The global problem of Myocardial Infarction more commonly known as a “heart attack” is well documented within the world health organisation; they have completed numerous studies within this sector to indicate areas for improvement in the of quality care in a prehospital setting. This case study evaluates the management of care approiate to scope of practise for paramedics on treating such conditions and their roles in meeting “the standards of proficiency that are relevant to their scope of practice” in accordance with the health and care professions council (HCPC 2019)
We will be exploring the paramedic’s tools at gaining a focused history as early as possible; to allow the correct treatment to be delivered to the patient and transportation to the correct hospital, using the Physical Assessment and Clinical Reasoning also knows as the PACAR assessment tool (Courses.uwe.ac.uk, 2019))
We will aslo explore the referral pathways available to the paramedics within the northern ireland ambulance service (NIAS), allowing the patient to have “ Door to balloon time within 90 minutes” (Nhs.uk, 2019) For the purpose for patient confidentially in this case study all the identifiable material has been edited to protect confidentiality and to comply with regulations such as the Data Protection Act (1988) and National Health Service Act (2006) which is covered in the (Legislation.gov.uk, 2019). To protect confidentiality in line with Health Care Professions Council standards (HCPC,2019) a Pseudonym of Mary has been assigned to the patient.
Marys presenting complaint was shortness of breath known as dyspnoea, some chest discomfort and a recent history of a chest infection, that is the details relayed to the crew on route to the call. On arrival the crew had a 70 year old female who was feeling unwell and was currently on medication for an on-going chest infection, patient was complaining of chest discomfort and pain on inspiration. Upon gaining informed consent from Mary the crew quickly realised that the patient was in pain , as Mary had given it a pain score of 9/10 once the pains core had been explained with 10/10 being the worst pain imaginable (Breivik et al 2008). She required immediate treatment once a focused history and baseline observations had been taken. Having been taught the new PACAR tool the crew had a full set of observations that they were able to quickly assess the ECG which has ST elevation in 3 of the leads and a clear indication of ST segment elevation myocardial infarction (STEMI) (NHS2019) The standard 12-lead electrocardiogram is a representation of the heart's electrical activity recorded from electrodes on the body surface allowing the paramedic to obtain information about the electrical function of the heart and interpret these finding along with Marys clinical observations to decide upon a treatment plan .
Marys initial observations were oxygen sat 98% Blood pressure 140/90 mmHG on both arms a with a temperature of 37.6oC , blood sugar of 6.4 mill moles per litre with a respiratory rate of 22 breaths per minute. The ambulance crew followed the protocol for a STEMI and gave the appropriate drugs and pain relief in accordance with JRCALC which were aspirin 300 milligrams, to thin the blood to prevent further clotting; by inhibiting the growth of the blood clot you can maintain some blood flow through the coronary artery which can keep heart muscle cells from dying. GTN 400mmg which causes vasodilation and increases blood flow to the myocardium being mindful of the side effects it has and known that that Marys blood pressure will be affected therefore continual observations are essential (Ferreira and Mochly-Rosen, 2012). After reassessing Mary’s pain (Caroline et al., 2013), the crew titrated 10mg of morphine sulphate to effect to reduce the pain to allow Mary to feel easier (Ghadban, Enezate and Payne, 2019) .Marys pain score was reassessed several times throughout her journey, it had now been reduce to 1/10 with the initial 5ml of morphine sulphate she was also give oxygen at 100% as this had positive effect on her breathing rate and over all anxiety (Atar, 2010). Having followed the key guideline placed within the Health and care professions council (HCPC 2019) which can guide the clinician to what is expected as “best practice” the crew realised that the patient required a possible Percutaneous Coronary Intervention or PCI. The appropriate care pathway had been identified by the crew and implemented as per NIAS referral in accordance with the European society of cardiology (ESC) 2017 guidelines for patients with ST elevation. The next step was to inform the patient of their findings and explain the process as they took control of the pain management. The ECG had been emailed to the relevant hospital department and a phone to confirm this followed. Having being accepted for PCI by the receiving unit Mary ,who was still pain free on her third set of observations and declined further pain relief , was giving a detailed account of her definitive care pathway and if she was happy with the proceed with their clinical decision given all the relevant facts.
The clinical decisions made for the patient has been demonstrated to be one the safest and most effective method to restore perfusion in patients with a STEMI. Therefore it highlights the importance of the door to balloon time (D2B), (Pennmedicine.org, 2019).
