"I would never do THAT..."

The EMT I worked with on Sunday is in Paramedic school so I took the opportunity to refresh some of my knowledge by quizzing him on his cardiac rhythms, ACLS algorithms, and other EMS related things. One of the questions that I asked him was, "Which drugs can you administer via an ETT?"

Of course the answer is LEAN (lidocaine, epi, atropine, and narcan), although NAVEL (the previous 4 plus valium) is also acceptable. ETT drug administration is falling out of favor as we realize that the drug absorption rate and dose widely varies and we don't really want to be putting fluids into the lungs of our patients unless it's truly necessary.

So the discussion included other options for drug routes if ETT and IV access weren't available. Those include IO (into the bone marrow space), IN (intranasal), and PR (per rectum--ie, in the bootie). He very seriously told me, "I will NEVER give medications rectally." So I told him this story:

It was late afternoon and the county had been steady but not busy. A few units were out but otherwise most of us were getting ready for dinner. The tones dropped and we were sent out of our zone to respond to an infant having seizures. Well, most of the time patients having seizures are done by the time EMS arrives and don't need further care, just a ride to the hospital and monitoring.

My partner and I checked en route. We talked about what to do when we got there and how we wanted everything to go. Dispatch radioed that the FD was already on scene and advising that the child was still actively seizing and had been for nearly 15 minutes now. They were administering o2 and would meet us on the sidewalk with the patient.

**Oh Hell in a Handbasket** Now we not only have a still seizing patient, but it is a child to boot.

I unclipped the narc keys and handed them to my partner. She got out the protocol book and we reviewed the pedi doses on Valium (IV and rectally). I told her that when we got to the scene, I was going to grab the pt and come back to the truck if she would get everything set up for us. About this time, dispatch advised that the FR was calling for Air Medical and did I want to go ahead and launch the helicopter?

Hmmmm....a seizing baby in what sounded like status epilepticus and no local pedi hospital...Well HECK YEAH.....gimme a fast ride to the level 1 pedi hospital.

So we arrived on the scene to find the FR standing on the sidewalk with the patient in his arms, still actively seizing. My partner dove through the pass through (space between the cab and patient compartment) and I went around and got a quick report. Mom was helped into the front seat and as soon as the pt was secured to the cot, I told my partner that I was ready to go. The FR asked if I wanted him to go with us. "No, I'm ok. I just want to go."

"But I am a National Registry Paramedic"

and so what if you are...so am I. DUH....Just get the hell out of the back of my truck and quit holding us up..... <--That's what I was thinking anyways. I would never be so rude as to say something like that to a FR on a scene.

So he went with us. The patient was hooked to a cardiac monitor (mostly artifact), o2 was continued, and my attentions were turned to gaining IV access. The FR made one attempt and it blew....so by my calculations the child had now been seizing for nearly 35 minutes. My priority, after securing the ABCs, was to stop the seizing. Without an IV, that meant rectal valium.

The child weighed 11 kgs as reported by the mother. So I broke the seal on the narc box and drew up the proper amount in a 3cc syringe. After discarding the needle tip, I took an 18 gauge catheter out and disposed of the needle, leaving me with the catheter tip. This I screwed onto the end of the syringe, and voila!! A way to administer the valium rectally.

Have you ever administered rectal valium to an actively seizing child? It's akin to giving a cat a bath. They wiggle all over and it's hard to keep the syringe in place after the drug is administered---necessary to keep the drug from running back out before it is absorbed.

It was the longest 8 minutes of my life. Watching to see if the drug would work, reassessing the pt status, determining my next course of action. As the seizing slowly stopped, I threaded a flexible catheter into the pt mouth and was able to suction his airway clear. A few minutes from the hospital, the patient began having irregular and agonal respirations. As the jaw was clenched, our only other option was to perform RSI to secure the airway, especially with the patient being such a high aspiration risk. I chose to assist the ventilations with a BVM as I could already hear the rotor blades from the helicopter. My thoughts were that the flight crew had much more experience with RSI for a patient that size and my efforts were better spent on good ventilations. They could figure out the proper doses of RSI meds MUCH faster than I could. I had the FR set up all the intubation equipment, we already had the length based resuscitation tape on the cot next to the patient.

When the flight crew boarded, I gave them a quick but detailed report and they agreed with my suggestion of RSI.

For my non medical readers:

RSI (Rapid sequence intubation) is a procedure that consists of administering a cocktail of meds that sedate and paralyze the patient in order to facilitate intubation. It is most frequently used for patients with traumatic head injuries, respiratory failure with impending respiratory arrest, and acute CVA (stroke). It can also be successfully used with patients who have overdosed on an unknown substance or with patients who are unable to maintain their own airways. It is not a procedure to be taken lightly, you must be sure of your intubation skills as a provider and feel comfortable that you can "sink" a tube on each patient. In my system, we used a combination of Etomidate, Succinylcholine, and Norcuron. We also premedicate with Atropine for the kiddos and Lidocaine for any with potential head injuries.

We prepared all the equipment and I successfully placed an ETT on my first attempt. Following intubation, the patient was ventilated well and packaged for transport. We got them all loaded into the helicopter and they flew to the Children's Hospital.

I called a few days later and was told that the patient was still on a vent and the EEG and brain scans had showed some kind of abnormality but because of the age of the patient, they weren't sure what it was or the treatment yet.

This patient was discharged about 2 weeks later and was home for 2 days before suffering another seizure. This patient has since become a regular for our service. They finally determined that there was some kind of lesion in this child's brain but determined it wasn't safe to do surgery because of the age. Unfortunately, the patient continued to have seizures despite aggressive treatment and today has significant mental, emotional, and developmental delays. We actually had a protocol written specifically for this child because it got to the point that all the Valium in the world wouldn't touch the seizures.

After relating this story to my partner, he said, "well, I guess I'll never say never again."

I told him that there was a big difference between saying that you would never do something vs. saying that you would prefer not to do something. I told him that the first time he laid eyes on a beautiful child with big blues eyes who had been seizing non stop for 30+ minutes, the thought of not giving a drug rectally wouldn't even enter his mind. I told him that I didn't want to perform a Cric (a different patient--for a different blog), but I did and because of it, the patient lived. But if I had always told myself that I'd never do one, the thought that a patient might need one would have never crossed my mind. And that patient would have died before he even reached a hospital.

Teaching moments...They are valuable when they come along and can be related to something that the student can easily identify with.

Until next time....