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The Mobile Coronary Care Unit
The Mobile Coronary Care Unit* William J. Grace, M.D., F.C.C.P. and John A. Chadbourn, M.D.
Under the support of a feasibility study grant from the Regional Medical Program, St. Vincent's Hospital and Medical Center of New York undertook a mobile coronary care unit project. The experience to date indicates that such a project is feasible and it is the feeling of the authors that considerable good can be done. The problems to be considered and worked out are mainly those of communication and more efficient use of the team by more clearly identifying the calls and isolating from the sick population the "middle-aged man with a pain in his chest."
Geddesl in 1967 and we have chosen to follow this activity at our hospital.
INTRODUcnON
I nformation derived from many sources and com-
piled by the United States Public Health Service indicates that there are approximately 500,000 deaths in the United States every year from acute myocardial infarction. Of this number, the best information available shows that at least half, and possibly two-thirds of these patients, die before receiving medical attention. The successful operation of coronary care units (CCU) throughout the country, resulting in substantial reduction in mortality rate, has been most gratifying and instructive. The success of these inpatient units in saving lives has been almost entirely confined to early detection and control of life-threatening arrhythmia. Therefore, it is likely that if one could reach the patient sooner, more patient lives would be saved by controlling the lifethreatening arrhythmias, the major cause of mortality. There is a variety of ways of getting to the patient sooner and controlling arrhythmias, including: 1) have the patients instructed to seek medical help sooner; 2) move the hospital services out of the hospital to the site of the patient (thus saving valuable time transporting the patient to the hospital; and 3) reorganize emergency room services so that the time lost in the preliminary examination and consideration of the patient in the admitting department is bypassed and shortened. The concept of moving the coronary care unit outside the hospital to the patient's side was called "Mobile Coronary Care Unit" by Pantridge and
METHOD
The mobile coronary care unit consists of the standard hospital ambulance with the follOWing portable equipment: a battery-powered defibrillator monitor; a battery-powered electrocardiograph and a case of cardiac medications. ° It is of paramount importance in our particular community, at least, that the equipment be battery-operated. There have been numerous occasions when a source of electrical power was simply not available, eg, in a church, subway station, in the small rooming houses of some of the "underprivileged," where the only source of electrical outlet is consumed by a single electric bulb. The battery-operated equipment, which has been used by this team, has functioned remarkably well. The personnel includes an attending physician, resident physician, emergency room nurse, ECG technician, as well as a student nurse observer, in addition to the driver and his assistant. This team is summoned from various points in the hospital to the emergency room by a personal paging system which each member of the team carries. This team has 4 % minutes to get to the emergency room, obtain their equipment and board the ambulance. Anyone who is not there· within this time is left behind. The calls to which the team responds are initiated by the Police Department and designated as "cardiac" over the telephone. The Police Department may have received their call from a patrolman or from any person who calls the Department on the emergency telephone number 911. The ambulance transporting the team and their equipment travels to the site of the call as rapidly as possible. The ambulance does not have an escort or siren, but uses only a flashing red light. On arrival at the call site, which may be anywhere in the St. Vincent's Hospital ambulance area (34th Street to Canal Street, Fifth Avenue to the Hudson River), the patient is immediately in the same environment as in the hospital CCU. The patient's vital signs are recorded and an electrocardiogram is taken. If the patient's
°From the Department of Medicine, St. Vincent's Hospital and Medical Center of New York, New York City.
OSee appendix.
