M. Masudul Hasan Nun  ( Department of Cardiology, Combined Military Hospital, Rawalpindi. )

From January 1983- December 1986 a total of 880 patients were received by the ‘flying Squad Team’ from Rawalpindi and Islamabad. The average uelay between the onset of chest pain and medical aid was considerably less in those patients evacuated by ‘Flying Squad’ compared to those who cameon theft own (3.2 + 1.2 SEM hours vs 6.5 + 2.0 SEM hours). Eighteen cases developed cardiac arrest outside hospi­tal of which 14(77.8%) were successfully resuscitated. Eleven (61.1%) left the hospital alive. Pre-hospital coronary care is an important adjunct to the hospital coronary care which significently reduces mortality (JPMA 39:157, 1989).

Flying squad services have existed in Rawal­pindi/Islamabad for over four years. The need for such services was realised because the clinical pic­ture in the first few hours following onset of myocardial infarction is quite different from that seen in the coronary care unit. Autonomic distur­bances which could trigger fatal arrhythmias are much more common and at this stage, the severity of ischaemic damage is most likely to be altered by appropriate emergency treatment^1,2. Most fata­lities due to ischaemic heart disease occur before a patient reaches hospital and many do not show warning symptoms³ . If patients with symptoms of acute myocardial ischaemia receive medical care within the first hour a significant reduction in mor­tality could be expected⁴. Accordingly, to deliver basic life support outside the hospital a rapid response emergency care system named “Hying Squad Service”, was operated at AFIC/NIHD Rawalpindi. The pur­pose of this report is to review the achievements and drawbacks of the pre-hospital systàm over the last four years (January, 1983 - December, 1986).

The Flying Squad Ambulance consists of a Defibrillator, portable drug box (consisting of life saving medicines), equipment for intravenous therapy and endotracheal intubation, a Medical Officer - trained in the cardio-pulmonary rests­citation, NursingAssistant - also trained in the cardio-pulmonary resuscitation, Stretcher bearer, Ambulance driver and Radiotelephone for con­sultation with the Cardiologist on call/hospital.

Calls for the flying Squad may come either from a patient or medical practitioner. Calls are received by a central control, which notifies the stand-by flying Squad on call in the unit Fart-I Order. Within five minutes the team leaves for the place of call. The activities of the team are peri­odically reviewed to ensure that they are not treat-lug inappropriately. The Flying Squad team are authorised to administer DC defibrillation, insert intravenous line and give specific drugs for specific indications. If there is doubt about management of some aspect of the patient’s ailment, the medical officer can contact the cardiologist on call or hospital on the radiotelephone for advice.

Between January 1983 and Decembçr 1986 a total of 880 calls were received by the Flying Squad Team. Out of these 840 ‘cases were ev­acuated to the hospital for advanced medical treatment. This forms 17% of total admissions to the coronary care unit (4860 cases). Seven hun­dred and fifty calls were received from Rawalpin­di and 130 from Islamabad. An average delay of 3.2 ± 1.2 SEM hours was observed in cases brought to the hospital after initial treatment while the duration increased to 6.5 ± 2.0 SEM hours for those cases who came on their own to the hospital.
Of 880 cases received, 757(86%) were coro­nary cases. Myocardial infarction was the cause in 475(54%) cases and coronary insufficiency in 282 (32%) cases, remaining 123 (14%) were non-coronary cases. The details are given in the Table.

Of 18 cases who developed cardiac arrest outside hospital, 14(77.8%) cases had successful resuscitation, and 4 (22.2%) died. All 110 cases who were brought on their own expired; these cases had cardiac arrest at home or during transit.

Mobile coronary care is an integral part of a stratified system for emergency cardiac care and has been developed to bring coronary care to the patient in his home⁵. The concept introduced by Pantridge in Belfast in 1966 was an advance of great importance⁶. In 1970 he argued that early treatment of cardiac abnormalities and blood pre­ssure following myocardial infarction might pre­vent an unnecessary extension of the infarct and this led to the growing interest in the limitation of infarct size⁷. In the year to follow, other countries also developed such services depending. upon theft requirement and resources⁸. The flying Squad Service was set up in AFIC/NIHD Rawal­pindi in 1982. Two regular fully equipped am­bulances started functioning from January 1983. In the present study 86% cases had coronary disease, 54% being myocardial infarction and 32% coronary insufficiency. The remaining cases had non-cardiac problems. In the Pantridge series, 2753 calls were received of whom 43% had proven myocardial infarction and 33% coronary insuf­ficienc⁹. In 18 cases who were evacuated in our series cardiac arrest occurred outside the hospital. Four­teen (77.8%) out of these were successfully revived and 11 (66.1%) cases left the hospital alive. Of the direct admissions, 110 cases were brought in dead, these cases either developed cardiac arrest at home or during transit. The high mortality reflects lack of basic CPR training amongst attendants and relatives. In Seattle, Washington, during the first three years of operation of Seattle unit, 202 patients were resuscitated6lS% of whom subsequently left the hospital alive¹⁰ . In Belfast 193 patients had car­diac arrest outside hospital and resuscitation was attempted in 155. Of these there were 55 initial sur­vivors and 38 left the hospital alive⁹. In Northern Ireland two comparable areas in a community were surveyed, one bad pre- hospital coronary care and the other hospital coronary care only. Mortality in the area with a mobile unit bad 38% lower values than the other area. This difference was more obvious amongst younger age groups¹¹. Similarly on introduction of a mobile unit, com­munity mortality was substantially reduced amo­ngst persons below the age of 70 in Charlottesville, Virginia12. Results from other studies⁴ suggest that many lives can be saved by these types of ser­Basic life support if provided by non-medics can achieve a survival rate of 20%¹⁰ and this rate is nearly 40%, if the cardiopulmonary resuscita­tion is provided by a trained attendant¹³. If de­fibrillation is delivered within a short time 50% survival is achieved¹⁴. The survival rate increases to 70% if an ideal situation is available with a defibrillator at hand¹⁵. Complications of cardiac arrest are minimised when cardiopulmonary re­suscitation and defibrillation have been perform­ed in a short time^16,17. There is sufficient indication that the quality of life after resuscita­tion is good in patients who survive and leave hospital^18-22. The relatively smaller number of patients re­quiring cardiopulmonary resuscitation in our se­ries does not under-estimate the usefulness of pre-hospital care. It should be noted that these figures apply to the early years of our service. The delays on the part of patients/doctors requestipg for the service, difficult roads and lanes of Rawal­pindi and relatively slow manoeuverability of our ambulances all contribute, though little, to the delays in providing immediate care. It is however, expected that as time goes on considerably better results will be expecte4. For the pre-hospital ser­vice to fulfill its role adequately the patients suf­fering from chest pain must request medical aid as soon as possible. This can only be achieved if the public are aware of the significance of these sy­mptoms. Special emphasis should be placed upon the education of those at high risk²³ . Another aspect is instruction in cardiopulmonary resuscita­tion amongst the public. A large majority who suf­fer a cardiac arrest do so outside hospital. If a high percentage of the community understood the prin­ciples of external cardiac compression and emer­gency, mouth to mouth ventilation, then there is good chance of the patient being kept alive until Hying Squad Team arrives^24,25. The standard de­pends largely upon the interest and involvement of the medical officer organising and assisting the service. A system of continuing supervision and in­struction is essential. In words of one of the pio­neers of pre-hospital coronary care Dr. J.S. Geddes “The proficiency of hospital doctors in basic and advanced life support must kee.p pace with the progress being made by citizens and paramedical workers²⁶."

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