Challenge: Thinking Outside the Medical Box | Seizure, Perhaps Diabetic

[capngeo]

For those who don’t know, in my “real” life, I’m a firefighter/paramedic. Been one for almost 25 years now. I just helped a buddy out through a medical problem while he was offshore; he was relaying via SSB through a shore station who was emailing me. The thought occurred that I am lucky in that I have a lot of EMS experience when things go wrong away from help. (Joanne is also a RN). I’m going to throw out a scenario every day or so, and I hope that other medical people will help out. The idea is to better equip a layman sailor for dealing with the medical emergencies by thinking outside the box.

Now for the disclaimer..... I AM NOT A PHYSICIAN, I CANNOT GIVE MEDICAL ADVISE, AND ANYTHING YOU GLEAN FROM THIS THREAD YOU USE AT YOUR OWN RISK!

So.. here’s the scenario for today. You are on a 125nm overnight passage in the Windward Islands of the Southern Caribbean. A crewmember is found unconscious, and actively seizing. 40ish female, 75kg. No medical history is known other than perhaps diabetic (she was seen checking her blood glucose level). There is no apparent trauma other than some minor bleeding from the mouth. Her teeth are clenched, it appears she has vomited in her mouth, and she is not breathing. She is convulsing violently for several minutes, with intervening periods of calmness, but never alert, followed by another prolonged seizure. A MAYDAY has been called, but you’re in the 3rd world and help is a long way off.

What do you do? Your med kit aboard is geared towards trauma, and you have little to no medical training, only a small book for resource, no internet, no SAT, just SSB.

I’ve got to attend to some boat stuff, as I just got aboard after a 5 week absence; I’ll check back in a bit to see where this has gone.

[sabray]

From early red cross I'm going with don't let her gag choke on her tongue. So clear passageways then I fall back to elevate feat blanket and get help. If shes conscious enough to drink orange juice or water may be good. Did I kill her?

[andrewsc]

You are probably the most qualified person to answer the question in your scenario capngeo. I have been an emergency medicine physician for 15 years. Outside of the hospital I find that prehospital trained personnel are generally more effective than your average physician. Imagine yourself in the wilderness, on a plane, on a boat... would you rather have an orthopedist taking care of this lady or a paramedic. No offense to the orthopods with nice boats on this site but I will take the paramedic every time.

The answer from a physician may depend on their background. An infectious disease doctor will wonder if there was travel in sub saharan africa... onchocerciasis; central america... cysticercosis; cannibal from new guinea... kuru. All pretty unlikely and there is nothing you can do on a boat or really anywhere to change the outcome if theses are the causes.

Sabray's answer is reasonable. Genereal supportive care is the start. Place the patient in a safe position so that they do not harm themselves. Put them on their side to try and decrease the risk of aspiration. Do not try to put a spoon or more importantly your fingers in their mouth. They will not swallow their tongue. In a diabetic the most likely cause is low blood sugar. Ideally you could discuss with the patient before hand what they do for low blood sugar. Maybe they have a simple intramuscular glucagon injection that you could be instructed on how to use prior to this event. The other alternative would be a high concentration glucose (sugar solution). Even a small amount in the cheek will absorb through the mucous membranes in the mouth and may be enough to turn things around.

The best thing is to know any medical conditions of crew on board and plan ahead with their help for potential contingencies.

[DRS]

Roll patient and finger sweep mouth to clear air way. Chin lift to extend / open air way. If bag and mask, or shield available use that. Do not use oral airway with seizing / vomiting patient. Begin assisted respirations. Confirm chest rise and feel for pulse. If no pulse begin CPR. The rest is irrelevent if patient does not have a heart beat or begin breathing on her own. If breathing starts its probable diabetic coma find tester and see if you can get a blood test
Now here's the tricky part if its low sugar and concious patient you could administer glucose , fruit beverage, or sugar. Not sure how you are going to go about that with an unconcious vic and no IV.
That my 2 cents and I'm not a doctor or anywhere near it

[Vyndance]

Is there a pulse? Unless you are going to intubate through her nose you are going to have to wait for a calm period then clear her airway,block her jaw and start rescue breathing and probably CPR. If she comes around check her sugar to see how to proceed.

[Gadagirl]

Turn her head to the side to clear her airways and perform mouth to mouth resuscitation? If that fails consider performing a tracheotomy? I know from 1st aid to check the pulse so I'd do that also but after trying to supply her with much needed oxygen. In between breaths place sugar under her tongue (send crew member to check luggage for needed meds) ?

What a fabulous thread idea! I'm going to enjoy learning. Thank you so much for sharing your knowledge.

[Hillbillylad]

A great idea for a thread thanks.
I'm guessing, she got seasick and vomited so much her glucose level dropped dangerously. So force mouth open to remove vomit if poss then give muth to nose if mouth is still locked while looking for her diabetic pen or whatever she told you she carried.
Or perhaps she got food poisoning from the fish she just ate. Would the Diabetic pen cause more harm? I dunno, but I'd give it anyway.

