Beyond the call of duty

It is perhaps fair to conclude that almost every doctor has been called upon to respond to a medical emergency when off-duty.

Although they may step calmly into such situations, saving a life is a dramatic act, offering immense relief to frantic onlookers and concerned family and friends.

Doctors rarely talk about such events publicly and seek little thanks for their oftentimes monumental, life-changing interventions.

“As an off-duty doctor, I have been asked to assist, or gone to the assistance of, people who have become unwell on planes, trains and automobiles, as well as people who have collapsed or fallen in the street or in public places,” Dr Peadar Gilligan, IMO President, revealed.

“I have had trains stop at the next available station and been asked if aeroplanes should divert with sick passengers. We do our best in these situations as a profession and clearly, in a serious situation we call or have called the ambulance service for their very capable assistance.”

<strong>Dr Peadar Gilligan</strong>

Wexford GP Dr Darragh O’Doherty has responded to a small number of medical emergencies when off-duty, including a choking incident in Dublin.

One particular event sticks out in his mind. Dr O’Doherty was at a hotel in Wexford for an annual hospice barbecue six years ago when an ex-junior minister collapsed in the lobby.

Dr O’Doherty was having dinner with the minister’s son (also a TD) when the cardiac arrest took place.

“The first stroke of luck occurred when he collapsed right beside a first responder,” Dr O’Doherty recalled.

“Then my brother, who is also a doctor, walked out of the bathroom straight into what was happening and began administering mouth-to-mouth while the first responder did chest compressions.”

At this point, Dr O’Doherty was called from his dinner to assist and was in the car park about to journey to his surgery to obtain a defibrillator when an ambulance arrived with one.

The patient was shocked a number of times but remained difficult to stabilise, as his heart kept stopping. “We would get him back and he would go again,” Dr O’Doherty recalled.

The next stroke of luck occurred when an emergency medical technician (EMT) trainer arrived from Rathdrum with a machine that performs chest compressions. Eventually, the patient was stabilised and travelled 30 minutes by ambulance to hospital, where three days later he regained consciousness.

“I didn’t do much. It really was a case of everything that could go right went right,” Dr O’Doherty surmised.

Louth GP Dr Darragh O’Neill was travelling to the IMO AGM in Killarney last month when he became stuck in a long traffic tailback on the Rock Road.

Unwilling to sit and wait, he turned the car around in a bid to avoid the traffic. It was at this point that his wife, sitting beside him in the car, saw a man suddenly collapse on the pavement nearby.

Dr O’Neill rushed to the man’s aid and started compressions and ventilation. The man was suffering a cardiac arrest and his heart had stopped beating.

Fortunately, Dr O’Neill had medical equipment in the car and two nurses assisted at the scene. His daughter, who plans to study medicine, also assisted, as she had completed basic life support training as part of her transition year at secondary school.

When the ambulance (which was fortunately close by) arrived, a defibrillator had already reached the scene and the man is alive today.

Recalling the incident, Dr O’Neill told the <strong><em>Medical Independent</em></strong> that he is one of more than 100 GPs nationally who act as GP emergency responders in collaboration with the HSE National Ambulance Service (NAS).

“I carry a defibrillator and a trauma pack with me most of the time but this time, because I was on holidays, my boot was nearly empty, so I only had basic equipment with me,” he explained.

<strong>Dr Darragh O’Neill</strong>

<h3 class=”subheadMIstyles”>The MERIT Project</h3>

The University College Dublin (UCD) Centre for Emergency Medical Science (CEMS) operates the Medical Emergency Responders Integration and Training (MERIT) Project, where currently, 160 GPs voluntarily carry defibrillator equipment and a breathing apparatus to respond to incidents and receive text message alerts to cardiac arrests in their communities.

The MERIT project was established in UCD in December 2004. Funders include the Pre-Hospital Emergency Care Council (PHECC) and the Department of Health.

