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Prehospital (Mis)Management of Status Subtle Seizures
Let it be stated that I am a lowly Paramedic Intern. Yes, I realize that I am not "experienced" as most Paramedics who have been on the street would define it, but I do have critical care experience: The transport of critically ill and injured people is a job I do on a regular basis as part of a multidisciplinary flight team. And yes, I understand what my preceptor says must go on the ambulance. But I have to say the amount of horror and powerlessness I felt at this is something I have to write about.
This call is one of the last three calls that I have to accomplish as part of my Pre-NREMT Internship for my Paramedic. We responded to a 45 year-old AAM as a man down, LEO first responders on scene with patient unresponsive. While en route, we were informed the patient had a 30 second grand mal seizure. Granted, it was very hot and humid outside, so heat illness was one differential we were considering, among others. Upon arrival, we found the patient unconscious on the left side, with drool coming from the mouth. Airway inspection found the airway to have an intact gag reflex, with no RSI on hand to manage airway, with adequate ventilation. The patient was limp. He had no medical history of seizures, only of hypothyroidism and hypertension. The paitent had no evidence of trauma. The patient was immediately placed on 15lpm NRB and placed in the unit. Large bore IV access was achieved and a bolus was started due to borderline blood pressure. BGL was WNL. It was at tht time, I noticed facial tetany and a left disconjugate deviated gaze with nystagmus. I informed my preceptor, and he disreguarded it, and the episode lasted for thirty seconds, and for about a minute he returned to his unresponsiveness. While evaluating his cardiac rhythm, he had another one. And then another one. I requested valium/versed to administer for the subtle seizure. My precptor informed me no, that he wasn't having a seizure. I asked to go to the nearest facility, in hopes they would believe me and load him with Ativan/Versed and an Anti-Convulsant such as Phenobarb or Cerebryx, or fly him to an ICU capable facility. He refused. We transported this man by ground emergency for 45 minutes to the nearest level 3 facility. He was in status subtle seizure the whole way.
His report never once mentioned the behavior I pointed out. While I pulled the nurse aside and informed her of the situation, he began to have a major fgrand-mal seizure that lasted two minutes before 2mg of Ativan finally controlled it, and he was loaded with 15mg/kg of Phenobarb. This is Day +2 now, and he still remains in ICU in a coma. I was so mad, I had him sign my paperwork and left when I got back because I was uncomfortable finishing the shift with him.
Was I wrong here trying to push for this? I realize that I am the "Lowly Student", but what he was having was unmistakable.
How would you have managed this in the field? Would you have disreguarded it as just another excited student?
This call is one of the last three calls that I have to accomplish as part of my Pre-NREMT Internship for my Paramedic. We responded to a 45 year-old AAM as a man down, LEO first responders on scene with patient unresponsive. While en route, we were informed the patient had a 30 second grand mal seizure. Granted, it was very hot and humid outside, so heat illness was one differential we were considering, among others. Upon arrival, we found the patient unconscious on the left side, with drool coming from the mouth. Airway inspection found the airway to have an intact gag reflex, with no RSI on hand to manage airway, with adequate ventilation. The patient was limp. He had no medical history of seizures, only of hypothyroidism and hypertension. The paitent had no evidence of trauma. The patient was immediately placed on 15lpm NRB and placed in the unit. Large bore IV access was achieved and a bolus was started due to borderline blood pressure. BGL was WNL. It was at tht time, I noticed facial tetany and a left disconjugate deviated gaze with nystagmus. I informed my preceptor, and he disreguarded it, and the episode lasted for thirty seconds, and for about a minute he returned to his unresponsiveness. While evaluating his cardiac rhythm, he had another one. And then another one. I requested valium/versed to administer for the subtle seizure. My precptor informed me no, that he wasn't having a seizure. I asked to go to the nearest facility, in hopes they would believe me and load him with Ativan/Versed and an Anti-Convulsant such as Phenobarb or Cerebryx, or fly him to an ICU capable facility. He refused. We transported this man by ground emergency for 45 minutes to the nearest level 3 facility. He was in status subtle seizure the whole way.
His report never once mentioned the behavior I pointed out. While I pulled the nurse aside and informed her of the situation, he began to have a major fgrand-mal seizure that lasted two minutes before 2mg of Ativan finally controlled it, and he was loaded with 15mg/kg of Phenobarb. This is Day +2 now, and he still remains in ICU in a coma. I was so mad, I had him sign my paperwork and left when I got back because I was uncomfortable finishing the shift with him.
