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Case of the Month: Offshore Innovation
When the phone rang at 12:40 a.m. and woke me up, I didn't realize the significance of the incoming call. I was the onboard paramedic for a semi-submersible oil and gas drilling rig in the Gulf of Mexico. The caller told me that a crew member with chest pain was being brought to the sick bay.
Case presentation: At the sick bay, I found a pale, diaphoretic 56-year-old man with pressure-like chest pain. The patient was alert and oriented, in moderate distress, with an adequate airway and regular respirations.
I immediately began care with the assistance of the off-tour drill crew and first mate, who had received first aid training to assist in this type of situation. We applied a pulse ox, supplied oxygen via nasal cannula, took vital signs, applied a cardiac monitor, initiated an IV and conducted a physical exam. Pulse, BP and pulse ox were within normal limits; respirations were 20/min. The patient had no relevant medical history and no known allergies. A 325 mg aspirin was administered.
The drilling rig's on-site supervisor was informed that a helicopter medical evacuation was required, and he immediately initiated the evac request. I instructed one of the team to contact medical direction via telephone while I prepared the patient for a 12-lead ECG. I informed the medical director of the patient's condition and the procedures that had been initiated. He concurred with the 12-lead ECG and the administration of nitroglycerin. I completed the ECG, and it was faxed to the physician. The nitroglycerin had no effect.
The medical director and I reviewed the ECG and agreed the patient was experiencing an acute anterior myocardial infarction (MI). I administered morphine to alleviate the pain. However, as the infarction evolved, more heart muscle was dying. The patient needed access to a heart catheterization lab immediately, but the helicopter that would transport the patient to a New Orleans hospital had an ETA of three hours.
I then reminded the medical director that I had access to Tenecteplase (TNK). The physician, therefore, made the decision that I should administer the fibrinolytic.
I initiated a second IV and began preparing the medication while the medical director spoke with the patient, describing the benefits (e.g., improves blood flow; minimizes damage to the heart muscle) and risks of administering TNK. (All fibrinolytic agents increase the risk of bleeding, including intracranial bleeding and hemorrhagic stroke.) The patient gave his informed consent to proceed. (For a fact sheet on TNK, visit www.tnkase.com/index.jsp.)
I administered the TNK, and within minutes, the patient's condition improved. His chest pain and pressure resolved, and soon the 12-lead indicated blood flow was returning to the heart muscle. My job now was to monitor the patient for arrhythmias and await the helicopter, still more than two hours from arrival.
An hour later, an arrhythmia occurred. The patient exhibited bradycardia, hypotension and a lowered level of consciousness. Per protocol, I immediately prepared to administer atropine while a team member contacted the medical director. I was already administering the atropine as the medical director was giving the order. The patient's heart rate and blood pressure returned to normal, and he returned to an alert state.
The medical evacuation helicopter arrived at 3:41 a.m., and I briefed the two RNs on board. The patient was transported to the helideck and prepared for the flight. The patient has since recovered and returned to work in the oil field.
Later, Genentech Inc., the manufacturer of TNK, advised us that the drug had never before been administered by a paramedic in the offshore environment. Its administration, however, was entirely consistent with current AHA/ACC guidelines for the treatment of an acute MI.