¡ECLAMPSIA!

I was working BLS this weekend, which basically means I’m lugging 30 lbs less equipment and they send us the stupid nonsense calls on purpose instead of by mistake. Except this one: comes over as your average boringass ‘SICK’ call, which can be anything from ‘My nose hurts’ to ‘I’m upset.’ This one was 23 year old female with headache. No further information. Fine. When we get there a dude’s flagging us down from outside the building looking real urgent. “She’s having a stroke or a seizure or something! Come quickly! Please!”

I’ve already mentioned that people love to hurry us along for even the lonliest little toothache or whatever, but as time goes by you can kinda distinguish between the guy that is just wants to someone around and the person who really and truly fears for their loved one’s life. This guy was definitely the second. Then he mentioned, as we hustled through an outer open area and up some stairs, that his wife had just delivered a baby five days ago.

Now here’s where any medic or EMT worth their salt should have the word ‘eclampsia’ dancing through their mind. Not as a definite, cuz we gotta wait till we see the patient and all that, but between the call information and the husband’s story, you have a pretty textbook eclamptic patient. What it is is an obstetrics disorder where the blood pressure shoots through the roof causing blurred vision, massive headaches, edema in the extremities and sometimes blood backing up in the lungs. All that is pre-eclampsia, when the patient actually goes into a full tonic-clonic seizure it becomes eclampsia proper, which is gets its name from the Greek word meaning “shining forth.”  It’s rare we see even a pre-eclampsia in the field and rarer still to see a fully seizing pregnant woman, but sure enough when we walk in we find the patient just finishing her last convulsion and settling into a postictal stupor complete with snoring respirations, drooling, rolling eyes and occasional tremors. (I’ve heard varying reports but apparently it can happen up to 4 weeks after delivery.)

So, like I said, I’m BLS and don’t have any medicines with me and really there’s nothing worse than being at the scene of some magnanimous disaster and utterly helpless to do anything about it (See previous posting for more on that…) The family is going through all the motions of utter freakout, from screaming that she’s going to die (her mom) to trying to shut the gloomy screaming lady up (her husband) to bawling and pointing (her nieces and nephews). The pregnancy wasn’t high-risk, plus it’s over, and she has no medical problems so you can see they were all taken totally off guard when she suddenly seized after complaining of headaches and blurred vision all day. I call for a medic bus to back us up and my partner and I start getting her ready to go. Baby’s sleeping quietly in her crib the whole time.

The medics are waiting for us downstairs. I give the story as I’m fighting the stairchair with the lady in it over some bumpy pavement, praying she doesn’t seize again and topple. We’re on the bus and let me tell you, when I’m working BLS and medics show up I generally make it my business to be quiet and stay out the way, mostly because the worst thing in an emergency is three alpha medics yelling three different things. Plus, the guy working was a friend of mine and knows what he’s doing. HOWEVER, just when it seems like we’ve fallen into the whole swing of the job and everything’s moving along smoothly, he goes for an utterly different medication, Dextrose in fact, which would infer a treatment modality for a whole other situation than what we’re dealing with.
“Wait!”
I really don’t like doing that, especially when there’s a student, another medic and an EMT all right there. The guy looked at me cock-eyed. I ran down the list of symptoms and watched it dawn on him. “Why didn’t you say all that when we got here?”
“I did!” I had!
“Oh! I didn’t hear you. And I figured my partner’da given me the story.” She hadn’t.
A moment went by where we all kinda looked at each other. Then I don’t know if anyone said anything or what but we all just fell back into the business of treating the patient, now truly on the same page. Magnesium Sulfate relaxes the smooth muscles and can ease/prevent the eclamptic seizures. We also treat asthma with it and a rare form of v-fib called Torsades de Pointes. You have to mix 2 gms of it up in a 50 ml bag of saline and set the drip rate to deliver it over 10 minutes, which is a little project unto itself, so while the other medic is doing that I get on the phone with our telemetry doctor to get clearance to give the medicine.
Talking to telemetry can be an outrageous experience. There’s a medic that you have to get through to actually speak to the doctor and he’s always angry about the fact that he’s wasting away in an office while you’re out there having fun in the street and he always manages to find something to pick a fight over. I brush through him as quickly as I can, doing everything possible not to take the bait of his irritability. Then some absurd pop song comes on, because I’m on *&*&#^#*! hold of all things and finally the doctor gets on. I spit the situation out quick to him and make it very clear with my tone that I know what I’m doing, because certain doctors enjoy verbally shredding medics when they smell uncertainty. “Alright give the mag,” he mumbles, hangsup and returns to his cave.
When I get back in the bus I see the medic has asked the student to draw up the 2 gms of Mag, which he’s done, but now he’s got the syringe full of medicine and is reaching for the patient’s IV, about to mainline it. I can’t say for sure that his would kill her, but anytime you dilute a medicine in saline and drip it over 10 minutes it’s for a reason. Both me and the other medic yell “NO!” and lunge at the student who realizes his mistake and cringes. We gank the syringe from him. “Sit down,” the medic says.
“But…”
SIT.
he does.
We put the mag in the bag and I hop in the driver’s seat while they set the drip rate. Get on the mic to give our notification as I peel off into traffic. She saves her last seizure for when we roll up into the ER bay, which makes getting her out of the bus and into hospital but we eventually manage and the doctors swirl in on her as we yell out the story once again. After some messiness, they break the seizures and she’s sleeping quietly when I leave, her worried husband holding her hand and shaking his head.

