Landmark Learning

Mike Abbott – Canyoneering and Seizures

I really enjoyed Landmark’s WFR-Recert course.  As I drove up, I questioned the wisdom of going all this way to “stick with WMI.”  In 30 minutes I knew I had made the right choice. Landmark has exceptional instructors and the KISS (keep it simple stupid) approach is perfect for my brain.

The section on seizures during my WFR-Recertification was important to my decision process in the events below.  I was not nearly as prone to an overreaction by the event as a result of my recent training.

Below is the modified trip report describing the patient and events that transpired on a recent trip I was leading.  I thought you might like to read about what happened to us out there in the desert wilderness!

Southwest Desert Trip, April – Seizures

This is a 47 y/o white female, 5’7”, 131 lbs BP 120/76, HR 76 at rest with a 20 year history of seizure controlled since 2006 by the regime of Lamictal 400 mg at night, 300 mg in the morning with Nortriptyline 40mg and Armour Thyroid 30 mg daily.

Approximately 6 months prior to signing up for the trip the patient experienced a single seizure attributed convincingly according to her physician (as related to me by the patient) from not taking the prescribed medications. The history of seizure is almost exclusively at night.

After lengthy communication by phone and email this participant was cleared for the trip with her seizure specialist doctor’s specific concurrence. She had been mildly hypothermic in the past with no seizures occurring. Her specialist had only been able to induce seizures through sleep deprivation as the driving stress (better understood by me post event). I had a private interview with the patient pre-trip to work through what the leadership team could do to facilitate her needs if she had a seizure on trail. I understood she preferred a quite time and fluids and would get a head ache. I took delivery of her back up medications at that time.

Undisclosed until our pre-trip interview was this participant had polio as a child creating a chronic right hand tremor. I later determined, while observing her on trail, muscular issues in her legs (somewhat like being locked/stiff when first standing and nervous). Also undisclosed was a high level of anxiety about hiking in a group which we determined post event.  After close and particularly vigilant observation in the opening days this participant performed adequately and was solidly in the middle of the pack as to overall performance.

This participant was escorted by me through a cold water swim on day 4 prior to the main swim up canyon with packs. Post light lunch by 30 minutes about 1300 hrs. She performed as a calm strong swimmer with her head out of the water for the approximately two minute swim in ~60 degree f water.

We then proceeded to wading in a short slot canyon (ambient ~70 f and no wind) with one small pool swim ending in a sunny area where we partially re-warmed before returning via the same route. The participant stated she was getting cold so I sent her to the sun and let her re-warm by large muscle exercises for approximately 10 minutes while I escorted a second participant through the short slot. She was wearing a swim bottom, top and shoes. We then completed the 2 minute return swim as a group without incident. The elapsed time for the side hike/swim was about one hour.

At the conclusion of the swim as we exited the remaining 50 yard slot canyon to the sun the participant again stated she was cold and exhibited fine shivering. I then escorted her to the sun after ensuring her shoes were put back on – the total submersion time plus re-warm events were not enough to allow true hypothermia and in my estimation controlling anxiety in this slot was key to both participants’ safety. I reassured the participants and slowed things down by 3-5 minutes.

Arriving in the sun she became very agitated and fine muscle shivering degraded in minutes to gross muscle shivering and marked reduction in LOC and ataxia. She stated she was not feeling well and was otherwise non communicative. She was clearly highly anxious to panicky and single task focused. I elected to have her complete getting dry clothing on which we had available but she required support by the second participant and me to do so. Gross muscle shivering and ataxic motions prevailed. A sat her down and friction rubbed her back and legs with her permission. She showed some improvement but LOC remained diminished. She accepted a Cliff shot block and I asked her to lay in the full sun supine with head elevated on the warm rock. Supine the patient was HR 72 strong and regular radial, RR 16 and regular but shallow, skin – not pale (cold water emersion normal ), A/O 4. I was concerned about her LOC and she was not articulating what she meant by “not feeling well.” I positioned myself to protect her from a slight breeze whilst allowing me to roll her to prevent any vomiting event resulting in an aspiration. I elected not to move her to elevate her legs as she showed some improvement and was 72 SR radial. My immediate concern was seizure or vomiting and her positioning was safe, warm and controllable. We were approximately 10 minutes in the sun at this point.

There were two seizure events. The first was less severe in nature and lasted perhaps 30
seconds. The patient was unresponsive to voice and no pain response was attempted. The patient made eye contact and was aware something had happened within ~20 seconds of regaining consciousness.

Within one minute she had a second event, more severe, appearing tonic-clonic in nature and lasting perhaps 30-45 seconds with a full body arch and some shaking. The patient did not vocalize. She similarly recovered making good eye contact, A/O 2 within 20 seconds of regaining consciousness with good vocalization. Patent was GCS 15 essentially immediately and A/O 4 within two minutes. She stated she was fine at 5 minutes though tired. She stated that she had a “hole” in her memory and was independently aware that she had had a seizure which I confirmed and explained to her briefly; HR 75 SR radial, RR 15 with adequate TV, skin PWD, eyes PERRL, Temp NT. She stated she had taken her medications. Patient stated she was completely warm approximately 20 minutes after her initial complaint – this was not a true hypothermia event.