The D2B has been explored in many countries and has a varying degree of results with time ranging from 60minutes to 120minutes. One study in San Francisco was clearly able to demonstrate a success rate of 94% in restoring adequate perfusion within 90mins when taken directly to PCI compared with a 24% rate under the 90 min going through an emergency department. (Tarver, T 2014). These cases provide clinical evidence that direct admission via ambulance is best practise. Further to these studies one in particular focused on the ambulance crews providing 12 ECG results on arrival to an emergency department decreased the D2B as this made the decision making process faster, allowing them to be fast tracked from the emergency room to the PCI. The study was instrumental in San Francisco in implementing the ability for a remote transmission of ECGs citywide (McCabe 2019).
Exploring Mary’s journey she a had a D2B time of 82minutes with a possible onset of a further 60 to 90 minutes, due to the distances involved the time between the standby being placed and the arrival at PCI it was 68 minutes. This more than adequate for the PCI lab , however recent studies has shown activation times with at least 10 minutes before arrival at hospital had a better in-hospital survival rate. (Glenn, 2019)
When on route to the hospital a further 3 ECG's were recorded to monitor the patients current cardiac condition and provide several pre-hospital baseline ECG's as these can be invaluable for the receiving PCI lab to gain a clearly picture of the events leading to the patients arrival. The patient’s pain was address during the journey as and when required and within the JRCALC guidelines. The patient was unsure of exactly what was happening and had asked for clarity on their condition. The crew informed Mary that she was having a myocardial infarct which is a heart attack and that the pain was due to that, although pain free again Mary did require further reassurance of a possible positive outcome which was sympathetically provided by the crew, health care professional are always mindful of the 6CS when dealing with patients in their daily duties. The procedure which lay ahead was also explained to Mary who had a calming effect on her and allowed them to come to terms with their condition.
The journey had now become relaxed for the patient as the paramedic had taken an excellent patient centred care approach in explain anything the patient had asked.. One of the problems using a person-centred approach is that you cannot tell the clinician how to approach people in a certain environment because every person and every situation is different. It’s not always about the actions of the clinician but the way in which they react in each situation. This is sometimes over looked, as empathy and a genuine person centred approach has to start within the clinicians. This is a skill which has to be developed over time and one that can take many years to master correctly everything was clearly explained to Mary and she was able to demonstrate a good level of understanding (Elwyn. et al 2014).
The receiving PCI lab was ready and waiting, this allowed for an extremely smooth transition from the ambulance stretcher to the PCI table with a seamless handover. Mary who was still pain free on arrival at the hospital PCI laboratory made reference on how professional the crew had been during her time in their care which was an excellent reflection on them as health care professionals.
Having had a positive outcome for the patient, we can look at the factors which lead then to that definitive point of care and if there was any further possible outcomes available to them. The history taking model used was relative new in NIAS and has still not rolled out across the trust so it was specific to the crew attending, had this been another NIAS crew whom had not been taught this PACAR tool the outcome would still have been the same although it possibly could have taken longer for them to arrive at their diagnosis. We can say this due to the trust wide approach to history taking using SOCRATES with the review of systems. Any given NIAS paramedic would have been using SOCRATES the review of relevant systems models as this provides a wide range of questions for this type of an event SOCRATES the acronym is used to gain an insight into the person’s condition (Clayton, Holly A. 2000). It stands for: Site, Onset, Character, Radiation, Associations, Time, Exacerbating/relieving factors, Severity. This would also indicate the need for a 12 lead ECG due to the severity of pain and the radiation of it, thus bringing the paramedic to the differential diagnosis of an acute STEMI. The only difference being the speed of the assessment, the PACAR tool focuses on the presenting complaint much quicker than SOCRATES.
The education of student paramedics with NIAS has continued to enhance their teaching year by year to include the latest and most suitable diagnostic tools to deliver the correct care every time a patient is treated.
To summaries the overall experience that the Mary during her treatment from time of ambulance arrival to the transfer onto the operating table can be shown as appositive one, mainly due to the level of care delivered the comfortable patient journey from home to hospital, the correct care had been implemented, the correct procedures had been adhered too and Mary had made a full recovery after her catheterization at the PCI lab. It was a positive experience for the crew, having researched the principles on the D2B we can see the increased development of Paramedic clinical decision making skills and the NHS trust policies changing to allow for a greater chance for a positive patient recovery from an STEMI with no cardiac defecate. The new PACAR tool had proved to be invaluable in the clinical decision making of the crew and is one that should be rolled out service wide for all paramedics in NIAS and not solely for new students as this can cause confusion with paramedic practise. This should be addressed during the paramedic post proficiency courses which are run annually.
This particular call clearly outlines the importance of using a PACAR assessment tool alongside an appropriate pathway referral to provide continuity of care for the patient. It provides yet another “ call” as piece of evidence that professional assessment results in excellent clinical care with a quicker outcome for the patient resulting in the “Right Patient, Right Diagnosis, Right Treatment” (Saranath and Khanna, 2015)