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IDrago

IDrago

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Recently we had a transfer for a pt who had a seizure earlier in the day. She was being transferred for eval at an urgent care about 20 minutes away. Pt was A/O x 4 denied dizziness, nausea and pain throughout transport. Had a Hx of epilepsy, htn, dm, hyperlipidemia and COPD. About 16 minutes into transport the **** hits the fan and she begins to have a seizure. So I lay the gurney flat, hold her head, and yell at my partner to upgrade to code 3. She was convulsing for about 3 minutes and then stopped but her jaw was still clenched and she was very rigid. I attached an NRM at 15lpm but I couldn't head tilt chin lift and definitely couldn't jaw thrust. So I grabbed her right shoulder and rolled her on her left side as best I could. About that time we arrived at the urgent care and got her in a bed immediately.

I've been working in BLS for almost a year and this was my first real "oh ****" call. That being said I wanted some feedback on what you all would have done and if there is anything that I could of done better. Thanks
 
You could of transport your patient to the ER and called for ALS. Did you get a bgl ?
 
JohnTheEMT said:
You could of transport your patient to the ER and called for ALS. Did you get a bgl ?
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BGL was 118 about an hour prior to us arriving on scene according to the SNF. I suppose I should of asked them to check it again in front of me. We decided not to divert to the ER or call for ALS on route as we we're only about 3-4 minutes out and the nearest ER was about 8 minutes out.
 
Those can be scary... Careful about holding the head of a seizure pt, better to just clear the area of anything they could hurt themselves on; if their head is the only part not moving, it's essentially the same as if their head was the only thing moving.


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One of the best pieces of advice I've heard about seizures is that "people with seizure histories seize." It sounds simple, but it's easy to freak out and panic when we see a patient suddenly suffer from generalized seizure activity in our presence. We're not there to see seizures themselves all that often, and they can certainly be dramatic. An old ER doc who taught me in paramedic school used to say that when he had a known seizure patient start to seize in his presence in the ED, he would amble away, get a cup of coffee, go talk about the latest baseball scores by the water cooler, then wander back in to the patient's room. If they were still seizing at that point, he figured it was probably time to intervene. A bit tongue in cheek and exaggerated, but you get the point.

This patient is a known epileptic and most likely medicated for it. She had a seizure earlier in the day, and clearly recovered just fine and was fully conscious, alert, and conversing with you appropriately. Three minutes isn't a terribly long seizure, and the fact that she recovered well from the previous one after an indeterminate post-ictal period hopefully means she will do the same this time. All that being said, I'd still divert to an ED and contact ALS depending on time. An extra 3-4 minutes transport time is not worth going to a doc in a box vs. a real ED. Urgent care facilities likely will need this patient transferred out, and will certainly be the wrong place for the patient if she seizes again.
 
Not surprising a patient with a known seizure history had a seizure, and no, three minutes is not a terribly long seizure. Most seizures will self-terminate in one to five minutes. Most patients who have a seizure will also have a classic post-ictal period, some do not, some have a "bad" one.

An isolated, self-terminating seizure is not a great concern, there are lots of people out there with known epilepsy who seize daily, or weekly, and are managed in the community by their parents or caregivers without the ambulance service ever being involved.

You did exactly what I would have done.

A good tip I have heard when estimating the length of a seizure when you first get there (if the patient is seizing) is to remember it takes two minutes for the job to go through Control, then the ten minutes it took you to drive there, plus the one minute it takes you to park the ambulance, get equipment out and rock up to the scene, so that's fifteen-odd minutes the patient has been fitting.
 
Im just curious as to why you decided to go to the urgent care over the ED?
 
CALEMT said:
Im just curious as to why you decided to go to the urgent care over the ED?
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I was wondering the same thing. Especially in a patient with multiple co-morbidities.

Either they don't need to go anywhere because they have a known seizure history and recovered from the earlier one just fine, or an infection or something is suspected, in which case they are best seen by someone familiar with their history.
 
CALEMT said:
Im just curious as to why you decided to go to the urgent care over the ED?
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My partner was unfamiliar with the area and stopping to check Google maps (our rigs aren't equipped with reliable GPS systems) to find the nearest ED was out of the question in my mind. Being that we we're 3-4 minutes out I figured better to get the pt to a higher level of care than delay care another 10mins or so.
 
Urgent Care is higher level of care?

Maybe we have different definitions of an Urgent Care facility....ours are typically Doc in a Box...handle all the minor stuff which clogs an ER normally or offers "sick call" for after hours of your normal primary care doc or weekend hours.
 
akflightmedic said:
Urgent Care is higher level of care?

Maybe we have different definitions of an Urgent Care facility....ours are typically Doc in a Box...handle all the minor stuff which clogs an ER normally or offers "sick call" for after hours of your normal primary care doc or weekend hours.
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A higher level of care than we are, a BLS crew of 2 EMTs? Yes absolutely. in any case it isnt your typical shoebox urgent care. Its closer to a community hospital than an urgent care.
 
