Posted by: medicblog999 | January 5, 2010

The next decision to be made……!

decisions

So, as we left it yesterday, we were just coming to the transport decision.

Thanks for all of the comments, they have been really interesting to read and seem to be mostly polarised into the two options of taking in the RR car or getting an ambulance to transport the patient.

My decision was to take her and mum up to the hospital in the car. My rationale for this was based on my relatively unremarkable findings on examination, the previous history of a febrile convulsion along with the information gained from the nursery worker which seemed to point to a febrile cause of the seizure. She had been cooled down now and as I explained to the mother, the reason for transport was more to do with need to look into the possible source of the pyrexia rather than the treatment of the convulsion itself.

As I would be transporting in the car, I like to have my patient report form completed before I leave, so I spent some time documenting my assessment, findings and decision. All in all, I had been on scene for about 30 minutes with nothing concerning happening to the child during that time. I was happy to take in the car and that is what I did.

Mum was still concerned and fretting about what had happened, she was obviously shaken by the whole thing, which was another factor in my decision for hospital assessment, to reassure the mother. As I drove up to the hospital, she kept on saying

“Are you sure that she is ok?”

“She seems to be sleepy, is that ok?”

I reassured her all the time that it was all normal for a child who may have had a fit. She will be tired and it is okay for her to have a little sleep on the way up.

About 5 minutes after leaving the scene and about 15 minutes away from the hospital, I hear…

“Oh my God!, ITS HAPPENING AGAIN !”

I glance in the rear view mirror and see mum, panic stricken, with her daughter lying in her lap, in the throws of definite Grand Mal seizure. Oh Crap!!

“Its ok, everything is ok. It will pass, just keep doing what you are doing. Support her in your arms and make sure she doesn’t hurt herself whilst she is moving”

I said that in the best calm and reassuring voice that I have.

“I’m just going to pull over for a second and come and check on her, ok?”

I moved to the back seat of the car and could see that she was still fitting. I place a 100% Oxygen mask on her and considered my options.

I have enough equipment with me to handle the fit if it continues, that isn’t an immediate issue. However, I don’t want to be sitting at the side of the road hoping that it will pass. Ideally she should be moving towards the hospital, just in case the fit continues.

I get on the radio

“Medic999 to Red Base”

“Medic999….Go ahead…”

“Yeah, further to this case …….., the patient is now fitting in the back of the car. Could you tell me the location of the nearest available vehicle please, Cat ‘A’ response”

“Nearest vehicle is at the hospital, ETA approximately 10 minutes”

I was hoping that one of my stations vehicles would be on station, as they would have been only 3 minutes away, however, Sods law works again!

By the time all of this happened, I looked back at the girl and she had now stopped the seizure activity and was now post ictal. At least I didn’t have to medicate her to stop the fit!

But, I now have a history of 2 fits in 40 minutes, this time with no evidence of a febrile cause. She still didn’t feel hot to touch and her blood sugar was normal. I am now concerned that she may fit again, and possibly move into status epilecticus.

And we are back to another dilemma…

You are stuck at the side of the road, 15 minutes from hospital (10  mins with lights and sirens). The closest ambulance is 10 minutes away. The patient has stopped fitting but now you are more than a little bit worried…..

What’s your next move, what would you do?

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Responses

  1. … Ack! Why'd she have to go and do that! You've got me now.Assuming she's post-ictal, and vitals are OK;Instinctually, I'd say attach the kid to the monitor (cardiac, spo2, bp, temperature, the works…), leave the 100% O2 on, and rendezvous with the ambulance, “Cat A” Response, @ 5 minutes away. (Have them respond Cat A from the hospital to a predetermined midpoint for a transfer…)… I think.

  2. Err, let me correct. I'd have them respond to your original location along a predetermined route…Here's why;If she fits again, and requires medication, you will be X minutes closer to the hospital, WITH an ambulance en route.If she doesn't, you meet on time (5 minutes) with your ambo at the midpoint.

  3. errrr, well, probably swear under my breath. get a cat a ambulance, monitor her while awaiting ambulance.

