Bainton, C. R., Peterson, D. R. (1963) New Engl. J. Med. 268, 569. Lown, B., Fakhro, A. M., Hood, W. B., Thorn, G. W. (1967) J. Am. med. Ass. 199, 188. Mittra, B. (1965) Lancet, ii, 607. Mower, M. M., Miller, D. I., Nachlas, M. M. (1964) Am. Heart J. 67, 437. Partridge, J. F., Geddes, J. S. (1966) Lancet, i, 807. Pemberton, J., McNeilly, R. H. (1967) Unpublished. Smirk, F. H., Palmer, D. G. (1960) Am. J. Cardiol. 6, 620. Yater, W. M., Traum, A. H., Brown, W. G., Fitzgerald, R. P., Geisler, M. A., Wilcox, B. B. (1948) Am. Heart J. 36, 334, 481, 683.
Addendum
patients who developed ventricular fibrillation outside hospital have been resuscitated. Both survive. 2 further
PROGNOSIS AFTER RECOVERY FROM VENTRICULAR FIBRILLATION COMPLICATING ISCHÆMIC HEART-DISEASE A. A. J. ADGEY J. S. GEDDES M.D., B.Sc. Belf.
M.B.
Belf., M.R.C.P. REGISTRAR
REGISTRAR
J. F. PANTRIDGE M.C., M.D. Belf., F.R.C.P. PHYSICIAN-IN-CHARGE
CARDIAC ROYAL VICTORIA
DEPARTMENT, HOSPITAL, BELFAST 12
Data are presented concerning the followup of fifty patients who survived ventricular fibrillation complicating ischaemic heart-disease. In thirty-one patients (62%) ventricular fibrillation complicated a clinically mild coronary attack. In these patients the long-term prognosis regarding survival seemed similar to that of patients whose myocardial infarction was not complicated by ventricular fibrillation. Residual disability among the survivors of ventricular fibrillation would not appear to be significantly greater than among those patients whose myocardial infarction was not so
Summary