PRAXES Medical Director, Dr. John Ross, recalls a case of remote telemedicine in which a serious medical incident took place at sea and how the team at PRAXES was able to provide world-class telemedicine support.
At approximately 2 pm, a crewman on a factory fishing ship, located 250 nautical miles offshore on the Grand Banks of Canada’s East Coast, developed chest pain while he was working in the fish processing area. Several minutes later he collapsed and co-workers found him unresponsive with a very slow pulse and laboured breathing. The captain, who had the most advanced medical training on board – advanced first aid, was summoned. At this point, the crewman was responsive but confused, sweaty and complaining of severe crushing chest pain. The captain obtained a heart rate of 40 beats per minute but was unable to get a blood pressure reading. He asked the bridge and ask for someone to contact the Coast Guard and request medical assistance. The bridge crew instead called a medical clinic and spoke with a doctor who recommended giving several sprays of nitroglycerine for the chest pain. Unfortunately, the contact was then lost. The captain arrived back on the bridge, followed proper protocol and contacted St. John Coast Guard Radio, part of Canada’s Joint Rescue Coordination Center (JRCC). They were quickly put in contact with the on-call PRAXES Emergency Specialists physician.
The captain briefed the physician on the the condition of his crewman and said he believed his patient was having a heart attack. The captain had experienced a heart attack himself, and believed the crewman may have been experiencing similar pain. He told the Praxes physician that a clinic doctor had recommended giving nitroglycerine. However, the on-line doctor was concerned about the slow heart rate and very low blood pressure. Nitroglycerine in that setting could kill the patient. The PRAXES physician explained that it may or may not help with pain symptoms but that it is not an important part of managing a heart attack.
The PRAXES physician and captain decided to administer ASA, a simple but critical treatment in breaking clots in coronary arteries (it is used by all critical care units in the world) that cause heart attacks as well as treatment for the man’s nausea and pain. The captain was next asked to repeat the vital signs regularly. At the same time, the PRAXES physician decided that an emergency medevac was warranted to get the man off the ship and to definitive care as soon as possible. The JRCC began working through the logistics of the medevac. The Canadian Navy’s Search and Rescue (SAR) team was contacted and the captain started heading for shore as the vessel was outside the range for a rescue helicopter.
Further calls between the captain and the PRAXES physician carefully followed the man’s progress. He was moved from the factory floor to the ship’s medical room and the medications began to have some effect. While the chest pain was still present it was now less severe. Fortunately, his vital signs had improved and the vomiting had stopped. During the wait for the helicopter, the PRAXES doctor calmly reassured the captain that he was doing everything possible within the constraints of that austere, remote setting.
Three hours after the initial call, a Search and Rescue (SAR) helicopter arrived, and a SAR Technician was lowered to the deck from the hovering aircraft. The patient was reassessed, loaded onto the stretcher and hoisted onto the aircraft. Two hours later, at the tertiary care hospital, the acute myocardial infarction was confirmed and the patient was taken to the coronary catheterization suite where the partially blocked artery was opened and two stents placed. He made an uneventful recovery and eight months later was back at work – no longer smoking and 20 pounds lighter.
The key components of this successful out come are:
- Having a medical kit on board to treat serious medical events – the more sophisticated, the more that can be done.
- Having crew members with a minimum of Advanced First Aid training.
- Having immediate access to an on-call emergency physician who understands the constraints and challenges of providing care in a marine environment, far from shore, and who is willing to provide decisive advice to an unknown person with basic medical training.
- Having highly trained and skilled search and rescue and/or medevac personnel available when emergency medical transport is required.