Was I wrong here trying to push for this? I realize that I am the "Lowly Student", but what he was having was unmistakable.
How would you have managed this in the field? Would you have disreguarded it as just another excited student?
Tags: mismanagement, paramedic, seizures, student, subtle
Replies to This Discussion
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Permalink Reply by Tom Bouthillet on -
Of course I would have listened, and been very happy that you communicated the observations. The case you describe is exactly why EMS needs training in Crew Resource Management. There's so much we can learn from aviation, but I don't know what the cure is for insecurity. It's tough to deal with.
Tom
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Permalink Reply by Ben Waller on -
Ego is a poor alternative to patient assessment.
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Permalink Reply by Kay Vonderschmidt on -
Pt assessment includes looking at the eyes, especially if the patient is suspected to be post-ictal/unconscious. Your assessment as explained above does indicate the patient was continuing to have seizure activity. Please remember not all paramedics (both student and preceptors) are educated/experienced alike. Everyone on the TEAM has something to contribute to patient care at all EMS providers level. No one is a "lowly" anything. It sounds like you have had a great education/experiences so far in your EMS profession - keep up the good work.
As for patient outcomes....you say that he is still in ICU and in a coma....what are some other diffs???
Stroke, Head bleed, toxins, ......
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Permalink Reply by Robert Sullivan on -
This is a great example of how we isolate EMS from similar disciplines that we can learn from. I never learned in my paramedic class that a deviated gaze could be a seizure, and your preceptor probably didn't either. You've probably seen how this is managed several times in a critical care setting, but did your paramedic program specifically discuss this? This would be a great topic to research and do a con-ed session on. But what do we do? Say that nurses don't know what they're doing because they only listen to doctors and other such nonsense.
To give a simple answer to your question, this is a good time to use medical control. Hopefully you can call the hospital your transporting to, since they will be the ones assuming care. One of my mentors simply put: "Don't make any thing more complicated than it needs to be. See X, do Y. If you see X and don't know what to do, call the doc." Of course education and critical thinking will decrease the need for this, but even ER docs have specialists to call.
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Permalink Reply by dr-exmedic on -
Robert Sullivan said:
Of course not, there isn't enough time to discuss atypical presentations in a NSC-based class. I still meet plenty of people who won't start chest pain protocol or at least consider a 12-lead on people who aren't having chest discomfort, but are having dyspnea, N/V, syncope, AMS, etc. (Altered mental status is actually the leading presentation of AMI in people over 70. But I digress.)I never learned in my paramedic class that a deviated gaze could be a seizure, and your preceptor probably didn't either. You've probably seen how this is managed several times in a critical care setting, but did your paramedic program specifically discuss this?
One of my mentors simply put: "Don't make any thing more complicated than it needs to be. See X, do Y. If you see X and don't know what to do, call the doc."
The trick--and not everyone in EMS has figured this out yet--is to, as Einstein said, "Make everything as simple as possible, but not simpler." Oversimplifying can be just as bad as overcomplicating; it's a fine line.
Good catch by the OP, though. Too bad the preceptor didn't agree.
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Permalink Reply by blair4630 on -
We don't have 12-leads because we're in the city and we're "too close to the hospital". I've argued this point many times to many people....when our very busy ED is overcrowded already, the question isn't about the 5 or less minutes it took to take them there, it's how long are they going to sit before that atypical presentation will get them one of the two EKG machines and discover that AMI they've been sitting in the ED with.</<br /> dr-exmedic said:Robert Sullivan said:Of course not, there isn't enough time to discuss atypical presentations in a NSC-based class. I still meet plenty of people who won't start chest pain protocol or at least consider a 12-lead on people who aren't having chest discomfort, but are having dyspnea, N/V, syncope, AMS, etc. (Altered mental status is actually the leading presentation of AMI in people over 70. But I digress.)
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Permalink Reply by Joshua Todd on -
Im glad someone agrees we need to adapt CRM to ground EMS.
Tom Bouthillet said:Of course I would have listened, and been very happy that you communicated the observations. The case you describe is exactly why EMS needs training in Crew Resource Management. There's so much we can learn from aviation, but I don't know what the cure is for insecurity. It's tough to deal with.
