A patient in a remote community is alive thanks to the heroic efforts of a medical team that included two Real-Time Virtual Support (RTVS) physicians.

The case is being highlighted as an example of how the Rural Coordination Centre of BC’s RTVS team is continuing to have an impact on health equity in BC.

It also shows just how important the new ROCCi (Rural Outreach in Critical Care and Internal Medicine) pathway is for patient safety.

Dr. Matt Petrie was only a few hours away from finishing an evening shift with RUDi (Rural Urgent Doctor in-Aid) when a woman in a remote community in northwest BC arrived at the local nursing outpost station after ingesting a toxic dose of medication. The nurses quickly recognized that the woman was very unwell and called virtual physician Matt over the iPad.

“I did some initial assessment and verification of information,” said Matt. “And then we started basic supportive care.”

The team was able to speak with the patient’s partner to find out what drug had been ingested. “I’d never seen this particular kind of drug in an overdose situation. It’s a pretty unusual drug for an acute ingestion,” said Matt, who is based in Kelowna.

He decided to call Poison Control. And he quickly learned that things were about to get tricky.

“The lady on the phone said ‘uh-oh,’ he recounts.

“She said, ‘Yeah, people get really sick, really fast. They lose their level of consciousness. They seize, and they’re prone to cardiac arrest’.”

Given how far the patient was from a hospital—and needing either a boat or helicopter to get there—Matt knew that he had to act quickly and call for support.

Calling ROCCi

Luckily, the RTVS team had recently been bolstered by ROCCi, a team of critical care and internal medicine physicians that are available for any rural provider to call from 9am to 9pm every day. And Dr. Ian Warbrick, from Port Alberni, was doing his first shift for ROCCi that day.

Matt, the more experienced RTVS virtual physician, asked Ian to step in to navigate the clinical elements of the case, while he called the BC Emergency Health Service’s Patient Transfer Network (PTN) and liaised further with Poison Control.

Just moments after Ian joined the call, the patient began to arrest.

Ian said: “We ran a code, which was, from my perspective, a nice way to actually start it, which sounds horrible, but the reason being, it’s algorithmic. So… you just go through what you have to do. Luckily, we got her back. Then, the real work started from there. Because this patient just died, now they’re back, and now we’ve got to keep them alive. So that’s where the work really kicked in,” he explained.

“By that point the nurses and I had already been through a scary thing. So we had bonded as a team.  We were a pretty cohesive unit.”

Ian and the team of nurses then had to figure out next steps to keep the patient going.

“There was no ventilator, no machine to give the patient breath.  Instead there were probably 4 to 6 individual community members that were taking turns counting and squeezing a bag-valve mask to breathe for the patient,” he recounts.

The community members also took it upon themselves to read out the patient’s blood pressure every three minutes.

“They were just so on it, it was really impressive,” said Ian.

Ticking clock

Matt was advocating for the PTN to bring a helicopter and jet to safely transport the patient. But due to the jet being dispatched from Vancouver, there was still going to be a significant delay in getting the patient out of the nursing station.

So Ian continually worked with the team of nurses to advise on the meds needed; in this case, the patient needed a higher than usual dose of life support medication, which also served as an antidote to the ingestion. Community members, meanwhile, continued to help with the ventilation.

Time is always of the essence when someone is really ill, but in this case it was even more apparent. The medication needed to keep the patient alive is rarely used in nursing stations, and they do not have extensive supplies.

Ian said: “At one point we were doing the math because I was realizing these guys have very few medicines at all, how much would they have of this drug? So the nurses searched through the entire station, gathered all of this drug that they had, and piled it in one spot. It became very real very quickly, because they determined we would run out of that medicine that is keeping this person alive at 4 am.”

Both physicians praised the nursing team saying they were a fantastic unit to work with, and stayed calm despite the highly stressful situation.

Matt said that at one point the transport advisors had wondered about waiting until the morning so they could travel in daylight. Matt explained: “She was basically having a full ICU-run case with three nurses and first responders in an isolated community. I told the patient transport team ‘She needs to be in an actual ICU, those are her definitive interventions’.

“’What we’re doing here is not the same as us doing this in an emergency department or an ICU somewhere. It’s a very different scenario’.”

Happily, transport was able to arrive about four hours after the patient first arrived at the station, and a doctor at St Paul’s was queued up to take over her care.

The pair later found out the woman had four more cardiac arrests while at St Paul’s. But that team was able to bring her back each time and she was released from the ICU a few days later. They expected her to make a full recovery.

Supportive help

Matt, who has been a RUDi doctor since RTVS was launched in 2020, had a lot of praise for Ian and the way he handled the case. “A lot of it is the medicine; the competency that Ian showed in this is huge. But how to communicate effectively and be supportive in that stressful environment, that’s a really important aspect of this as well. And Ian did a great job.

“It’s stressful for the nurses. That’s way above their independent scope of practice.

“It’s Ian’s first time doing this by video. That’s a challenging case in any scenario, let alone trying to do it by video where you can’t actually physically impact it. So to be able to  communicate and run that in a way that the nurses felt supported despite all of those things, I think is a huge part of this. I think it’s obviously a reflection of Ian’s personality and ability.”

Dr. Scot Mountain, the medical lead for the ROCCi pathway, said the case was remarkable.

“Not only is there no way she would have gotten out of the community without both of them working on it, but also I think what they did in terms of support, and the degree of support was really heroic.  It was above and beyond what would have happened, I think, in a lot of rural hospitals with better access to transport,” Scot said. “So I don’t want to over-dramatize it, but I don’t think it’s a stretch to say that I can’t imagine any way that lady would have survived without both RUDi and ROCCi being available to work on that case.”

Scot continued: “Matt did an amazing job of recognizing the severity of the case and mobilizing the important resources right away. He called Poison Control and got great information from them, and then he started mobilizing transport immediately, which was a critical piece of this, because it was a really difficult transport done late at night from a remote community, and without him advocating for it and pushing for it right away, it never would have happened.

“He also then tagged in the ROCCi physician right away to get the clinical support, and they started that together.  But Ian was then able to carry on with the clinical support for the patient while Matt worked all the behind-the-scenes logistics to get the patient to the support they needed in a higher level of care. It’s just an amazing story of two pathways working together in a new way that we haven’t been able to do before, but we can now that we have ROCCi up and running.”

ROCCi is available to rural providers for both critical care and internal medicine support. Visit our Getting Started page to find out how to connect.