[DeepFrz]

If she is having grand mal seizures you can't do much until they stop. Put her on her side. Try to make sure she doesn't injure herself further by kicking and thrashing around. Put a cushion or jacket under her head. If she comes out of the seizure she will be frightened and confused, try to reassure and comfort her. When she is more coherent you can find out about the blood sugar.

If you try to sweep a finger through her mouth when she is in a seizure the rest of the crew will be bandaging you and you will start to type like Zee...

[dinosaur]

ooooooo, i like this thread!

right off the bat from your analysis i am going to say the first TWO big factors here that need to be delt with are the not breathing and the seizing. i say the seizing is a big deal because you don't want her falling overboard from it. normally you don't want to restrain the movements of a seizing person, but i say that could have to go out the window given the situation. once she is out of danger from going overboard or dragging you overboard, you need to tackle the whole "not breathing" issue. if the medical kit contains an AED that may or may NOT be useful. is the water choppy? is she soaking wet? is water coming on the boat making it hard to create a dry environment? if so, the AED cannot be used. i don't know a ton about diabetic seizures, so i don't know if a shot of glucagon would be appropriate to someone who is unconscious and not breathing. and that is IF the med kit has glucagon shots. Also we don't know FOR SURE that she is having a diabetic seizure. usually other symptoms make themselves present before the seizure. the crew member could be having an allergic reaction, or could have been exposed to a toxic chemical accidentally. i'm going to fall back on standard red cross protocol and say the victim is unconscious and not breathing so begin CPR. there is obviously vomit in her mouth so begin by clearing the airway, perhaps during one of these calm periods. you don't want to get your fingers bit off and you don't want to try clearing the vomit with a foreign object incase she clenches up and gets hurt even worse. maybe putting her in a sideways recovery position and applying a heimlick maneuver could clear the vomit out without risking anyone's safety? check for breathing, if still no breathing gotta go with chest compressions and rescue breathing.

best case scenario... your mouth tastes like vomit and she recovers consciousness with a few broken ribs.

[skipmac]

Well, have a very little training but do have a daughter that is EM doctor. I may call her and ask but maybe that's cheating.

What I've learned is first evaluate and address ABC: Airway, Breathing, Circulation. Failure of any of these the patient will be dead in minutes.

So, check and clear the airway if necessary. See if the patient can breathe on her own, check pulse for hear beat. CPR if necessary until stable.

Then do what you can to address the cause. In this case very possibly blood sugar although on a boat the patient could have fallen so check for lumps, bruising, etc around the head.

Of course radio for help or expert advise if at all possible.

[Astrid]

Once airways have been cleared and the patient has been secured and is breathing on her own, assuming she is, a quick look through her belongings for medications might be in order. It is possible the seizure was brought on by failure to take a medication, and it might be up to you to find out what she is supposed to be taking.

Cruise ships usually have a medical staff on board, and if you can raise one of them on SSB the ship's doctor may be able to give advice based on what you find out.

[capngeo]

Wow! Jumping to all sorts of conclusions... so I ‘ll add a little more.....
She was down below, no worries about falling overboard... downtime was unknown, but she is on her third WITNESSED seizure right now... she was breathing when the seizures abated, but shallow and slow. No AED, NO BVM, bandaids and aspirin are all you have in the med kit.

I told my buddy to go below and rifle through her bags and belongings; try to find anything medical related and tell me what it was.... remember this was all third hand through email/SSB link... he found lebetiracetam (Keppra), Humulin N, Heparin, and Biaxin... a glucometer, an automatic BP cuff, Xanax, Valium and an epi pen hmmm...

Oh CRAP! another seizure, BRB!

BTW, Thanks for the flowers Doc.... but remember when we’re baffled, we call YOU guys!

[capngeo]

Originally Posted by Astrid

Once airways have been cleared and the patient has been secured and is breathing on her own, assuming she is, a quick look through her belongings for medications might be in order. It is possible the seizure was brought on by failure to take a medication, and it might be up to you to find out what she is supposed to be taking.

Cruise ships usually have a medical staff on board, and if you can raise one of them on SSB the ship's doctor may be able to give advice based on what you find out.

Capital Idea! I didn’t think of that!

[capngeo]

Originally Posted by dinosaur

. i'm going to fall back on standard red cross protocol and say the victim is unconscious and not breathing so begin CPR.
.

CPR is really tough to do on someone actively seizing when on land.... couldn’t imagine on the water.

One thing to remember... if they’re seizing, they HAVE a pulse... and if the reason they are not breathing is because of trismus (jaw clenched shut) rescue breathing is not likely to work unless perhaps mouth to nose.... In my world, I wouldn’t attempt it. I’ve probably attended 1000 seizures and there were one of two outcomes:
1] they came out of it with or without treatment and spontaneously started breathing or....
2] they died right there (DRT) and THAT stopped the seizure!

[capngeo]

Originally Posted by DeepFrz

If you try to sweep a finger through her mouth when she is in a seizure the rest of the crew will be bandaging you and you will start to type like Zee...

You Sir, owe me a monitor! A mouthful of Cap’n and OJ just sprayed it!