We performed a shoulder to shoulder walk for 25 feet to monitor and rested 10 more minutes.  She was visibly careful walking but overall gate and foot placement were as I had observed in the past days. She required no support. Patient postictal state was very short – of unknown duration but measured in minutes. We were walking this patient to the shade to reduce environmental load 30 minutes after initial distress. I elected not to do a complete PAS. I had been shoulder to shoulder with this participant since lunch and felt I would not reduce anxiety with the exam – anxiety and overall stress management were my main concern at this point.

Interventions’: 1 gram acetaminophen for headache (stated as normal intervention for tx by pt), ~100 ml water and two Cliff shot blocks (2x 210 mg Na, 20 mg K, 12 g simple sugars).

We made an initial evacuation decision and elected to return to camp barring any further incidents. It was ~1500 hours at the decision point and we were easily three hours to hand off to Rangers trying to meet us by foot. We had no meaningful provisions or overnight gear. We made the one hour + walk back to camp, secured the pt with belays at all up ropes and made the return without incident. The patient performed normally for her throughout with improvement in engagement with me and pace throughout. She reported a headache and fatigue – normal for her in symptom for a seizure event. Patient elected to not talk, also normal for her and took water when requested on the walk.

Protocol is to evacuate any participant who has a first time seizure, a long duration seizure or a seizure markedly atypical for the patient. This patient was in the margins. We did not expect her to have a seizure, and normally but not exclusively, her seizures are at night. I contacted one of our supporting physicians by satellite phone, a Psychiatrist, we felt our best resource. His recommendation was to evacuate. I attempted to reach the patients physician multiple times.

We ensured good food and fluid uptake that night, gave her a functional air mattress and let her sleep. She was confirmed as sleeping at 2000 hrs. I interviewed the patient after she had had 10 hours of solid sleep. The interview was focused on determining the stressors that contributed to the events and to determine her state of mind. Importantly she had not had adequate sleep the prior three nights. The events for sleep were manageable going forward (upset stomach from a meat based meal – pt was vegetarian and elected to try the dish) and a deflating pad (which we traded for a good leader pad after the patch did not fully work). We were aware of these issues had attempted to patch her pad the night prior but I was unaware that sleep deprivation was the one stress test that had triggered her seizures in controlled conditions. The second stressor was fear the group would know she had a history of seizure and was not qualified to do the trip. This issue was self resolving as participants banded together and reduced her anxiety demonstrably.

There was no way to hide that something had occurred so I had briefed the group the prior evening about this patients needs and our options looking to the next day. The patient had begun her menstrual cycle in the past days. I had no reason to believe she had any infection. Physical exertion, unknowns about slot canyon swims and the cold water were determined to be additional stressors. Having now experienced the cold water and narrow slots the patient observed her anxiety about going up the canyon was markedly reduced. We agreed that she had begun to panic when she got back to the sun the day prior. At the interview pt stated she had easily ten hours of sleep and felt fully rested. She had taken her medications as directed. She stated she would rather be evacuated than have another seizure – I believed this. She also stated that in her opinion she was not sleep deprived and had great confidence that she would not have another seizure. Finally she said her overall sense and self assessment of her symptoms of this seizure event was exactly per her prior experiences in all respects.

Barring another seizure, we did not feel this patient was a candidate for a helicopter evacuation.  We were then faced with a single leader escort down canyon to meet park rangers for a boat evacuation or keep the patient with the main group and go up through the narrows of West Canyon. We were emboldened by the “aura” of the event I witnessed. I had a solid five minutes from pt clearly in distress to unconsciousness. We felt we could maintain patient safety leveraged by reducing triggering stressors much better in a group environment going up canyon. We also felt patient well being was very much enhanced if she was allowed to remain with the group and potentially on the trip –further reducing stressors. The main concern of going up canyon was the potential of managing a seizing patient in deep water and a narrow slot for perhaps 50 feet to dry sand bars.

We developed a risk management plan acceptable to the leader team for that event. We reduced the final stresses under our control by emptying her pack and having her escorted uniquely by myself while the other two leaders managed the group in its entirety. One assistant leader provided additional support at known deep water points. Finally we preferentially inflated one inner tube so that the pt would never be submerged in cold water.  We set aside two sets of dry micro fleece. She ended up in the water once but never got particularly cold, performed as hoped and completed the entire trip without further incident. Once in open country and in the heat we returned pack weight to her incrementally.

Further interventions: none

These two books have been very helpful to me leading in desert environments:
1.  Fixing you feet, John Vonhof, ISBN-13: 978-0965738606 —–Vonhof also has an informative blog.

2.  Exertional Heat Illnesses, Lawrence Armstrong Phd. ISBN-13:  9780736037716
— Good case studies and data in Armstrong.

Thank you for the exceptional training at Landmark and WMI of NOLS!

Mike