My first bad call happened on my third shift as a new paramedic. We were called to a home of a 26 y/o female having a seizure. Now, when we arrive at most seizure calls, the patient has typically stopped seizing, which is exactly what I expected. However, not this patient. As we arrived at the house, a man greeted us at the door, and then walked upstairs. When we walked in, we called out "EMS" and we were directed up the two flights of stairs and into the bathroom of a back bedroom. There, we found the female patient on the floor of her bathroom in left lateral recumbent and the fire department surrounding her. The fire department, a BLS crew, had already placed the patient on high flow oxygen via non-rebreather, and had obtained a pulse oximetry reading and a blood glucose value - two excellent pieces of information.
As I approached the patient, I realized that she was foaming at the mouth, and actively seizing. I immediately suctioned her mouth, felt for radial pulses. She had strong/equal/regualr radial pulses, which indicated to me that she had a blood pressure of greater than 90 mmHg systolic. As such, I gave her the anti-convulsant medication that we carry. She did not stop seizing. I inserted a nasal airway, and asked for extrication ideas. The fire crew asked if I thought carrying the patient down the stairs would work. I agreed with their plan, citing that it would be too difficult to put a seizing patient in a stair chair.
When we made it down stairs and put the patient on our stretcher, I immediately reassessed the patient. She was still seizing, but now, did not have radial pulses. I knew that giving her more of the anti-convulsant medication was now contraindicated because her blood pressure could no longer handle the drug. We quickly got her into the ambulance and began transporting emergency to the closest hospital. Once in the back of the ambulance, I placed the patient on our cardiac monitor so that I could keep track of her heart rate and pulse oximetry. I put the patient in trendelenberg, and began looking to obtain IV access. She had no veins. NONE! All I could think was "oh boy, this isn't going to be pretty". Still, the patient had no radial pulses, but I had to keep her airway in mind. My patient was still breathing, irregularly, but adequately as she maintained an oxygen saturation in the mid 90's.
I continued my search for an IV and asked my rider to hang and prime a liter of saline so that I could give the patient a fluid bolus, raise her blood pressure, and give her the anti-convulsant she desperately needed. As I looked for a vein to start an IV, I was monitoring my patient's airway, and realized she as no longer breathing at an adequate rate, and that her respirations were becoming increasingly irregular. I asked my rider to switch places with me and continue looking for an IV.
I began oxygenating the patient with an Ambu bag. Her seizures continued, with only few 20-30 second intervals without seizure activity. My rider could not obtain an IV, so I asked him to insert an IO (to drill a needle into her leg which would provide me with access to give fluids or medication. At this point, I called medical control to advise them of the situation and to see if they had any better ideas. That is, I knew I could not give the patient more of the anti-convulsant because she did not have a stable blood pressure, and the medication would decrease her blood pressure further. I did not have access, so I could not give her a fluid bolus to raise her BP. The doctor agreed with me that continuing with a rapid transport was the best plan at this time.
As soon as I got off the phone, my rider advised me that he was unable to find the landmarks necessary to place the IO. I said ok, but realized that my patient was no longer breathing on her own. I inserted an oral airway, and she accepted. At this point, I've realized that the best thing for me to do for this patient is to establish a definitive airway. However, we were about two minutes away from the hospital, and establishing an airway would mean I would either (a) not complete it before I get to the hospital or (b) sacrifice valuable oxygenation time. Not to mention the fact that it is always possible that she would wake up and I'd have to pull the tube. I had my rider switch places with me yet again, and I inserted the IO as we pulled into the hospital.
I rechecked the patient's blood pressure and found that she now had a stable blood pressure. I withheld the anti-convulsant, despite the fact that she was still seizing, because I know that the blood pressure I obtained was a result of the trendelenberg position teasing her baroreceptors into believing that she had an adequate blood pressure.
My partner opened the back doors to find me bagging the patient.
Lessons learned:
1) Airway takes priority! As much as I wish I could have gotten vasculature/intraosseous access sooner so that I could have given my patient a fluid bolus, and potentially more medication, I had to take care of my patient's airway.
2) There will be times when the paramedic cannot complete every task he or she wants to complete.
3) When the hospital is unable to do the same things you're unable to accomplish, you've done all you can do for that patient.
In the hospital:
-The doctors and nurses eventaually raised the patient's blood pressure enough to give her more anti-convulsant medications. They intubated her and admitted her to the ICU.
An interesting twist:
-While exposing the unconscious patient, we noted multiple bruises on her body, all roughly the size of fingers. So was her seizure induced by head trauma/abuse, perhaps? I don't know...and that was definitely a discussion that ensued in the ER.
