NURSE MACGYVER

A 44-year-old nurse who works in a remote medical facility in Coral Bay, Australia, was the only person on duty when he began to experience heart attack symptoms and knew he would have to attempt his own treatment.

His story, told by Felicity Lee, MB, from the Sir Charles Gairdner Hospital in Nedlands, Western Australia, and colleagues, appears in a March 8 letter to the editor in the New England Journal of Medicine (NEJM ).

According to the letter, the nurse had severe chest pain and dizziness and was more than 1000 km (600 miles) from Perth and 150 km (about 93 miles) from the nearest medical facility.

The nurse performed and emailed his own electrocardiograms to an emergency physician via the Emergency Telehealth Service (ETS), which was started in 2012 by the Western Australian Department of Health to facilitate care in isolated communities. According to the writers, the physician who read the test relayed these results:

"The first electrocardiogram showed complete heart block, right bundle-branch block, hyperacute T waves in the inferior leads, and reciprocal ST-segment depression in the anterolateral leads." The second, taken 50 minutes later "showed sinus tachycardia with 2 mm of inferior ST-segment elevation."

When the nurse got the results, he self-cannulated and administered aspirin, clopidogrel, sublingual nitroglycerin, intravenous heparin, and opiates. He prepared for thrombolysis and was able to interact in real time with the ETS.

After thrombolysis, his ST-segment elevation and symptoms resolved.

The Royal Flying Doctor Service arrived and transferred him to a cardiology unit in Perth.

The next day, imaging showed severe stenosis in the mid-right coronary artery with blood flow of Thrombolysis in Myocardial Infarction grade 3 and mild left ventricular dysfunction. A stent was inserted and he was discharged home 48 hours later with continued therapy.

Nick Genes, MD, PhD, an emergency medicine physician and medical director of telehealth services at Mount Sinai Health System in New York City, told Medscape Medical News, "that's not a bad outcome for a STEMI [ST-Elevation Myocardial Infarction]."

He said he's never heard anything quite like this story.

"I've heard colleagues relay stories of their own diagnosis or diagnosing friends or performing feats in airplanes, but never quite so dramatic or quite so far from definitive care," he said.

Some who experience heart attack symptoms could be sweating or vomiting and not able to perform the measures, he notes.

"The great thing was he was able to start heparin and then a thrombolytic in a timely fashion before there was extensive damage to the heart," Dr Genes said.

Perhaps the most effective thing he did was take aspirin, Dr Genes said. "We obsess over the thrombolytics and the stenting, but aspirin is very effective therapy, even for a STEMI. It's not the only therapy, but it's a good first step."

Dr Genes said he was surprised the nurse used an opiate and surmised it was probably morphine.

"Morphine has been part of the standard of care for chest pain for a long time, but recently has been called into question because it has been shown to inhibit the effectiveness of clopidogrel and some other platelet aggregation inhibitors," he said. "We've actually stopped giving morphine in a lot of these cases."

Dr Genes said it was a big risk to take an opiate in the nurse's circumstance because, "You wouldn't want to impair yourself, because you're the only one taking care of yourself."

The story is particularly remarkable, Dr Genes said, because the nurse is relatively young, and had the wherewithal to notice the symptoms.

"It's hard to imagine looking at my EKG, realizing the significance of it and then getting to work on what needs to be done. I really salute this nurse for having the clarity of thought to initiate this protocol," he said.

The letter writers said self-management of a myocardial infarction should never be attempted unless it is the only option.

In this case, "In the absence of other trained medical personnel or resources, the actions of this patient are likely to have had a substantial beneficial effect on the clinical outcome," they write.

Dr Genes agrees. "This guy is very courageous. Kudos to him," he said. He added that he salutes NEJM for publishing the letter, but wished the nurse could have gotten the benefit of being one of the authors.

"This would definitely make for a great documentary," he said.

The authors have disclosed no relevant financial relationships.