The challenges of treating status epilepticus in rural Canada

Though unified by challenges in the treatment of status epilepticus (SE), rural Canada is simultaneously massive and diverse, spanning the Pacific, Atlantic, and Arctic Oceans. According to the national statistical agency, the most rural jurisdiction in Canada is the Arctic territory of Nunavut. In particular, the Kivalliq region of Nunavut represents a unique epidemiologic SE space because any treatment beyond typical first-line lorazepam and second-line phenytoin by a non-neurologist locum tenens requires airborne evacuation over a thousand kilometers away to a single hospital with a single electroencephalographic (EEG) laboratory. This distinctive mode of healthcare delivery affords unique insights into the challenges of treating SE in rural Canada, such as lack of EEG infrastructure, a markedly high incidence of SE, the struggles of enduring cultural and socioeconomic trauma, and a relative lack of local epilepsy care as recommended by the World Health Organization. For example, despite empiric treatment and waiting over 2 days on average for EEG, 1 in 5 patients still had ongoing or possible electrographic seizures. At the same time, Kivalliq experiences routine dramatic changes in light-dark exposure each year to afford unique insights into circannual SE chronobiology in relation to the chief human zeitgeber of sunlight. This shows that challenges may also represent opportunities, such as for existing and emerging technologies to synergistically address enormous treatment gaps to improve SE care for the people of Kivalliq, while providing novel insights that may also help improve SE clinical care around the world.