Invasion of the Body Snatchers

So here I was, just after my last post and thinking I knew what I was going to write-up next.  Of course, I spent days running around as always (This class is taking more time than some in the past) and a couple weeks passed by.  Then, two duties ago, we had us a “blog worthy” winner.  I got a really nice comment on the last post about the covering the interventions here…so, I’ll have to cover the other end of the spectrum…

It was a Thursday night, which meant two things were for sure:  We were hoping for a quiet night so we could go to work in some semblance of a rested state on Friday, and there was no way we were going to get any sleep.  The unit was the usual suspects, Wayne, Cat and I and we had earlier run a call for something or another, and heard the neighboring unit come into our due for seizures.  Our engine crew went to support them, and they were gone quite a while.  In the end, I saw that the call was a refusal, so when we got back from the ER, I asked them about it.  The guys told me that the patient was a guy who had a history of seizures, questionable compliance with his meds, and was pretty out of it when they got there.  Thing was, he kept saying “I Feel Fine, I’m okay” over and over and resisted efforts to get him checked out.  Oh yeah, and he was BIG.  I asked how much they thought he weighed, and I got, “not big fat, big ripped.”  Apparently, this was a large, muscular guy, with a loose grip on reality while they were there, who didn’t want to go anywhere.  The medic had seemed uneasy letting him stay, but ultimately got a refusal.  “Great” I think, “so much easier to leave this dude in MY due.”  I comment that we’ll likely be back later and the Engine crew agrees.

It sucks being right sometimes.  Not long after (like under an hour), we get punched to the same address…40 year old male…seizing.  Great.  I think, and probably mutter, a dark and vile curse on the previous medic as I walk over to the unit.  Cat had just laid down to bed about 15 minutes before, so I’m thinking she was just drifting off…I HATE getting calls that soon after laying down myself, so I know she’ll be feeling perky.  We head out, the engine right behind.  

As we are arriving on the scene, dispatch comes over the air and updates that the patient is now reported to be unconscious.  Dispatched asked if we’d like another unit dispatched (Unconscious calls get a medic and two support units here).  I wave that off for now, and tell dispatch that I’d advise when I saw what was going on.  I’m thinking he’s just postictal, a period of time after a seizure where the patient’s brain is basically ‘resetting’ from the electrical storm it just went through.  Patients are often drowsy, very slow to respond or react etc during this time, and sometimes when they stay out for a while families think they are even dead.  Then again, sometimes they are right, so we go in ready for either end of the spectrum.  

We enter the house and are led upstairs….back bedroom…of course.  Our engine guys weren’t lying.  In the bed was a BIG man.  He looked about 6 foot 4-5 inches, and somewhere north of 240 lbs (110 kg) and about 4% body fat.  He was unresponsive, but breathing well, and generally looking postictal as expected.  The room we were in was pretty small, with the bed the patient and an electric keyboard on it, a small nightstand with a light, an corner entertainment unit with a TV and some obviously very well used free weights on a barbell.  I notice all of this because we are having a hard time getting many people into the room to get the patient on a board to carry downstairs, and because I’m thinking that if this dude starts flailing, we are pinned in a tight area with lots of other big objects and people are going to get Hurt.  Wayne, Cat and some of the engine guys are moving pretty quick with the board and straps, but I start to notice some movement in the patient, and I start to encourage speed over pretty.  This gets me some pretty classic looks from my partners, and they make clear that no further encouragement is required.  Grin.  (Okay, so sometimes I verbalize more than I have to, good thing I’m so terribly cute doing it).  

About that time, our patient looks up, sees straps across his chest and over his arms and proceeds to remove them.  Let me be clear, he was well strapped down, with his arms under the straps and he pushed them off with very little apparent effort.  He starts to lay back down, but notices the leg straps…..”Okay, Okay, Easy, easy….we’re taking them off, you’re fine…take it easy” I start saying as I’m popping off the straps.  We missed our window to get moving, and now that he’s kinda flaying around, we are never going to be able to go down the stair in any safe way.  The straps come off, and we roll him onto the bed.  He pulls the blankets up and passes out.  Nice.  I take the blankets off of him, and he doesn’t move…yep, he’s out again.

At this point, the siege begins.  I radio out to dispatch in the midst of the strapping attempt to confirm that we don’t need the extra unit, then have them radioed later to start police our way.  Nothing has gone wrong yet, but I don’t know how violent he is going to be, but I know he has the potential from the engine crew, and while he agreed to the previous medic that he’d need to be seen if he had another seizure, I’m not sure that he’ll be okay with it.  Sometime the Police being around telling someone to go seems to motivate people.  

