ROBOT TO THE RESCUE
Remote control surgery saves infant
On a chilly afternoon at the end of November, Quentel Merasty was at home in the northern community of Pelican Narrows when she realized her four-month old son, Guentzel, was having a seizure.
Pelican Narrows, population 2,000, is more than an hour’s drive from the nearest hospital in Flin Flon, on the Saskatchewan-Manitoba border. The nearest airstrip to medevac someone out of the community is a bumpy 45-minute drive away, in Sandy Bay.
The Pelican Narrows nursing station is served by fly-in doctors on one- or two-week rotations. Some days there are no physicians in the community.
Nov. 19 — when Quentel rushed in with her seizing infant — was one of those days. Quentel Merasty, mother of Guentzel Merasty: He started twitching his one hand and then we called an ambulance right away. The ambulance took long and then we got a ride there. He was still twitching. Latoya Patterson, a nurse practitioner at the Pelican Narrows nursing station: On presentation he was completely ashen, so his colour was very poor. He was unresponsive. And all his limbs were twitching … I knew that there were circulation issues and, because he was having generalized twitching at four months old, that was a seizure situation. Ivar Mendez, Unified Head of the Department of Surgery at the University of Saskatchewan: There is actually a rating scale of how urgent a case is; we score patients from one to four. So when you are a score of one that means that your life is threatened … If you don’t have the appropriate care, you either will die or have a permanent injury … This was a No. 1.
Patterson: It was a normally healthy child who was all of a sudden having seizures and mom said it was going on for the five minutes before she got here and usually a seizure over two minutes is concerning. So a situation like that, you start worrying about the brain, you start worrying about his welfare and his ability to actually live. And so it was what we call a resuscitation situation, which is why I called for help.
In 2014, Pelican Narrows became the first site in Canada to offer health-care services through remote presence technology. There is a robot at the nursing station and when staff require expert help, they phone a specialist physician in Saskatoon, more than 500 kilometres away. The specialist logs onto a computer system, remotely drives the robot to the
emergency room, observes what is happening and speaks through the robot to advise nursing staff on how to proceed.
There are now 12 communities in northern Saskatchewan equipped with remote presence technology. Physicians in Saskatoon respond to two or three remote calls a week. Tanya Holt, head of Saskatchewan’s Pediatric Intensive Care
Unit: We’ve developed a robot call schedule so I was on-call for remote presence and I got a call from Pelican Narrows. One of the nurse practitioners had a very sick baby that had been brought in and they were alarmed by how ill the child was and phoned and asked me to see the patient immediately and so I logged on to my laptop, which was at my desk, and I was there within minutes to support their team.
Patterson: Often (the system) will ask for demographic information, who’s this person, what’s their registration number, how old are they, what are their symptoms. In a situation like that, I just told them that this was a code and I needed help right now. So it took maybe about two minutes for her to be available.
Holt: The robot is docked somewhere else and I autonomously drive to the emergency location in the Pelican Narrows clinic and then I see the entire team surrounding the bed of this critically ill baby … Babies are usually awake. The baby was unconscious. And babies usually don’t work hard to breathe and the baby was working very hard to breathe and I could see that immediately … The baby was actually actively having a seizure and I could also see that immediately.
The normal heart rate for a fourmonth-old is between 100 and 110 beats per minute. Holt could see on the heart rate monitor that Guentzel’s heart was beating at 207 beats per minute.
Holt: The very first thing you need to intervene with a critically ill baby is to recognize the urgency of the situation and vital signs help that a lot. The child was on a monitor and I was able to assess his vital signs and determine whether they were abnormal or normal and they were certainly abnormal … The very objective finding in the vital signs that told you that this baby was in a life-threatening situation was the heart rate. That heart rate tells you that he’s in shock and, what we know about shock and living in remote communities, is that if you reverse shock within 75 minutes, there’s a 96 per cent chance of survival in babies. But with every hour that passes that you don’t reverse shock, there’s a two-fold increase in mortality. So timeliness in treating shock cannot be understated.
Merasty: I was so scared. I was so scared that I would lose my baby. But I prayed and prayed and told the nurses, ‘Please help my baby,’ and they told me ‘We’re trying, we’re trying our best, don’t cry Quentel.’ So I’m holding his hand and telling him ‘Baby, wake up, I still need you.’
