Reteplase designed for use in the field
January 1, 1998
Reteplase designed for use in the field
$16,000 to equip an ambulance
One of the first patients in the nation to receive reteplase (r-PA, Penzberg, Germany-based Boehringer Mannheim’s Retavase) in an ambulance was en route to Ingham Region Medical Center in Lansing, MI. He had called 911 ten minutes after his chest pain began.
Equipping an ambulance with a 12-lead EKG and a reteplase setup involves an investment of about $16,000, says Esther Perez, a paramedic instructor in the Ingham area. In addition, the emergency medical service (EMS) staff has to be trained to read the 12-lead, run down a thrombolytic checklist for indications of acute myocardial infarction (AMI), and make sure no contraindications exist, such as a bleeding history or stroke. (See reteplase contraindications, p. 4.)
Only about a dozen facilities in the United States have the capability to offer field administration. Mark Veenendaal, MD, a cardiologist with the Thoracic and Cardiovascular Institute in Lansing says the ambulance that transported the reteplase patient was equipped with 12-lead EKG units a necessity for prehospital administration.
"If the drug is started en route," says Veenendaal, "blood flow can return to the heart 30 or so minutes before the patient reaches the emergency department (ED). The sooner you dissolve the clot and reestablish blood flow, the less damage there will be to the heart muscle." Time is muscle heart muscle and this procedure saves money as well in terms of length of stay and cost of services.
Physician may or may not give go-ahead
The day the team administered reteplase to the patient on the way to Ingham, they transmitted the patient’s heart rhythms by cellular modem to the hospital’s ED, where a physician verified this was a heart attack and gave the order to administer.
Reteplase comes in a kit to mix with sterile water for quick IV injection. The kit contains two single-use vials (10.8 U of powder) and two single-use 10 ml diluent vials with needles and syringes.
"If the doctor feels there’s a bleed risk," says Perez, "or if the patient is not a good candidate otherwise, he won’t order reteplase." Advanced age, for example, is a warning factor as is retinopathy in a diabetic patient. Uncontrolled hypertension carries a 14-fold increased risk of stroke. Other risk factors include recent surgery, stroke, bleeding ulcer, or aneurysm. "The EMS crew won’t even touch reteplase if the patient has belly or back pain below the umbilicus because of risk of a kidney aneurysm," says Perez.
Are EMS workers exposing the hospital to litigation by administering the therapy? No, says Perez. The EMS team doesn’t have to get a signed consent because the patient often already has morphine for pain. "Our hospital attorneys say the physician is technically making an on-line call for the drug," she explains. The physician receives the history and vital signs, decides if the patient is a candidate for the drug or the cath lab or both, then instructs the EMS team based on that decision.
"In a way," says Perez, "the situation is the same as if we were calling a cardiologist from the ED. [The physician] is not present in that case either."
The cardiac staff at Ingham is trying to find ways to shorten that time. Even after transport, the patient’s evaluation takes time. "When patients used to come through the door with a three-lead EKG from the ambulance, it could take an average of 90 minutes to get the drug in," says Perez. Now the average time to Ingham’s cath lab is 30 minutes. "Since we started doing 12-leads en route and pre-triaging patients, time has been cut back considerably, especially when we get the go-ahead to administer reteplase in the field."
Perez notes that the ambulance is one of few places in health care where providers outnumber patients. "In the ED, nurses have to split their time and attention among a number of patients, all with differing symptoms and conditions. In the field there are typically two or three providers taking care of one person."
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