Okay, the aside here:  A seizure patient that has a single seizure that ‘breaks through’ their meds is not an emergency by itself.  In fact, the transport can be BLS by our protocols.  A patient having multiple seizures is ALS, and needs to be evaluated.  The issue is that seizures that occur in multiples have a nasty habit of getting closer and closer together, and may start to overlap into one long big seizure (Status).  This is bad, as often a patient is not breathing during the seizure, so the big long one leads to hypoxia, brain damage and death.  Oh, and all that muscular movement does really bad things for your blood sugar…also bad for continued existence.  So, that is why I am a little worried about this guy, and why he needs to go for evaluation.

So, as postictal patients do, he slowly starts coming back around.  As he does he is looking confused, coming in and out of responsiveness, and he keep saying “I’m okay, I feel fine”.  At first slurring badly and then slowly he starts getting clearer.  I decide to use his speech as a measure of his recovery.  Over a few minutes, Rock, (a firefighter off the engine) and I get the patient sitting up in bed, and I notice that he is rubbing his hands together in a repetitive motion, like he’s trying to dry them.  I point it out to Cat and she nods.  This repetitive motion is it self a type of seizure, called a complex partial seizure. And it goes to confirm my assertion that he needs to go for evaluation.  Rock keeps talking to him, trying to get him to come along, and I let everyone know that he is going to ‘seize’ again and when he does we’ll grab and go.  I get nods all around.  

About this time, PD arrives.  Two gentlemen arrive to the room and promptly have an “Oh shit” look appear on their face.  Told you this was a big dude.  As Rock and I keep working to talk our patient downstairs, they start talking options.  I hear the officers say things like Sergeant, and then Tazer and I start to get a little nervous.  I whole heartedly agree that if the patient decides we are a threat, that a Tazer is a good idea, but I shudder to think about what blasting the seizure patient with electricity will do to him.  More officers arrive shortly there after and I think we end up with 3-4 officers and their duty Sergeant in pretty short order.  All this time, Rock and I are doing two steps forward, one step back with the patient.  We get him sitting, then he lays down and pulls up the blankets.  We hide the blanket and get him to sit, then start to stand, but he looks at all the people and sits back down.  This repeats several times.  Finally, we switch tactics.  I ask Rock if he’s good to go with the patient, as he seems to be developing a “rapport” with him…at least while he’s lucid.  I get a nod, and I have everyone back out of the room, and get a cot down the stairs.  The Police officers back out of the hall, but there is an officer in every door along the way..just in case.  Rock starts telling the patient he needs to sit, then stand, then walk…all to show us he is okay.  After 15 min or so, he has the patient coming down the stairs, and I’m stunned.  The patient goes all the way downstairs to the cot even.

Of course, he steps OVER the cot, and gets water from the refrigerator.  I’m just happy we are downstairs.  I’ve taken the time to explain to the officers that he needs to go to the hospital, he is NOT lucid enough to give an ‘informed’ consent to refuse, and so we are stuck.  The Sarge tells me that they can’t put him in custody because he’s not actively trying to harm himself or anyone else, so they are in a jam too.  I explain that his not going is a choice that could result in his demise, but that doesn’t cut it for them.  So we are left with Rock the Negotiator.

The patient eventually sits on the cot, but will not lay back in position.  He gets a better idea of what’s up and eventually stands up and starts for the stairs.  I stand in his way,  but turn my back to him, and take the most non-threatening posture I can as I block him.  He’s still giving the “I’m okay, I feel fine” mantra, and the hand rubbing happens but has slowed, but he’s still not totally back.  I’m not too proud to say this guy could hurt me, Wayne, and Rock and never get out of his postictal state, and if the situation goes violent, we’d eventually win, but a lot of people would be hurt doing it and we do not want that.  Knowing that only his most basic mental function was working, I avoided eye contact, slumped my shoulders and stood with my back to him as I slowly moved back and forth with him…blocking the stairs.  All the while, Rock is talking and trying to work him.  I can tell though, that he has had enough, and will not be headed back to the cot.  When the patient taps me on the shoulder and says “Excuse me” I really have no choice but to move aside.  

The PD briefly block his advance up the stairs, but the Sarge steps in and has them back off too…he’s thinking like I am and we don’t want a lot of patients here.  So, the patient is back upstairs, back room, and in bed.  We are all exhausted and we’ve been here almost an hour…back to step one.  PD asks if we can knock him out, and I tell him we don’t have the meds for that, and even if we did, HE could go after that guy with a needle!!  Cat calls the ER for ideas, and is met with a busy, and unusually rude nurse, who does NOT put the doctor on as asked (Another issue I’ll address later), and basically doesn’t bother to hear the whole report before giving the “He’s walking, talking and refusing, there’s nothing you can do”.  Cat tries to explain that he’s still postictal, but is cut off and all but hung up on.  Great, now I got a big, disoriented seizing dude, and a livid, tired, annoyed (and fine looking) wife/partner.  Wonderful.  We take another survey of ideas, end up empty, and we collect the refusal signature from the patient’s mother.  I’m angry and tired, and I document the hell out of the fact that Nurse Wratchet provided our on line medical support in getting the refusal.  We pack up and I thank the Police profusely for their help.  They are supportive and agree they were needed.  We all agree that we’ll be back here, and they ask to be called for again if it happens.  No Problem!

