To the Editor:

Figure 1. Figure 1. Electrocardiograms Obtained by the Patient. Panel A shows the first 12-lead electrocardiogram that was obtained from the patient described in this report. This electrocardiogram shows complete heart block, right bundle-branch block, hyperacute T waves in the inferior leads, and reciprocal ST-segment depression in the anterolateral leads. Panel B shows the second 12-lead electrocardiogram, which was obtained 50 minutes after the first recording. This electrocardiogram shows sinus tachycardia with 2 mm of ST-segment elevation in the inferior leads and reciprocal ST-segment depression in the anterolateral leads.

A 44-year-old man presented with severe chest pain and dizziness to the nursing post where he worked in Coral Bay, Australia, more than 1000 km from Perth and 150 km from the next nearest medical facility. He was the only nurse on duty when the symptoms occurred. Since no other medical personnel were available, he performed and emailed his own electrocardiograms to an emergency physician by means of the Emergency Telehealth Service (ETS). 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 (Figure 1A). The second electrocardiogram, obtained 50 minutes later, showed sinus tachycardia with 2 mm of inferior ST-segment elevation (Figure 1B).

He self-cannulated both antecubital fossae for intravenous access and self-administered aspirin, clopidogrel, sublingual nitroglycerin, intravenous heparin, and opiates. Preparations were made for thrombolysis with tenecteplase, with real-time video interaction with the ETS. He attached his own defibrillator pads and prepared adrenaline, atropine, and amiodarone. After thrombolysis, there was resolution of his ST-segment elevation and symptoms.

He was transferred by the Royal Flying Doctor Service to a tertiary cardiology unit in Perth. The next day, coronary angiography revealed 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. A drug-eluting stent was inserted, and his residual moderate coronary artery disease was managed medically. He was discharged home 48 hours later and continued appropriate medical therapy.

Western Australia covers more than 2.5 million square kilometers,1 and much of the state is sparsely populated. The provision of health care to persons living in rural locations is an ongoing challenge. In 2012, the Western Australian Department of Health started the ETS to provide health services to isolated communities, using health care professionals who could be accessed by means of information and communication technology.2 This system was intended to facilitate diagnosis and treatment and to aid in disease prevention, research, and continued education in these communities.3,4 The initiation of this service has improved the delivery and accessibility of health care.1

Thrombolysis is the standard treatment for patients with ST-segment elevation myocardial infarction who are more than 120 minutes away from a hospital that is capable of performing primary percutaneous coronary intervention.5 Patients undergoing thrombolysis also undergo cardiac monitoring, intravenous access, and monitoring for infarct-related and thrombolysis-related complications. 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. However, a person’s self-management of a myocardial infarction cannot be considered medically appropriate if any other option is available.

Felicity Lee, M.B., B.S.

Paul Maggiore, M.B., B.S.

Kevin Chung, M.B., B.S.

Sir Charles Gairdner Hospital, Nedlands, WA, Australia

[email protected]

Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.