  4. Speaking as a layman, I would continue towards the hospital and try to get the ambulance roling from the hospital to try to head you off. That way if you need to stop and treat you will be that much closer to the ambulance and hospital. It not, you can either transfer when you intersect with the ambulance or get it to follow you the rest of the way. Either way I think that I would be running with lights and sirens. You have already decided that this is a Cat A, so I think that would be a given.Easy enough to make decisions sitting on my sofa at home, much harder to do under pressure at scene.I am interested to know what you decided to do.

  5. … Ack! Why'd she have to go and do that! You've got me now.Assuming she's post-ictal, and vitals are OK;Instinctually, I'd say attach the kid to the monitor (cardiac, spo2, bp, temperature, the works…), leave the 100% O2 on, and rendezvous with the ambulance, “Cat A” Response, @ 5 minutes away. (Have them respond Cat A from the hospital to a predetermined midpoint for a transfer…)… I think.

  6. Err, let me correct. I'd have them respond to your original location along a predetermined route…Here's why;If she fits again, and requires medication, you will be X minutes closer to the hospital, WITH an ambulance en route.If she doesn't, you meet on time (5 minutes) with your ambo at the midpoint.

  7. errrr, well, probably swear under my breath. get a cat a ambulance, monitor her while awaiting ambulance.

  8. Speaking as a layman, I would continue towards the hospital and try to get the ambulance roling from the hospital to try to head you off. That way if you need to stop and treat you will be that much closer to the ambulance and hospital. It not, you can either transfer when you intersect with the ambulance or get it to follow you the rest of the way. Either way I think that I would be running with lights and sirens. You have already decided that this is a Cat A, so I think that would be a given.Easy enough to make decisions sitting on my sofa at home, much harder to do under pressure at scene.I am interested to know what you decided to do.

  9. UUuuggh!! I shoulda seen this coming; didn't expect part two!O.K. we now have a seizing patient with an anxious mom…that now makes one real patient and a potential patient.Continuing further is now OUT unless we make the patient managable. If the child starts to seize again, there is risk for traumatic injury to herself and mom and not to mention the most important…hypoxia.Get the transport unit enroute to your location most rikky tick, while you establish I.V. access incase this happens again. O2 stays on, of course and we continue for rondevous with transport unit. By this time they are most likely either there or very close by.(Now kicking myself in the arse for not seeing this coming)

  10. I'd agree with @scottthemedic – if she's now stable, I'd run to hospital with the van running towards you. There's a paramedic with the patient (you) in case things kick off again, and it minimises the time until she's at the hospital.

  11. Now, I'm not a medical professional, but I have to admit that at this point, I'm limited in treatment options. Obviously the best thing to do is to get this kid to definitive care ASAP. I'd probably arrange for the truck to make their way to my position along a common route and proceed along that route to them myself. As soon as we meet up, the patient goes on board the truck. At least then if I have to stop again, they're still en route to me.

  12. At this point, you are in the proverbial rock located close to a hard place. Transport was and still is a good choice (and the only one at this point). You bring up many of the concerns transporting in the RRC to hospital. The best option would be an intercept. Have the closest unit respond high priority towards you as you begin to transport to the hospital. While the overall transport time will be the same, the time to a more conducive environment to work the patient will be reduced by half (in theory).

  13. BF&B! Beat feet and boogie! Start whatever interventions are indicated by your protocols then scoot to the hospital! If you wait there for 10 minutes for the ambo, then there will be ten more minutes BACK to hospital plus scene time. The fastest thing to do now is stabilize and transport in the RR car.IMHO!!

  14. This patient needs to be seen in the ED ASAP. I would recommend traveling code three to the hospital and request the ambulance standby should this patient decide to fit again and u have to manage them. As this patient is coming out on their own I don't see status being a problem as of yet.

  15. I'd say stay where you're at and have the ambulance respond. I always error on the side of quality care over speedy transport. Unless of course there is something the hospital can do that you can't.

  16. I'd go ahead and get some O2 going, plus start an IV and apply the cardiac monitor. Move closer to the rendezvous with the ambulance if possible, but definitely get some interventions going.