452
453
MOBILE CORONARY CARE UNIT problem is a cardiac one, an intravenous is started and ECG monitoring is begun. Adequate time is taken to stabilize the patient's condition, if necessary, before the trip back to the hospital. The return to the hospital is made as calmly as possible and without police sirens, etc. The patient is taken directly to the coronary care unit unless this is not clearly indicated, in which case the patient is held in the emergency room where further tests and treatment may be carried out. On arrival at the hospital, the team turns the patient responsibility over to the coronary care unit staff or the emergency room staff. The mobile coronary care unit team is then free to organize their equipment in preparation for another call. No special ambulance is used. The vehicle used is the routine hospital ambulance which transports the team and its battery-powered, portable equipment. OUTLINE OF PROBLEMS WIllCH WERE FACED BY THE
MCCU TEAM
Problem 1: Can such a team be mobilized from the hospital staff, join with the ambulance crew and proceed to the site thereby overcoming the organization, traffic and communication problems of the hospital and the metropolitan community? Problem 2: Can a CCU be set up outside of the hospital and can this CCU deal effectively with life-threatening arrhythmias? Problem 3: Will there be too many "false alarms?" Problem 4: Does the MCCU do any good in terms of saving lives and relieving suffering? RESULTS OF
CURRENT EXPERIENCES
Problem 1. Can the MCCU team be mobilized from the hospital and deliver itself to the site thereby overcoming the organizational, traffic and communications problems of the hospital and the metropolitan community?
Some patients were reached as quickly as three minutes. In the majority (51 percent) of the calls, the ambulance reached the site in eight to nine minutes. In the first 161 caIls it is to be noted that the ambulance left the hospital without the team on only two occasions. On one occasion the problem was related to breakdown in the hospital paging system and in the second case it is not clear why the doctors did not get there in time. Problem 2: Can the life-threatening arrhythmias be treated effectively under these circumstances? The life-threatening arrhythmias we have seen can be effectively dealt with under the circumstances of a MCCU. The patient can then be transported back to the hospital effectively after the life-threatening arrhythmia has been controlled. Table 1 indicates the life-threatening arrhythmias which have been seen in our experience to date and have been dealt with effectively. It is of some interest to note that the distribution of these types of arrhythmias is in contrast to the usual findings in the CCU in hospitals. The number of bradyarrhythmias is considerably larger than is generally reported in the in-patient services. In 161 cases, the following 52 arrhythmias were found: Table I Bradyarrhythmias Sinus bradycardia ( 50 or less) 1° HB 2° HB (Wenckebach) 3° HB Nodal rhythm AIV dissociation Sinus arrest Tachyarrhl,thmias Sinus tachycardia Atrial flutter Atrial fibrillation Ventricular fibrillation
Total 11
3 2 1 1 1 2 1
The answer to this question is unequivocally "yes." The experience thus far clearly indicates that this team can be mobilized quickly from the hospital, can be transported to the site, a CCU can be set up at any site-home, office, subway station, restaurant, church, etc. The following data indicating the length of time between the reception of the call at the hospital and the arrival at the site bears on this point:
-One survivor.
On the basis of the first 100 calls, the MCUU was delivered to the site of the patient within 14 minutes of receiving the call at the hospital. There were a few occasions when the ambulance was held up in insurmountable traffic at 14th Street and Sixth A venue requiring 20 minutes to reach the site. The longest run was 25 minutes in heavy traffic.
The only arrhythmias recorded above which could not be effectively dealt with were two instances of ventricular fibrillation which failed to respond to defibrillation. The one patient who was successfully defibrillated from documented ventricular fibrillation is, as of this writing, liVing and well.
DIS. CHEST, VOL. 55, NO.6, JUNE 1969
Premature Beats
Total 22
PAC
VPC
Total 20 11 of 33 arrhythmias were bradyarrhythmias.
