During a shift you are dispatched to a 17-year-old female patient seizing. Although the underlying cause of a seizure can be relatively complex, being dispatched to a seizure is a rather standard callout for most paramedics. Central nervous system (CNS) depressants such as midazolam or diazepam are a front-line drug that most ambulances services utilize to reduce the seizing patient before a short transport to hospital.1 However, consider the difference in the case pathology if the CNS depressants you have don’t work, or there are very limited transport options, or the hospital is an ocean away?
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This article will review a case of a seizing patient on a remote island in Vanuatu following a large tropical cyclone.
Vanuatu is an archipelago made up of 83 islands in the Pacific Ocean that host some of the most remote communities on earth with limited access to primary health care. Its tropical climate experience average temperatures between 23-28 degrees Celsius (about 73-82 degrees Fahrenheit) with an increase in cyclonic activity between January and March each year. A few days following a major cyclonic event, around lunch time, a call for assistance came from a remote health post on Ambrym, a volcanic island in Malampa Province. A teenage girl was reportedly suffering recurrent seizures at a local health post where a single doctor was rendering assistance. A solo paramedic was tasked with the response and retrieval.
Due to the vast distances between the islands, aeromedical retrieval is the most beneficial way to access and extricate patients. However, a lack of state funded helicopter or fixed wing services mean island-based paramedic crews must rely on civilian providers of both rotary and fixed wing services, or sometimes marine vessels. The latter can cause extensive delays in the patient accessing assistance.
Although an airstrip on the south of Ambrym was operational, the patient was located in a village on the northern side of the island. This ruled out the possibility of a fixed wing retrieval, which would have been faster and more practical. A privately owned Robinson 66 helicopter was the only aircraft available to the responding paramedic at the time; however, this aircraft was less-than-ideal for retrieval.
For those unfamiliar with rotary aircraft, an R66 has five seats, two in the front, and a bench seat in the back that can accommodate three people. It is powered by a Rolls-Royce RR300 turboshaft engine and fully loaded its maximum range is 600 km with a max cruising speed is 222km/h.3 This placed the patient just over one hour to contact. During the flight, the crew was made aware that the patient had been seizing in her village for several hours before being brought to the island’s health post for assessment.
Upon landing, the crew was met by some local villagers who guided the paramedic to a shed nearby. The patient was located in a makeshift clinic set up immediately after the recent tropical cyclone. The shed had two long slider doors, four tin walls and a concrete floor with many other locals milling around seeking assistance. A lone international doctor was in attendance and working with a nurse to attend the sick and injured.
The attending doctor explained that a local islander had approached the health post at approximately 9:30 a.m. and he had explained to the staff that his daughter was seizing. She was known to have seizures, but she was not currently prescribed anything to manage them. The doctor was unable to leave the health post and had requested that the patient be brought to him. Not long after the verbal exchange, the villager arrived carrying his daughter who was still actively seizing. The doctor immediately requested a medivac through the Ministry of Health and commenced treatment.
By the time the crew had landed on Ambrym and arrived at the health post, the patient had received a total of 50 milligrams of Diazepam however she was still seizing (status). The attending doctor had exhausted most of his available medical supplies and was in the process of administering the last available dose of Diazepam. A second line agent Phenytoin was then infused over 20 minutes which was successful in reducing the seizures.
She was carried by a team of local villagers back to the helicopter in a non-seizing, altered conscious state. Due to the limited space inside the aircraft, the patient was positioned across the rear beach seat with her head in the lap of the attending paramedic that would allow adhoc airway management if required during the flight. While this will no doubt challenge some of the readers’ stance on safety and professionalism, sometimes what is necessary in remote circumstances is outside of the acceptable norm.
The only aircraft available at the time of the dispatch was a small helicopter and without it, the patient would have suffered much longer and likely deteriorated. The patient’s airway was the priority concern, and with such limited space to move, this was the only feasible way to retrieve her from the remote island, and the best method to ensure her airway could be managed and manipulated in flight.
The patient’s dad occupied the front left seat, the pilot the front right, and the paramedic and patient across the backseat. The cardiac monitor was unsecured on the floor near the patient’s feet with capnography, SPO2, ECG and BP running. The oxygen kit was located near the patient’s head and under the paramedic’s feet. A set of conveniently placed LMA’s, securing strap and a bag valve mask were within reach of the oxygen kit.
To further complicate the situation, the crew was then advised that the patient had never flown before. This increased the risk of a possible adverse response if the patient became aware midflight. Although sedation was discussed and Ketamine and Fentanyl were both available, it was decided that due to the distinct lack of room in the aircraft and her gently increasing conscious state, any sedation and intubation would be withheld.
During the return flight the patient’s condition continued to improve, she maintained her own airway, and no other interventions were required. The patient was safely transferred to an awaiting ground ambulance in Port Vila.
While this case review describes an unusual approach to a medical retrieval, remote healthcare providers in developing nations face major clinical, ethical and legal challenges such as these described. The challenges of prehospital care are dynamic, yet in the remote context they are even more so. In these situations, a careful assessment of risk verses reward is paramount. In these situations, it I just as important to withhold certain interventions as it is to administer them.
- Broughton W. Pre-hospital paediatric seizures: midazolam versus diazepam. Journal of Paramedic Practice. 2014;6(10):532-534.
- Clemency B, Ott J, Tanski C, Bart J, Lindstrom H. Parenteral Midazolam Is Superior to Diazepam for Treatment of Prehospital Seizures. Prehospital Emergency Care. 2014;19(2):218-223.
- R66 Introduction & Specifications – Robinson Helicopter Company [Internet]. Robinson Helicopter Company. 2020 [cited 5 November 2020]. Available from: https://robinsonheli.com/r66-specifications/.