  17. Keep driving to the hospital. Based on what has transpired, the hospital is what the child needs.

  18. Keep driving to the hospital. Based on what has transpired, the hospital is what the child needs.

  19. If vitals appear WNL and there are no further interventions indicated at this time, diesel bolus… or in this case patrol. Run the kid in code 3 by car with the ambulance rolling to intercept.

  20. Your patient has had what sounds like a very brief siezure and is now post-ictal and recovering. What happens if you drive towards the hospital or to rv with the crew and she fits again!? she has already had 2 seizures within the space of 40 mins, so it would be unwise to transport her yourself. you have once already put yourself, other road users, the patient and her mother at a higher risk by stopping on the carrigway ,splitting your attention between the task of driving and keeping an eye on the patient and reasuring her mother. My actions would have been:In the first part of the scenario, request a crew cold response and wait on scene. in the above case, assuming you have stoped in a safe place:Ensure ABC are intact, re examine the patient and attempt to identify a cause for the seizure. Cannulate the patient while she is still post-ictal.Ensure you have your drugs close to hand (diazamuls appropriate dose for pt. calculated and drawn up). Wait for crew and montitor. keep the crew responding cat A.when back on station, compleate your accident/incident form.

  21. Your patient has had what sounds like a very brief siezure and is now post-ictal and recovering. What happens if you drive towards the hospital or to rv with the crew and she fits again!? she has already had 2 seizures within the space of 40 mins, so it would be unwise to transport her yourself. you have once already put yourself, other road users, the patient and her mother at a higher risk by stopping on the carrigway ,splitting your attention between the task of driving and keeping an eye on the patient and reasuring her mother. My actions would have been:In the first part of the scenario, request a crew cold response and wait on scene. in the above case, assuming you have stoped in a safe place:Ensure ABC are intact, re examine the patient and attempt to identify a cause for the seizure. Cannulate the patient while she is still post-ictal.Ensure you have your drugs close to hand (diazamuls appropriate dose for pt. calculated and drawn up). Wait for crew and montitor. keep the crew responding cat A.when back on station, compleate your accident/incident form.

  22. I saw it coming – you wouldn't have posted it otherwise! It's why I always tell my responders to call an ambulance rather than transport themselves – what if they do it again when you are halfway to the hospital? And if I do call an ambulance and you respond – then it's your problem, not mine!I think that you have to stay where you are now and wait for the vehicle. You can currently manage the patient in the back of your car, but if she fits again while you are driving on blues and twos, you'll have to rely on the mother to manage the airway until you can park safely, and driving with one eye on the mirror while you look for a safe place is a recipe for disaster. And if the weather is anything like today, there's no guarantee that you'll actually be able to find a place to stop (mind you, there's also no guarantee how long it will take the ambulance to reach you).Thanks for posting this one – it's always good to try second guessing someone from the safety of your computer.

  23. I'm a bit confused by this. Of course there are things hospitals can do that can't happen out on the road… Speedy transport, in the right situation, IS quality care, and quality care providers know their limitations.

  24. No doubt in my mind: stay exactly where you are and wait for backup. You are not going to be able to manage this girl's airway and drive at the same time, and, unless she is fully awake, she has a potential obstruction. You cannot observe her in the back of the car, and by now Mum will be a bag of nerves, and apt to make you crash the vehicle at every movement of her child. This may be a febrile convulsion (number two) but why is she febrile? Is this meningococcal septicaemia? Get obs on her, get O2 on her and sit tight. You can manage her perfectly well where you are (possibly not as easily as if you were in the nursery, but I missed my chance to have my say on part 1…)

  25. I'm a bit confused by this. Of course there are things hospitals can do that can't happen out on the road… Speedy transport, in the right situation, IS quality care, and quality care providers know their limitations.