7 1 11 36
14
454
GRACE AND CHADBOURN
Problem 3: Will there be too many false alarms? On the basis of the first 161 cases the following breakdown is submitted: Table 2
TOTAL CALLS Calls
BonaFide Calls
Unnecessary Calls
30
14 12
1-50 51-100 101-161
26 38
-
Total Calls:
-
6
11
-
37
94
Others
12 12 30
Table 3
CARDIAC CALLS
Series
1-50 51-100 101-161 TOTAL:
Acute MI orR/O
Serious Total Heart Chest Pain BonaFide Disease Non-Cardiac Calls
12 9 20
-
41
-
5 10 4 19
13 7 14
-
34
30
26 38 94
Bona fide calls include: 1) patient with a myocardial infarction or whose symptoms and ECG findings are sufficiently severe to consider him a R!O coronary patient; 2) patient with heart disease, having manifestation of congestive heart failure; 3) patient who has chest pain and! or shortness of breath not due to cardiac disease but mistaken for it by the person summoning the ambulance. Unnecessary calls include: 1) cancelled call by the Police Department after the ambulance has left the hospital; 2) false alarm-an unjustified call, eg, someone feels that an ambulance will come more quickly if he calls "cardiac patient;" 3) an obviously intoxicated patient, and that is the predominant problem; 4) ambulance left without the doctors on board. Other calls include: 1) dead on arrival; 2) death in ambulance; 3) a patient who is seriously ill but does not have a cardiac or coronary disorder, eg., patient with a stroke. COMMENT
It is to be noted that the number of "bona fide calls" has been increasing and the number of "unnecessary calls" has been decreasing, eg, of the patients with acute myocardial infarction and! or serious heart disease there were 24 such patients in the last 50 calls, as compared to 17 in the first 50. Considering that no special educational program was carried out in the community or with dispatching policy agency, the authors are gratified to find this number of cases have been properly labeled.
The number of unnecessary calls has been surprisingly small. We anticipated at least half the calls would be considered by all observers as unnecessary. The problem with "false alarms" or "nuisance calls" seems to be rather serious at the present time and it is rather discouraging to the team to rush to the site and then find an individual who is Simply intoxicated. The team has decided that a certain number of these calls will have to be made, for such a patient might tell the Police that he has a cardiac condition and demand an ambulance. At the moment it is very difficult to determine how to deal with this. It will be noted that 10 percent of the patients were dead on arrival of the team (DOA). It is likely that these patients were alive or at least breathing when the call was placed. This, then, further emphasizes the need for a MCCD. Problem 4: Does the MCCD do any good in terms of saving lives and relieving suffering? In the first 161 calls, there were 41 patients with or suspected of having acute myocardial infarction; there were 19 patients with serious heart disease, in congestive failure, or paroxysmal tachycardia; three of these patients had ventricular fibrillation and it was possible to resuscitate one of these, who is now living and well. He had an inferior wall myocardial infarction. This is the only unequivocal evidence which may be stated to be a life-saving episode. The authors feel that at least one other episode of slow heart rate and its management outside the hospital might be considered life-saving, but this is more difficult to document. COMMENT
It is apparent, therefore, that of the individuals seen who had myocardial infarction (20), one patient was successfully resuscitated from ventricular fibrillation. Over and above saving lives is the phYSician's and community's responsibility to alleviate suffering as quickly as possible. There is little doubt that the prompt attention to serious cardiac disease by the MCCD will result in more prompt alleviation of suffering and serious symptoms in the patients with heart disease than by our present system of delivering the patient to the emergency room. In support of this idea, we submit information (Table 4) based on the length of time from the onset of a patient's symptoms to the time that CCD is instituted. These data clearly indicate that substantial time is saved and that the patient's suffering is alleviated far more quickly and promptly than was possible by former systems. DIS. CHEST, VOL. 55, NO.6, JUNE 1969
455
MOBILE CORONARY CARE UNIT Table 4 TIME ONSET SYMPTOMS TO CCU
Routine Hospital Procedure Mobile Coronary Care Unit
No. Patients
Average
130 29
6.1 hour 3.5 hour
We have unequivocal evidence of one life-saving episode, but it must be recognized that it is difficult to evaluate other experiences which might have been life-saving. The early control of a very slow heart rate, or of a rapid supraventricular tachycardia may very well have saved an individual's life and a fatal outcome could be expected if they had had a two to three hour wait for the institution of coronary care in the regular course of events in this city. DISCUSSION
