Professional competence is defined as doing things, always in the Interest of patients. It’s generally believed small hospitals are not competent enough to treat cardiac emergencies . . .Do you agree with that ? No, Its largely a myth . Do you know there is a absolute lack of proficiency threatening to plague our country’s coronary care system. ? It’s the professional Incompetence by the space age, star hospitals (mis)managed by masters of the noble business. None (am I right ?) of this hospitals either monitor or publish the outcome of their treatment.
Backed by pseudo scientific data , amplified by unrealistic expectations of ill Informed patients , some hospitals are avoiding Initial emergency treatment of acute MI , instead they waste time ( load DAPT ofcourse !) in securing the finance for the costly Invasive procedures or refer them out of their premises if they can’t afford for it.In the ensuing emotional and financial melee many of the ill-fated patients lose vital time window of thrombolysis as well ! and carry risk of fatality or damaged myocardium.
Every stake holder in the current coronary care system simply assume the enforced modality must be far superior because they administer the most modern and costly treatment suggested by few high intensity cared clinical trials originating from west. The wisemen who run the corporate hospitals never realise medical competence and outcome is not entirely defined by science. Their primitive cognition wouldn’t allow to think beyond business equations either.
Please believe me, time and again, I have witnessed patients reaching Government hospitals after being shunned away by big (Some times even medium sized ) hospitals who boast themself only as PCI enabled care. Even if they want to lyse they stock only the Tenekteplace .
I think tragedy is a lesser word to describe the scenario , where a distressed family is trying to arrange for a Rs30,000 shot of Tenekteplace when thirty times cheaper still equally efficacious (Rs 1000 Streptokinase) is concealed from their visibility .The Govt should urgently look into instances of large private hospitals avoiding Govt insurance scheme patients even in cardiac emergencies ! To label our poor patients as unaffordable ones is a outright misnomer, rather its the rich hospitals that are “not affordable” to lose profit and treat our countrymen , in a cost effective manner is the reality !
Who is Poor ? You decide.
Two forbidden things in coronary care
1.Cajoling and manoeuvring a distressed family for a primary PCI as a routine treatment hyping its beneficial effect and underplaying the true advantages of thrombolysis in largely technical jargons is the current norm in most coronary care units.
2.Another issue is , after confused confabulations with the duty medical officer, if a rare patient family choose the option of thrombolysis , comes the next googly*. Many noble minded hospitals do not stock the low-cost and equally efficacious thrombolytic agent and offering only the costly option to the anxious families when the myocardium is on fire.
Hospitals that practice these two coronary protocols need to be shamed and labeled as “Coronary Incompetent ” In spite of having 24/7 cath labs. (Realise , they are just like any remote rural hospitals , at least the later can’t be faulted as they don’t withhold a reperfusion strategy !)
Final message
I think , mindless proliferation of cath lab based cardiac care , which follow this theme , ie “Thrombolysis incapable but PCI capable “ are biggest threat to coronary care in our country ! For the best coronary care for any country ,what we need is efficient prehospital thrombolysis team .We have conveniently forgotten the great study of CAPTIM wherein the ambulance drivers replicated the same effect of primary PCI performed by highly trained cardiologists in modern labs.
In India, primary health centers which is within few km reach of entire population can be designated as static ambulance equivalents with basic resuscitation facility . If a multipurpose health worker can be trained to lyse, with remote supervision that will accomplish 90 % of what the cathlab guys can achieve ! Selective shifting is suffice.
Postamble : Ofcourse, not doing pPCI for high risk or complicated STEMI is unscientific and we need to have proper consenting and referring frame-work for such patients.
Counter point : One of my colleagues asked me ? Why do I enjoy attacking the established scientific practices ? May be I have a problem , yes, but I think in a true medical democracy we have right to debate anything , absolute truth is a ongoing journey !
*Googly: An unplayable ball delivered to a batsman in the game of cricket.
Dr.S.Venkatesan MD 