  26. No doubt in my mind: stay exactly where you are and wait for backup. You are not going to be able to manage this girl's airway and drive at the same time, and, unless she is fully awake, she has a potential obstruction. You cannot observe her in the back of the car, and by now Mum will be a bag of nerves, and apt to make you crash the vehicle at every movement of her child. This may be a febrile convulsion (number two) but why is she febrile? Is this meningococcal septicaemia? Get obs on her, get O2 on her and sit tight. You can manage her perfectly well where you are (possibly not as easily as if you were in the nursery, but I missed my chance to have my say on part 1…)

  27. I couldn't make up my mind before, but it's easy now. The mother will never in a million years believe you if you tell her that everything will be fine for the 10 minutes it will take you to get her to the ER in the car, and that she shouldn't worry at all that you're using lights and sirens this time! You'll have a questionably patient and a hysterical mother in a very small car, all while trying to drive emergency. Not my idea of a good time. Pull into a safe spot, initiate care, and wait it out.

  28. Well I hate when that happens. You can have 20 of these with not one issue but the 21st is the one that will jump up and bite you in the ###. First It is not safe to try and monitor the patient and the road at the same time. Second what would you do if you showed up at the patients house and they had just had 2 seizures in the last hour; you would stop and treat the patient the same as if it was a passenger in a car that seized on the side of the road. Your position of being a single medic waiting for transport is not unusual to a lot of us on the East coast of the US. You manage what is going to kill the patient the fastest hypoxia and airway obstruction. You have the tools to manage that and the drug to stop the seizure. The chance that the patient has a AVM or meningitis are far lower than the chance of hypoxia, hypercarbia, airway obstruction and aspiration are. You can fix those problems for 10 min. If this was your case don't beat yourself up, things happen, you do your best with what you have and move on. If only I could get some of my demons to listen to that advice I would not have as much anxiety when the pager goes off or occasional trouble sleeping at night.

  29. Well I hate when that happens. You can have 20 of these with not one issue but the 21st is the one that will jump up and bite you in the ###. First It is not safe to try and monitor the patient and the road at the same time. Second what would you do if you showed up at the patients house and they had just had 2 seizures in the last hour; you would stop and treat the patient the same as if it was a passenger in a car that seized on the side of the road. Your position of being a single medic waiting for transport is not unusual to a lot of us on the East coast of the US. You manage what is going to kill the patient the fastest hypoxia and airway obstruction. You have the tools to manage that and the drug to stop the seizure. The chance that the patient has a AVM or meningitis are far lower than the chance of hypoxia, hypercarbia, airway obstruction and aspiration are. You can fix those problems for 10 min. If this was your case don't beat yourself up, things happen, you do your best with what you have and move on. If only I could get some of my demons to listen to that advice I would not have as much anxiety when the pager goes off or occasional trouble sleeping at night.

  30. Fastest and easiest thing to do is to drive as quickly and safely as you can with hazard lights on all the way to the hospital. If you wait for the ambulance you kill 10 mins waiting for the ambulance to transport, then its another 10 mins back in the ambulance (20 mins) by all rights your 15 mins from the hospital, go as quick as possible.

  31. Fastest and easiest thing to do is to drive as quickly and safely as you can with hazard lights on all the way to the hospital. If you wait for the ambulance you kill 10 mins waiting for the ambulance to transport, then its another 10 mins back in the ambulance (20 mins) by all rights your 15 mins from the hospital, go as quick as possible.

  32. Stay right where you are and wait for the ambulance. If you had called one in the first place this would not have happened (gallows humor? LOL). You would have your hands too full continuing on, too many “what ifs”. ABC,s, O2, protecting patient, reassuring Mom, keep gathering history, and soon your ambulance will arrive.

  33. If you’d had a CFR with you, that would have been problem solved! The CFR could have been in the back doing visual obs all the way. Mind you, we’re not allowed to do kids under any circumstances.

    Whilst the chance of another fit in 15 minutes is low, I think it’s time for throwing in the towel and waiting for an ambulance.

    And no, I haven’t peeked at the “answer”.

  34. There is nothing different that a hospital would do for a status seizure that I can't do as a paramedic in the field.

  35. There is nothing different that a hospital would do for a status seizure that I can't do as a paramedic in the field.


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