Projected Problems to be Solved One of the problems of operating a MCUU in metropolitan New York is traffic congestion. It often takes 15 minutes to travel to the most distant location within the ambulance district. There is a problem of false alarms and cancelled calls. Since the calls may be initiated by any person, there is considerable inaccuracy in labeling patients as cardiac. In this regard, we have attempted to educate the police force and their communications personnel in obtaining certain pertinent information about the patient. This information includes the age, sex and state of consciousness of the patient. This helps to eliminate, for example, 20-year-old women who are called in as cardiac patients. On such a call, the ambulance would be dispatched, but the team would not accompany it. The experiences related in this report can be considered the results of a feasibility study as to date. The evidence is clear that the hospital can mobilize this team, get it to the site and deal with life-threatening arrhythmias. In order to increase the efficiency of the opera-
DIS. CHEST, VOL. 55, NO.6, JUNE 1969
tion our present effort is education of the community. We have made a number of visits to discuss the problems with the dispatching policy agency and we plan to make additional ones. We are planning to have meetings with various groups in the local community consisting of industry, physicians, business organizations, etc. to indicate that the ambulance is available for the "middle-aged man with a pain in his chest." Historically, the ambulance is associated with accidents and bleeding. People at the moment do not seem to request an ambulance for the diagnosiS of pain in the chest. It is up to the medical profession to deliver this message more effectively not only to the members of the community, but also to themselves, that the "middle-aged man with a pain in his chest" is a person of high risk until he is seen and expertly diagnosed. APPENDIX
Medications and Supplies Used in the Mobile Coronary Care Unit 7. Ouabain 1. Meperidine 8. Lanatoside C (Demerol) or (Cedilanid ) morphine 9. Furosemide (Lasix) 2. Atropine 10. Epinephrine 3. Lidocaine (Adrenaline) (Xylocaine) 11. Isoproterenol (Isuprel) 4. Quinidine 12. Ampules of 5. Metaraminol bicarbonate (Aramine) 13. Blood pressure cuff f. Diphenylhydantoin 14. Oral airway (Dilantin) 15. Complete IV setup REFERENCES
1 PANTRIDGE, J.G., AND GEDDES, J.S.: A mobile intensivecare unit in the management of myocardial infarction, Lancet, 11:271, 1967. 2 United States Public Health Service Data. Reprint requests: Dr. Grace, 153 West 11th Street, New York City 10011
Under the support of a feasibility study grant from the Regional Medical Program, St. Vincent's Hospital and Medical Center of New York undertook a mobile coronary care unit project. The experience to date indicates that such a project is feasible and it is the feeling of the authors that considerable good can be done. The problems to be considered and worked out are mainly those of communication and more efficient use of the team by more clearly identifying the calls and isolating from the sick population the "middle-aged man with a pain in his chest."
Geddesl in 1967 and we have chosen to follow this activity at our hospital.
INTRODUcnON
I nformation derived from many sources and com-
piled by the United States Public Health Service indicates that there are approximately 500,000 deaths in the United States every year from acute myocardial infarction. Of this number, the best information available shows that at least half, and possibly two-thirds of these patients, die before receiving medical attention. The successful operation of coronary care units (CCU) throughout the country, resulting in substantial reduction in mortality rate, has been most gratifying and instructive. The success of these inpatient units in saving lives has been almost entirely confined to early detection and control of life-threatening arrhythmia. Therefore, it is likely that if one could reach the patient sooner, more patient lives would be saved by controlling the lifethreatening arrhythmias, the major cause of mortality. There is a variety of ways of getting to the patient sooner and controlling arrhythmias, including: 1) have the patients instructed to seek medical help sooner; 2) move the hospital services out of the hospital to the site of the patient (thus saving valuable time transporting the patient to the hospital; and 3) reorganize emergency room services so that the time lost in the preliminary examination and consideration of the patient in the admitting department is bypassed and shortened. The concept of moving the coronary care unit outside the hospital to the patient's side was called "Mobile Coronary Care Unit" by Pantridge and
METHOD