We leave the scene and head back for the hospital to pick up a supply we were missing, and I’m generally hoping Cat doesn’t just show up and kill a nurse right there on the floor when the MDT jingles.  Same address…Seizures….”It’s him Wayne…GO!”

Wayne had already slapped the lights back on, and was pulling a high-G U-turn as I spoke.  Dispatch calls for us on the radio.  “M512 is direct on the dispatch and responding…please add PD to this call” is my response.  As we turn, I see the engine flipping around and leading the way.  Communications confirms PD is on the way and I yell back to Cat, “You take the cot to the stairs, we’ll get the patient”.  She’s okay with that plan, and frankly, I want her downstairs just incase things don’t go by plan.  I radio to the engine to just send in manpower, don’t grab any equipment, that we are just going to evacuate the patient as fast as possible.  Dispatch updates that he is unconscious again and I smile.  (See, I can’t legally take a competent patient to the hospital no matter how bad they need it.  We can argue his competence on the first call later.  An unconscious patient is legally assumed to want treatment and transport under “Implied Consent”.  SO, as long as he’s out, he’s going to the ER…and it’s only a 5 min drive away…without lights and sirens.)  PD is right behinds us as we slide onto the court where the townhouse is.

As I’d later tell the story, we hit that house like a SWAT team.  Wayne and I are met going through the door by Rock and Rick off the engine.  We all run up the stairs and right to the bedroom.  Our patient has seized himself off the bed, knocked over his lamp and lacerated his forehead.  He’s out cold, and snoring as he breaths.  “Okay, he’s breathing, let’s get out of here.”  We try to grab him by the blanket he’s wrapped in, but it’s a loose weave cotton thing that stretches all to hell.  We roll him out of it and I grab his ankles, they grab shoulders and hips, and we take off down the stairs like the building is on fire.  It is not pretty, but it works, and we get him on the cot.  He’s quickly strapped down…hands under the straps…and we are on the move.

Rock rides with us, and I tell Wayne to take off as soon as he gets into his seat.  We just secure the patient to the cot, for his safety, when I feel us starting to move, sirens blazing.  I’m sweating like a fat man, and we are all winded, but here we are.  The patient is still unconscious, but he’s breathing and everything looks good.  He’s got a laceration, but it is very minor.  He’s not seizing, so that is a plus.  We have a  SHORT talk about getting an IV etc, and decide that we are going to rapidly transport, and not do anything to stimulate the patient unless he starts to actively seize again, in which case we’ll hit the IV on the run and push Ativan.  I call the ER and tell them I’m coming, coming fast, and will be there with a postictal patient, 3 seizures tonight, with no vitals or interventions, unconscious and promising to be uncooperative when he wakes up.  Fortunately I have a nurse I know on the line, and she knows that something’s up.  “Okay, see you in two.” Is all she says.  I look up and see that PD is having to respond lights and sirens just to keep up as we get to the ER parking lot.

Our patient wakes for a second, looks up, gets pissed and pulls on the straps, and then falls back again.  The clock is running out as we stop.  I hop out and we rush him into the ER.  

I see the nurse that talked to Cat and she’s surprised we have the patient.  “We got your refusal, he seized again like I said, and he’s here unconscious under implied consent.  He’s waking up and is uncooperative…now which room was ours?”  She’s not thrilled, but I have her cold and she points to one of the big rooms in the back.  We are there with two techs, a couple nurses, the PD that came with us, and hospital security.  Moving him over to the ER bed wakes him and we are forced to hold him back, but per the ER doc, they get a fast IV and have him sedated in short order.  The doc knows the patient and agrees with our assessment of what is going on, and that this guy stays postictal and is uncooperative every time he sees him.  (So that went our way…finally).  

We give what report we can and go off to do the paperwork.  We are real careful with the first one of course, and it takes a little while to clear.  We leave with a chuckle.  “Well, sometimes you help and it’s pretty, sometimes you help and it’s ugly” I comment on the way out.  On the way back to the firehouse we wonder if SWAT needs any new members, and chuckle at how we must have looked to the PD or any bystanders rushing into a house, then flying back out with a guy in our arms.