Tom
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Permalink Reply by Ben Waller on
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One of my former employers had a 12-lead and field thrombolytics program that included standing orders to do the 12-lead and start the protocol, regardless of transport time/distance. The last time I checked the stats, door-to-intervention time was negative 21 minutes 95+ percent of the time the protocol was used.
The recieving facility's cardiologists had the philosophy that we could reperfuse the patient in the field more quickly than the hospital could work the patient up. Most of the time, they were right.
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Permalink Reply by Chance Gearheart on -
Suprisingly enough, his CT and BMP were negative, along with his tap and UDS. They were going to run an MRI and an EEG, as well as a more complete metabolic study. They're thinking he either has a new-onset lesion/tumor, or that he possibly has an intercerebral hemorrhage or some kind of metabolic disorder. As for toxins, he was working in the yard when last seen, so there is a possibility of some chemical exposure, but he didn't fit the SLUDGE toxidrome for pesticides. There was no evidence of any insect or reptile bite. He also didn't seem to fit in with the picture of a viral or bacterial illness, and family said he hadn't been sick. The one thing I did think about, though, was an overdose of hypothyoridism medication resulting in a thyroid storm, but his EKG, temperature, and overall physical appearance during assessment didn't really impress me as that. Honestly, had we had RSI, I would have tubed him, as I was severly concerned about his ability to maintain his airway when he was post-ictal.
@Joshua - I agree. The ability to have a specialized crew in an EMS system, or to utilize crew resource management is much more important than following the traditional team leader-patient care provider model in a resuscitation situation or complex condition such as this.
@Robert - Our Paramedic program didn't touch on subtle seizures or partial motor except to explain what they were, and that was only 15 minutes on each. Programs like AMLS, STABLE, and Wilderness EMT/Paramedic are much more helpful. (It's funny how an adult subtle seizure can mimic a neonatal seizure).
Kay Vonderschmidt said:Pt assessment includes looking at the eyes, especially if the patient is suspected to be post-ictal/unconscious. Your assessment as explained above does indicate the patient was continuing to have seizure activity. Please remember not all paramedics (both student and preceptors) are educated/experienced alike. Everyone on the TEAM has something to contribute to patient care at all EMS providers level. No one is a "lowly" anything. It sounds like you have had a great education/experiences so far in your EMS profession - keep up the good work.
As for patient outcomes....you say that he is still in ICU and in a coma....what are some other diffs???
Stroke, Head bleed, toxins, ......
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Permalink Reply by Jerry on -
Blair, IMHO, we have done this to ourselves; we are the ones that keep bringing up "transport time" when what we should be talking about is time from "at patient" to "transport complete" Add the DRIVING time to the patient contact time and your argument becomes closer to 30 minutes vs the 8 to 10 minutes of drive time in "major cities." Look back at your time on task and see if this isn't a better reflection of time to treatment. . .
Additionally, from set up to completion, a 12-lead should "add" approximately 60 - 90 seconds; we all know that there is that time on nearly "any/every" scene.
blair4630 said:We don't have 12-leads because we're in the city and we're "too close to the hospital". I've argued this point many times to many people....when our very busy ED is overcrowded already, the question isn't about the 5 or less minutes it took to take them there, it's how long are they going to sit before that atypical presentation will get them one of the two EKG machines and discover that AMI they've been sitting in the ED with.</<br /> dr-exmedic said:Robert Sullivan said:Of course not, there isn't enough time to discuss atypical presentations in a NSC-based class. I still meet plenty of people who won't start chest pain protocol or at least consider a 12-lead on people who aren't having chest discomfort, but are having dyspnea, N/V, syncope, AMS, etc. (Altered mental status is actually the leading presentation of AMI in people over 70. But I digress.)
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Permalink Reply by Nick Eubanks on -
I think treatment for the seizure activity would have been appropriate with physician approval/consult. Would haved used caution administering Benzos with borderline BP (small incriments). Good call.
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Permalink Reply by JB Wallace on
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It certainly is frustrating to be paired with a medic who "knows it all" and won't consider other opinions. It took me a long time to recognize those subtle signs of seizure activity for what they were, but that's why continuing ed is a must for all of us.
You were between a rock and a hard place here and really had no options. If it makes you feel any better, the damage had probably already been done and controlling the seizures may not have significantly changed the outcome.
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