The mobile coronary care unit consists of the standard hospital ambulance with the follOWing portable equipment: a battery-powered defibrillator monitor; a battery-powered electrocardiograph and a case of cardiac medications. ° It is of paramount importance in our particular community, at least, that the equipment be battery-operated. There have been numerous occasions when a source of electrical power was simply not available, eg, in a church, subway station, in the small rooming houses of some of the "underprivileged," where the only source of electrical outlet is consumed by a single electric bulb. The battery-operated equipment, which has been used by this team, has functioned remarkably well. The personnel includes an attending physician, resident physician, emergency room nurse, ECG technician, as well as a student nurse observer, in addition to the driver and his assistant. This team is summoned from various points in the hospital to the emergency room by a personal paging system which each member of the team carries. This team has 4 % minutes to get to the emergency room, obtain their equipment and board the ambulance. Anyone who is not there· within this time is left behind. The calls to which the team responds are initiated by the Police Department and designated as "cardiac" over the telephone. The Police Department may have received their call from a patrolman or from any person who calls the Department on the emergency telephone number 911. The ambulance transporting the team and their equipment travels to the site of the call as rapidly as possible. The ambulance does not have an escort or siren, but uses only a flashing red light. On arrival at the call site, which may be anywhere in the St. Vincent's Hospital ambulance area (34th Street to Canal Street, Fifth Avenue to the Hudson River), the patient is immediately in the same environment as in the hospital CCU. The patient's vital signs are recorded and an electrocardiogram is taken. If the patient's
°From the Department of Medicine, St. Vincent's Hospital and Medical Center of New York, New York City.
OSee appendix.
452
453
MOBILE CORONARY CARE UNIT problem is a cardiac one, an intravenous is started and ECG monitoring is begun. Adequate time is taken to stabilize the patient's condition, if necessary, before the trip back to the hospital. The return to the hospital is made as calmly as possible and without police sirens, etc. The patient is taken directly to the coronary care unit unless this is not clearly indicated, in which case the patient is held in the emergency room where further tests and treatment may be carried out. On arrival at the hospital, the team turns the patient responsibility over to the coronary care unit staff or the emergency room staff. The mobile coronary care unit team is then free to organize their equipment in preparation for another call. No special ambulance is used. The vehicle used is the routine hospital ambulance which transports the team and its battery-powered, portable equipment. OUTLINE OF PROBLEMS WIllCH WERE FACED BY THE
MCCU TEAM
Problem 1: Can such a team be mobilized from the hospital staff, join with the ambulance crew and proceed to the site thereby overcoming the organization, traffic and communication problems of the hospital and the metropolitan community? Problem 2: Can a CCU be set up outside of the hospital and can this CCU deal effectively with life-threatening arrhythmias? Problem 3: Will there be too many "false alarms?" Problem 4: Does the MCCU do any good in terms of saving lives and relieving suffering? RESULTS OF
CURRENT EXPERIENCES
Problem 1. Can the MCCU team be mobilized from the hospital and deliver itself to the site thereby overcoming the organizational, traffic and communications problems of the hospital and the metropolitan community?
Some patients were reached as quickly as three minutes. In the majority (51 percent) of the calls, the ambulance reached the site in eight to nine minutes. In the first 161 caIls it is to be noted that the ambulance left the hospital without the team on only two occasions. On one occasion the problem was related to breakdown in the hospital paging system and in the second case it is not clear why the doctors did not get there in time. Problem 2: Can the life-threatening arrhythmias be treated effectively under these circumstances? The life-threatening arrhythmias we have seen can be effectively dealt with under the circumstances of a MCCU. The patient can then be transported back to the hospital effectively after the life-threatening arrhythmia has been controlled. Table 1 indicates the life-threatening arrhythmias which have been seen in our experience to date and have been dealt with effectively. It is of some interest to note that the distribution of these types of arrhythmias is in contrast to the usual findings in the CCU in hospitals. The number of bradyarrhythmias is considerably larger than is generally reported in the in-patient services. In 161 cases, the following 52 arrhythmias were found: Table I Bradyarrhythmias Sinus bradycardia ( 50 or less) 1° HB 2° HB (Wenckebach) 3° HB Nodal rhythm AIV dissociation Sinus arrest Tachyarrhl,thmias Sinus tachycardia Atrial flutter Atrial fibrillation Ventricular fibrillation
Total 11
3 2 1 1 1 2 1
The answer to this question is unequivocally "yes." The experience thus far clearly indicates that this team can be mobilized quickly from the hospital, can be transported to the site, a CCU can be set up at any site-home, office, subway station, restaurant, church, etc. The following data indicating the length of time between the reception of the call at the hospital and the arrival at the site bears on this point:
-One survivor.
