EDITOR—Edhouse et al have shown that in an urban area such as Sheffield the optimum method of hastening thrombolytic treatment for acute myocardial infarction is for patients to dial 999 and be brought to the casualty department and for the thrombolytic treatment to be given there.1 This reduced the door to needle time to a median of 41.5 minutes.

In North Derbyshire, a mix of urban and rural areas adjacent to Sheffield, we have a system of direct admission to the Chesterfield and North Derbyshire Royal Hospital coronary care unit by paramedics (bypassing the accident and emergency department) when the paramedics diagnose an acute myocardial infarction from a 12 lead electrocardiogram obtained at the patient's home.2 In the 21 months since the system was introduced in May 1997 I have collected data on all admissions to the coronary care unit.

The unit has received 889 patients with myocardial infarction, of whom 159 have been delivered directly by paramedics. Altogether 495 of the patients have received thrombolytic treatment, including 131 of those delivered by the paramedics. The mean (median) times from arrival in hospital to thrombolysis (door to needle times) were 89 (107) minutes …