Holt: When a baby is seizuring, that can be dangerous for the brain and their overall outcome so we needed to get that seizure stopped and so that was the No. 1 thing on my list and then the best way to do that is to use a medication to stop the seizure and there’s several that we have on our list and if they don’t work then we move on to the next.
Eventually the medication worked and the seizures stopped, but Guentzel was still unconscious.
Holt: We recognized that the baby essentially was in shock and our working diagnosis at that point was the baby had septic shock.
I was so scared. I was so scared that I would lose my baby. But I prayed and prayed and told the nurses, ‘Please help my baby.’
Septic shock is a fancy term for a severe infection that’s putting the child in a life-threatening situation because of low blood pressure and we call it perfusion so, at that point then, we have the seizures stopped, we continue to monitor the neurologic status and we give fluids, we give support with medications for the heart.
Merasty: All the nurses, they’re all on him, there’s stuff on him.
Under Holt’s guidance, nurses and nurse practitioners in Pelican Narrows used intravenous lines to administer medications, fluids and antibiotics.
Roughly 30 minutes after Guentzel was brought into the hospital, he began to wake up.
Holt: We started to see the baby begin to rouse and this, of course, for the team is the most amazing feeling because they have this baby that presents unconscious, seizuring, in shock, and, all of a sudden, the baby’s starting to wake up and do normal baby things like look around and make normal baby noises and move appropriately and these are things that, then, the team starts to feel reassured and calm down and the entire room starts to settle and then we regroup and we get another set of vital signs.
Patterson: It’s a relief, right? Because now you’re not wondering if he’s going to pass away or not, wondering if you’re going to lose him. You can actually see a response and see that we intervened quickly and well.
Merasty: I was so happy when they told me that he was going to be OK.
Guentzel was still not out of the woods. As soon as Holt saw the ashen, seizing infant on her laptop screen she knew he would need further intensive treatment that wasn’t available in Pelican Narrows. While she was working with the nurses remotely, she dispatched a pediatric critical-care transport team to pick up Guentzel and bring him to the intensive-care unit at Royal University Hospital in Saskatoon. She stayed connected with staff in Pelican Narrows while the team was en route, making sure the baby remained in stable condition.
Mendez: The runway in Pelican Narrows is not functional. When we go to Pelican Narrows we have to land in Sandy Bay, which is about a half-hour away.
Holt: This time they took a fixed wing plane to La Ronge and a Twin Otter into Pelican Narrows and then they Twin-Ottered back to La Ronge and fix-winged back to Saskatoon.
Mendez: It took two and a half hours to get there with Tanya immediately mobilizing it, so if she hadn’t been there, it could have taken four hours.
Guentzel spent less than a week in ICU before being discharged. He is now back home in Pelican Narrows and does not appear to have suffered any adverse effects from his seizures. Holt believes the shock was caused by a bacterial infection.
Merasty: He’s better. He smiles. He giggles. It’s not clear what Guentzel’s outcome would have been if Holt hadn’t been able to remotely assist in his resuscitation via the robot.
Holt: Over the last four years, since we’ve been using this technology, what’s struck me is how present I feel as a part of the team there and that, outside of being able to feel the baby myself, I feel like I’m there and helping manoeuvre care and support the team … I’m a lot more aggressive with therapy when I’m there in person … I can’t say for sure (what would have happened without this technology), but what I do know is that he was in a life-threatening situation there and we were able to get him quite stable within 30 minutes to an hour.
I think the more important question is: What would his outcome have been?
He may have survived, but would there have been any morbidity? And morbidity means: Would there have been a decrease in function long-term? And that’s what we generally see is that if they survive the impact of a period of time where care hasn’t been optimized it can lead to kind of subsequent dysfunctions in the future. Now, what we saw is this little baby who was thriving essentially and this is a mom away from a critical scenario.
Mendez: What you’re seeing here, is — I think — a window into what the future would look like. We need to go where the patient is. We need to go in real time.
The patients that need expert care should actually be able to get it in real time. And that’s where technology’s going.