On the basis of the first 100 calls, the MCUU was delivered to the site of the patient within 14 minutes of receiving the call at the hospital. There were a few occasions when the ambulance was held up in insurmountable traffic at 14th Street and Sixth A venue requiring 20 minutes to reach the site. The longest run was 25 minutes in heavy traffic.
The only arrhythmias recorded above which could not be effectively dealt with were two instances of ventricular fibrillation which failed to respond to defibrillation. The one patient who was successfully defibrillated from documented ventricular fibrillation is, as of this writing, liVing and well.
DIS. CHEST, VOL. 55, NO.6, JUNE 1969
Premature Beats
Total 22
PAC
VPC
Total 20 11 of 33 arrhythmias were bradyarrhythmias.
7 1 11 36
14
454
GRACE AND CHADBOURN
Problem 3: Will there be too many false alarms? On the basis of the first 161 cases the following breakdown is submitted: Table 2
TOTAL CALLS Calls
BonaFide Calls
Unnecessary Calls
30
14 12
1-50 51-100 101-161
26 38
-
Total Calls:
-
6
11
-
37
94
Others
12 12 30
Table 3
CARDIAC CALLS
Series
1-50 51-100 101-161 TOTAL:
Acute MI orR/O
Serious Total Heart Chest Pain BonaFide Disease Non-Cardiac Calls
12 9 20
-
41
-
5 10 4 19
13 7 14
-
34
30
26 38 94
Bona fide calls include: 1) patient with a myocardial infarction or whose symptoms and ECG findings are sufficiently severe to consider him a R!O coronary patient; 2) patient with heart disease, having manifestation of congestive heart failure; 3) patient who has chest pain and! or shortness of breath not due to cardiac disease but mistaken for it by the person summoning the ambulance. Unnecessary calls include: 1) cancelled call by the Police Department after the ambulance has left the hospital; 2) false alarm-an unjustified call, eg, someone feels that an ambulance will come more quickly if he calls "cardiac patient;" 3) an obviously intoxicated patient, and that is the predominant problem; 4) ambulance left without the doctors on board. Other calls include: 1) dead on arrival; 2) death in ambulance; 3) a patient who is seriously ill but does not have a cardiac or coronary disorder, eg., patient with a stroke. COMMENT
It is to be noted that the number of "bona fide calls" has been increasing and the number of "unnecessary calls" has been decreasing, eg, of the patients with acute myocardial infarction and! or serious heart disease there were 24 such patients in the last 50 calls, as compared to 17 in the first 50. Considering that no special educational program was carried out in the community or with dispatching policy agency, the authors are gratified to find this number of cases have been properly labeled.