STAT EP

Seizures suck.
Now that we’ve got that important announcement out of the way, lemme clarify some things bout EMS and seziures: If you call 911 right after someone seizes, the call type is just “Seizure” and they send EMTs. If you call while someone is having a seizure, they presume it’s been going on for long enough to qualify as status epilepticus, which is a prolonged series of seizures without a lucid interval inbetween, and the job becomes a “Stat Ep,” and they send paramedics. Also, if you call 911 and say “Yo, I’m abouta catch a seizure son!” they make the job a “Stat Ep” and send medics, unfortunately. This happens more often than anyone would care to know about. (More on the difference btwn EMTs and Paramedics here.)

Anyway, there’s a couple reasons one might catch a seizure. Most common is epilepsy, which really just means you’re prone to seize, but there’s also hypoxic seizures which you get from lack of oxygen and usually precede death by a couple seconds, withdrawal seizures, including delerium tremens, and seizures resulting from traumatic brain injury. But by far the most common seizure call I’ve ever done is this one guy, we’ll call him Fred, that we always find blasted out his mind and writhing in a puddle of his own pee on the last stop of the cross town bus in Harlem. This dude, every—-night gets obliterated, on what Fred?
“ABTHOLUTELY!!”
The Vodka?
“YETH!”
Are you sure?
“ABTHOLUTELY!!”
Ok.
And winds up cursing out everyone around and screaming that he’s having a seizure (so it’s a Stat Ep). Or sometimes chest pain (“The Cardiac”). Then we lug his pee-covered ass to the hospital and by some unknown bum magic Fred always emerges the next day at dawn, not only sober and with a British accent but wearing pressed pants and alligator shoes, all dapper and ready for another day of getting blitzed and writhing round in his pee.

True seizure patients are usually really out of it for a while after they come around, sometimes get violent and wanna pound you for taking them to the hospital, sometimes they do not under any circumstances want to be bothered by anyone and often act like a teenager not getting up for school in the morning. Also they’re confused, cuz last they remembered they were sitting at the table or whatever and suddenly they’re across the room with a fat lip looking up at me and I’m holding a big needle. Or, in what might a worst case scenario we had a while back, they wake up butt naked in the basement of an HIV shelter covered in their own feces. I’m still not sure how the dude got down there. I mean, he was a resident of the place, but still- damn. The security guard was ornery and couldn’t give us much of a story. I tossed the dude a sheet and he kinda cleaned off best he could, mumbled something about ‘yeah this happens sometimes’ (o.O) and walked out to the ambulance. Well…hobbled kinda.
When we got to the hospital he insisted on walking in, even though we realllllly dont recommend it cuz if you seized once you might damn well seize again. But dude wanted to walk and wouldn’t be dissuaded.
Halfway between the bus and the door he turns the wrong direction and takes two steps. I open my mouth to say “No it’s over…” and then realize what’s happening. I break into a mad dash towards him as his body goes rigid and he starts to keel over backwards, get there just in time to stop his head from exploding on the concrete and lower him down gently as his whole body rocks into a grand mal seizure. My partner that night,  a confirmed jackass, pokes his head around the corner.
“What’s wrong?”
I’m holding this 300 lb seizing man’s face away from the gravel in an ER bay. What the *#&(@*%)#@*#*Q@ do you think is wrong?! “Get me the stretcher!”
“What happened?”
“STRETCHER!! NOW!!”
Partner disappears and shows up not with the stretcher but with…an oxygen tank.
Lemme tell you something: yes, by the guidelines and protocols, a seizure patient gets oxygen. Yes. This is true. But what this one in particular needed was to not be seizing on pavement. And what this paramedic needed was not be holding him up. I think I cursed out my partner. I’m not totally sure, cuz it all happened very fast, but eventually he made the stretcher happen, after some grumbling. It’s probably a good thing my hands were busy. By the time we got dude on the stretcher he’d wrapped up the shaking and fallen into that deep sleep. At least he woke up in better circumstances the second time.