Dr O’Neill, who is a lecturer with CEMS, is a MERIT 3 doctor. This means every two years, he undertakes a course and is offered the option to become an emergency first responder.

In 2015, a MERIT 3 text alert system was introduced, which involves GPs being alerted by text message from the NAS to nearby emergencies. The initiative receives vital charitable support from Irish Community Rapid Response.

GP responders operate within an identified location, around which a 10km radius is generated by the ambulance dispatch centre, which has a database of community responders, including MERIT GPs. If a cardiac arrest occurs within that radius, their computer system automatically pushes out a text alert to a GP’s phone and if the GP is in a position to respond, they can do so.

Dr Tomás Barry, UCD College Lecturer with CEMS, explained that when the MERIT Project was launched, 100 GPs initially signed-up.

“The MERIT Project is part of a broader piece around trying to offer basic life support care in the community as quickly as possible following cardiac arrest,” Dr Barry said.

“There would probably be a predominance of GPs in areas that would maybe be more rural and areas that might be perceived to be further away from ambulance base locations. That’s not exclusively the case, but it probably would be a theme.”

The significance of the project is immense. It holds a survival to hospital discharge rate of 17.4 per cent — significantly higher than the overall rate experienced in Ireland of 7.8 per cent.

To date, more than 500 GP practices across Ireland participate in the project, which among its many objectives aims to establish structures to train, equip, monitor and integrate GPs into the delivery of agreed aspects of pre-hospital emergency care.

It also explores the establishment of liaison structures between GPs, ambulance services and GP co-operatives, and facilitates the provision of defibrillators for use by GPs within their current practice settings.

<h3 class=”subheadMIstyles”>Out-of-hospital cardiac arrest</h3>

According to the <em>Out-of-Hospital Cardiac Arrest Register Annual Report (OHCAR) 2016</em>, there were 2,389 cases of out-of-hospital cardiac arrest where a resuscitation was attempted, with 67 per cent of cases occurring in the home.

Some 49 per cent of cases were witnessed by bystanders and 84 per cent had bystander cardiopulmonary resuscitation. Around one-fifth of cases had a defibrillation attempted before the arrival of emergency medical services. Some 7.8 per cent of cases were discharged alive from hospital.

“Since the last <em>OHCAR Annual Report</em> was published in 2015, there has been an increase of 9 per cent more cases reported to OHCAR,” the report notes.

“Bystander attempts at CPR have risen by 6 per cent… The use of mechanical CPR has increased from 18 per cent of cases in 2015 to 55 per cent of all OHCAR cases.

“Attempted defibrillation before EMS arrival has increased from 18 per cent to 20 per cent. ROSC [return of spontaneous circulation] before hospital arrival has increased from 26 per cent to 28 per cent. ROSC on arrival at hospital has increased from 18 per cent to 21 per cent.”

Studies have shown that early CPR and defibrillation are known to increase survival following OHCA.

Dr O’Neill pointed out that GP responders respond to calls along with an ambulance, and not instead of an ambulance. The GP responders are not insured to break traffic lights and carry oxygen, he added.

Defibrillator pads must be replaced at a cost of €50 after being used and the GP uses their own money to replace pads, Dr O’Neill said. “Over a year, I get about a dozen calls,” he revealed.

When asked why he became a MERIT GP when GPs are already so overloaded with the work in their daily practices, he responded: “Why wouldn’t you? It’s the skill set we have.”

Dr O’Neill has run courses at his local GAA club to teach people how to use defibrillators and is keen for as many people as possible in the community to learn basic life support.

“Football clubs all have defibrillators but some clubs don’t have anyone taught how to use it, so I run courses,” he explained.

He added that because of various health policies in recent years, sicker patients are presenting at general practice and he noted that they are more likely to have acute events at general practice.

Separate to his responder duties, Dr O’Neill recalled six “witness events” in the last five years and said that three of these lives were saved.