The number of unnecessary calls has been surprisingly small. We anticipated at least half the calls would be considered by all observers as unnecessary. The problem with "false alarms" or "nuisance calls" seems to be rather serious at the present time and it is rather discouraging to the team to rush to the site and then find an individual who is Simply intoxicated. The team has decided that a certain number of these calls will have to be made, for such a patient might tell the Police that he has a cardiac condition and demand an ambulance. At the moment it is very difficult to determine how to deal with this. It will be noted that 10 percent of the patients were dead on arrival of the team (DOA). It is likely that these patients were alive or at least breathing when the call was placed. This, then, further emphasizes the need for a MCCD. Problem 4: Does the MCCD do any good in terms of saving lives and relieving suffering? In the first 161 calls, there were 41 patients with or suspected of having acute myocardial infarction; there were 19 patients with serious heart disease, in congestive failure, or paroxysmal tachycardia; three of these patients had ventricular fibrillation and it was possible to resuscitate one of these, who is now living and well. He had an inferior wall myocardial infarction. This is the only unequivocal evidence which may be stated to be a life-saving episode. The authors feel that at least one other episode of slow heart rate and its management outside the hospital might be considered life-saving, but this is more difficult to document. COMMENT
It is apparent, therefore, that of the individuals seen who had myocardial infarction (20), one patient was successfully resuscitated from ventricular fibrillation. Over and above saving lives is the phYSician's and community's responsibility to alleviate suffering as quickly as possible. There is little doubt that the prompt attention to serious cardiac disease by the MCCD will result in more prompt alleviation of suffering and serious symptoms in the patients with heart disease than by our present system of delivering the patient to the emergency room. In support of this idea, we submit information (Table 4) based on the length of time from the onset of a patient's symptoms to the time that CCD is instituted. These data clearly indicate that substantial time is saved and that the patient's suffering is alleviated far more quickly and promptly than was possible by former systems. DIS. CHEST, VOL. 55, NO.6, JUNE 1969
455
MOBILE CORONARY CARE UNIT Table 4 TIME ONSET SYMPTOMS TO CCU
Routine Hospital Procedure Mobile Coronary Care Unit
No. Patients
Average
130 29
6.1 hour 3.5 hour
We have unequivocal evidence of one life-saving episode, but it must be recognized that it is difficult to evaluate other experiences which might have been life-saving. The early control of a very slow heart rate, or of a rapid supraventricular tachycardia may very well have saved an individual's life and a fatal outcome could be expected if they had had a two to three hour wait for the institution of coronary care in the regular course of events in this city. DISCUSSION
Projected Problems to be Solved One of the problems of operating a MCUU in metropolitan New York is traffic congestion. It often takes 15 minutes to travel to the most distant location within the ambulance district. There is a problem of false alarms and cancelled calls. Since the calls may be initiated by any person, there is considerable inaccuracy in labeling patients as cardiac. In this regard, we have attempted to educate the police force and their communications personnel in obtaining certain pertinent information about the patient. This information includes the age, sex and state of consciousness of the patient. This helps to eliminate, for example, 20-year-old women who are called in as cardiac patients. On such a call, the ambulance would be dispatched, but the team would not accompany it. The experiences related in this report can be considered the results of a feasibility study as to date. The evidence is clear that the hospital can mobilize this team, get it to the site and deal with life-threatening arrhythmias. In order to increase the efficiency of the opera-
DIS. CHEST, VOL. 55, NO.6, JUNE 1969
tion our present effort is education of the community. We have made a number of visits to discuss the problems with the dispatching policy agency and we plan to make additional ones. We are planning to have meetings with various groups in the local community consisting of industry, physicians, business organizations, etc. to indicate that the ambulance is available for the "middle-aged man with a pain in his chest." Historically, the ambulance is associated with accidents and bleeding. People at the moment do not seem to request an ambulance for the diagnosiS of pain in the chest. It is up to the medical profession to deliver this message more effectively not only to the members of the community, but also to themselves, that the "middle-aged man with a pain in his chest" is a person of high risk until he is seen and expertly diagnosed. APPENDIX
Medications and Supplies Used in the Mobile Coronary Care Unit 7. Ouabain 1. Meperidine 8. Lanatoside C (Demerol) or (Cedilanid ) morphine 9. Furosemide (Lasix) 2. Atropine 10. Epinephrine 3. Lidocaine (Adrenaline) (Xylocaine) 11. Isoproterenol (Isuprel) 4. Quinidine 12. Ampules of 5. Metaraminol bicarbonate (Aramine) 13. Blood pressure cuff f. Diphenylhydantoin 14. Oral airway (Dilantin) 15. Complete IV setup REFERENCES
1 PANTRIDGE, J.G., AND GEDDES, J.S.: A mobile intensivecare unit in the management of myocardial infarction, Lancet, 11:271, 1967. 2 United States Public Health Service Data. Reprint requests: Dr. Grace, 153 West 11th Street, New York City 10011