True Grit and Telemedicine: How a Nurse Saved His Own Life

Troy Brown, RN

Disclosures

May 09, 2018

A Courageous Act

Many in the healthcare community were astonished to read the story, highlighted in a recent Medscape article, of Ryan Franks, a 44-year-old nurse who was alone in a remote nursing post in Western Australia when he suffered a myocardial infarction (MI) and treated himself. This story, which originally appeared in the New England Journal of Medicine,[1] was a testament to the lifesaving potential of virtual emergency medical care in remote settings and to the courage of a nurse who found himself in truly frightening circumstances.

But he did have help. Shortly after developing severe chest pain and dizziness, Franks called two volunteer ambulance drivers and sent an ECG to the Emergency Telehealth Service (ETS) 700 miles away in Perth, where emergency physician Dr Beatrice Scicchitano recognized that he was having an MI and gave him instructions.[2]

Still, his actions were nothing short of heroic. By the time he was transferred out to a tertiary cardiology unit two and a half hours later, he had performed numerous ECGs, started two antecubital intravenous (IV) lines on himself, drawn a blood sample, attached defibrillator pads to his chest, prepared emergency drugs, medicated himself, and administered a thrombolytic.[1] Both Franks and Scicchitano instructed the ambulance volunteers on what to do if he lost consciousness.

He started two lines on himself, while having a STEMI.

Medscape readers were thrilled that he made a complete recovery after having an inferior ST-segment elevation MI (STEMI). "The whole story was amazing! Most fascinating is that he started two lines on himself, while having a STEMI," one reader commented.

'FaceTime on Steroids'

The remote nursing post where Franks works is 93 miles away from the next closest medical facility. A single nurse typically staffs the post with the assistance of a remotely stationed emergency physician as part of the ETS. The high-definition videoconferencing technology of the ETS has been described by some of its users as "[FaceTime] on steroids."[1]

Justin Yeung, director of the ETS, explained to Medscape how it works. "We call the interface a virtual room, but essentially it's face-to-face high-definition videoconferencing. We run consultations via desktop Web-based videoconferencing too—secure and encrypted—so I can also dial in if the doctor requires a three-way videoconference."

On that day in early December 2017, Franks developed severe chest pain and dizziness after leaving work. Initially in disbelief, he soon realized that he was having a heart attack. He returned to the clinic, where he was alone. He did an ECG on himself, emailed the results to the ETS physicians in Perth, and drew his blood for troponin levels. He was sweating profusely, which made it hard to attach ECG leads and to get a good reading.

After reading his ECG, Scicchitano instructed Franks to start two antecubital IV lines. During this time, Franks also took aspirin, clopidogrel, and sublingual nitroglycerin, and injected small doses of fentanyl as ordered by Scicchitano.

At the time, Yeung wasn't aware that a staff member was in trouble. "I was monitoring ETS activity remotely by laptop, but I wasn't dialed into the consultation. To be honest, there was nothing in the run sheet that was out of the ordinary at the time. Chest pain being thrombolyzed—pretty standard stuff. I only found out early the next morning that the patient was one of our nurses," Yeung explained.

'Unbelievably Difficult to Do'

Franks had been through this before. He knew the drill. But he never imagined he might be on the receiving end of his skills.

Franks continued to obtain ECGs on himself and relay the results to Scicchitano, who gave him further orders and instructions.[2] With the aid of the volunteers, he administered medications to himself and applied defibrillator pads. As his condition worsened, he prepared adrenaline, atropine, and amiodarone, and he and Scicchitano instructed the volunteers on which medications to give if he lost consciousness. Within an hour he had self-administered tenecteplase for thrombolysis.

One commenter related a personal story about a time when she had to start an IV on herself and said it was "unbelievably difficult to do. Think about it—you need an arm to stick, a hand to hold the catheter, and a hand to pull the skin taut ... that this nurse did it while alone and having chest pain is amazing!" she wrote.

Franks's amazing story, fortunately, had a happy ending. With the expert guidance of the ETS, he managed his own treatment for almost 3 hours before he was airlifted out. "ETS received his referral at 19:25, the doctor made contact at 19:29 (we do this by phone first to ensure that the remote site does have the patient—and the right one—in the resuscitation room and in front of the camera, of which there are generally two). Franks left the clinic at approximately 22:00 to go to the air strip and then to Perth," Yeung said.

The Royal Flying Doctor Service transferred Franks to a tertiary cardiology unit, where coronary angiography showed severe stenosis in the mid-right coronary artery with blood flow of Thrombolysis in Myocardial Infarction (TIMI) grade 3 and mild left ventricular systolic dysfunction.[1] He underwent placement of a drug-eluting stent and medical management of his residual moderate coronary artery disease,[1] and was discharged to his home 48 hours later.

"He was never alone," Yeung affirmed. "We have had two cases in the past few days where remote-area nurses have dealt with critically unwell cases, the only doctor being the remote ETS emergency physician. In both cases the far-site nurse was walked through the insertion of, in one case, a laryngeal mask airway, and in both cases, intraosseous needles. Neither nurse had performed these emergency procedures before. With videoconferencing and the expertise of the physician behind the camera, we were able to walk the nurses through the procedures, management, and evacuation," he explained.

One Medscape reader wrote, "It's hard to describe what it's like working [remotely], and when you tell people stories, they often think you are exaggerating. Try suturing your right hand using only your left! Hats off to the nurse."

The 'Beauty of Telehealth'

Several readers commented about the value of telemedicine in underserved areas.

"This is the point and the beauty of telehealth—to put emergency physicians where there are none—to begin treatment while transport is on its way, until the patients can be transferred to distant medical centers for further stabilization," said one.

Another nurse said that Franks's story is "a testament to telemedicine and nursing (without whom remote care wouldn't be possible) and interdisciplinary collaboration."

Telemedicine provides rural nurses and other healthcare providers with clinical supervision that is as close to in-person as it gets. With cutting-edge technology, telemedicine can save lives in the prehospital setting, but it depends on having someone at the "patient end" to carry out the instructions and orders of emergency medicine physicians. Without both, many seriously ill or injured patients living in remote areas might never make it to those healthcare centers at all.

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