Our Paramedic, Rachel recalls a recent experience when reflection was essential. With her partner and a paramedic student, she was called to a gentleman who’d had 3 falls in 24 hours and his family were quite rightly concerned. He seemed alert and chatty, aware of what was going on and able to answer questions. On examination he had low blood sugar (corrected quickly with food/drinks) and his temperature was reading LO (low meant under 34 degrees) but with no obvious reason other than the low blood sugar; the house wasn’t cold and he was suitably dressed. Although his blood sugar increased to a normal range, his temperature still read LO. This affected the crew's ability to get an accurate oxygen level reading as his fingers were too cold. The patient was cannulated at the scene.
On the way to hospital, with the patient wrapped up like a burrito in foil and blankets and sleeping peacefully, Rachel became concerned about a couple of really tiny changes to the observations and stood up to check a few things. The patient suddenly roared loudly, threw his head back, went rigid, turned purple and stopped breathing.
Driver alerted, the ambulance pulled over and the other crew member jumped in the back. Rachel had laid the patient flat, put an OP airway in, got oxygen on, and was using the BVM to breathe for the patient. The student was monitoring the pulse and BP. A 12 lead ECG was carried out quickly. The patient was breathing at around 6 breaths per minute so still needed respiratory support. But, there were no clues as to what had caused this ‘seizure’ and respiratory arrest. The hospital was alerted and the patient taken straight to resus. Much later on, the crew found out that the seizure had been caused by an undiagnosed brain condition that couldn’t have been discovered prehospital.
Afterwards, the two crew and the student took a few minutes to reflect and talk through the job step by step. It was a very dramatic and dynamic development in a short space of time. Everything had happened so quickly and they needed to make sure everything that could have been done was done. It was also the first time the student had experienced a patient deteriorating so rapidly to this extent when she had carried out the examination, taken his history, and been chatting and laughing with the patient and his family, creating a great rapport in the house.
Not knowing the cause, our conclusion was that whatever had happened, it couldn’t have been anticipated (this was confirmed by the final diagnosis), though the attention to monitoring and seeing those minute changes en route had indicated that things were starting to happen a minute or so before the seizure, which was good.
The crew acted quickly and worked well together to secure the ABCs and rule out anything acutely cardiac which could have meant a different pre-alert and different destination at the hospital. So from a clinical perspective, it was felt that everything that could have been done was done.
From a more emotional perspective, it was a huge shock. Feelings are important. The student talked about how she’d never experienced anything like this before and found it upsetting that she’d had such a good relationship with the patient and then experienced such a sudden and dramatic deterioration. It worried her because she hadn’t seen the warning signs and didn’t know what to do. She remembered freezing for a few seconds and felt she had been slow to check his breathing when instructed to.
So a discussion around expectations and her stage of training followed, as it’s important to learn rather than lose confidence. It was also one of those jobs that you will never forget, so if someone presents in a similar way, you’re likely to be on high alert and have suspicions.
Rachel and her partner had also been surprised by the speed and severity of the situation, and the need for an instant reaction without knowing the cause. All agreed that it reiterated the importance of ABCs as that’s what got the patient to hospital. For the student, it also reinforced the need for cannulation if there’s even a tiny suspicion that you might need it later - in this case Rachel cannulated basically because she didn’t know why the patient was so hypothermic with no real reason, and it didn’t improve even when his blood sugars did. Her ‘Spidey Sense’ was tingling! Trying to get a line in when your ABC isn’t secure is a problem you could well do without and that was a valuable lesson.
The reflection in this case meant that all three crew who attended could analyse the job at every stage and consider whether their response individually and as a team was appropriate and fast enough. It allowed a decompression time to talk about how it had made them feel, and how that was different for each person due to personality, job role, relationship with the patient and role in the emergency. The learning points for all 3 were different too as they are all at different stages of their careers, with different levels of experience and viewing it from a different perspective.