I would have chosen NOT to upgrade to Code 3 travel, kept the patient safe, and known for certain that the receiving facility was capable of properly evaluating this patient... otherwise I would have diverted to the hospital-connected Emergency Department as that facility is highly likely able to properly evaluate the patient and/or care for the patient until an appropriate transfer to a facility that can handle neuro problems can be arranged if they cannot properly care for such a patient. Unless that Urgent Care Center is designated as an EMS receiving facility, I wouldn't have transported the patient there anyway. I would have told the patient you can sign my AMA form and find someone to take you there because I won't... now if the UCC is designated as being able to receive EMS patients, then I'd certainly transport there and advise them that the patient likely needs to be transferred to another facility as this is now the 2nd seizure of the day in a patient that probably doesn't have multiple seizures daily.
 
IDrago said:
A higher level of care than we are, a BLS crew of 2 EMTs? Yes absolutely. in any case it isnt your typical shoebox urgent care. Its closer to a community hospital than an urgent care.
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But can they properly care for your patient?
 
In most places, you cannot transport a patient to an urgent care unless it's a scheduled transfer. If you're transporting emergent, odds are you should not be transporting to an urgent care.

We actually have the ability to transport to our local urgent cares but there is no way we would take a sick patient there.
 
Hey IDrago,

Interesting story and thanks for sharing for some insight from the more experienced providers here in the forum. It takes a lot to share your story and actions in the spirit of M&M or Grand Rounds and that does not go unnoticed by a lot of folks here.

As has been said a million times before, anyone can Monday Morn QB a call to death and you should not take any criticism you see here as an attack on you. You will meet (or read) a lot of providers in EMS, and as you probably know, you take the good and leave the rest.

Not knowing your area and how your operations differ from what I am used to, I will spare you the comparison. Some of the shnier pearls of wisdom here are the comments from Chaz, SpecialK, and Akulahawk. The important thing is pt safety. I would agree not to try and secure the head or anything, just pad and assure no further injury. As stated above, seizures are far scarier looking then they usually are(trauma and poisoning notwithstanding) and when they occur in a pt with a seizure HX...even more so. Airway is a primary concern and you addressed that. The urgent care piece is the call you made and not wrong according to your reasoning at the time. Given the more in depth information provided here you may choose to act differently in the future. For the most part, good job. Remain calm, ABC's and protect the pt.

For me, call reviews (of which this is not but sort of is i guess lol) often miss some of the logistical angles associated with call management. I would look to address your partners and your, familiarity with the area so that you might better be able to respond and decision make with the most accurate information, which would include knowing where the nearest ED was. That would be a good start for improvement.

I would also do a bit of research on seizures from places like the Epilepsy Foundation and other organizations that have great quick trainings for laypersons and providers on seizures. Most epileptics have seizures and most seizures do not require ambulance response. That is valuable context for you in case you ever get another pt. You may also want to revise your transfer procedure as a provider. As you mentioned, a BGL would have been most appropriate in a post seizure pt as the the previous level was obtained +1hr. An evaluation of the pts overall condition might have also revealed a clue to you that the transfer might have needed to be ALS. It may not have. But in any case, review your actions, plan any changes, and file away for the next one.

Keep it up.
 
Thank you all for the feedback. I made what I thought at the time was the right call but I still had the feeling that I could have done something different that could of improved the outcome. This is definitely a call I'm going to remember. Except next time I'm going to better prepared for it. Thanks again
 
What did the doctor at the Urgent Care say about the call and decision to continue to the UCC and not to divert to the ER? That'll be the biggest learning point I think.

Sounds like this was a pretty arranged transfer where the UCC was called by the SNF and already accepted the patient for post seizure care, and was already expecting your arrival? If so then you're probably fine, but my $.02 for takeaway would have been to clarify any plan with the sending facility for a seizure enroute, if they didn't have one, call the receiving facility yourself and ask if the doc would want you to continue in and divert.
 
Just as an aside, if you are two EMT"s, both able to drive the rig and you know the area it takes less than a minute to swap out and then you drive to the ER
 
Jim37F said:
What did the doctor at the Urgent Care say about the call and decision to continue to the UCC and not to divert to the ER? That'll be the biggest learning point I think.

Sounds like this was a pretty arranged transfer where the UCC was called by the SNF and already accepted the patient for post seizure care, and was already expecting your arrival? If so then you're probably fine, but my $.02 for takeaway would have been to clarify any plan with the sending facility for a seizure enroute, if they didn't have one, call the receiving facility yourself and ask if the doc would want you to continue in and divert.
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I cannot imagine any urgent care being real stoked about getting an emergent ambulance to their facility...
 
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