Sedation

I should be working today, but (and I want loads of sympathy here folks) I'm off sick with a work related injury. Thankfully it's nothing too serious, certainly nothing as serious as last time.
On Thursday we got called to a big conference centre in town for a (possibly) suspended/dead/fitting male – so we rushed over there and were met by their security who had rather cleverly staked out both entrances to this place so that they could lead us to the patient. Parking up we had to climb a couple of flights of stairs carrying nearly all the equipment from the ambulance. Our first response bag, oxygen and associated kit, defibrillator, suction and carry chair are quite heavy, and as were were in a rush to get up the stairs we were a bit out of breath when we reached the patient.

The first thing that we saw (and were very happy about) was that the patient hadn't suspended, and was instead thrashing around on the floor with some security guards and the centre's medic sitting on top of him. Approaching closer we saw that he wasn't fitting, but was instead very combative, trying to fight off the people who were holding him down in a very confused nature. Aha! we thought, 'he's post-ictal'.

During the post-ictal phase of a seizure, the fitting has stopped, but the patient is often disorientated, sleepy or aggressive. In this case it appeared that the patient was both confused and aggressive – he wasn't responding to anyone trying to talk to him to calm him down, and he could only make guttural sounds. Normally these episodes last less than half an hour, so we stay with the patient until we can get them into the ambulance.

Sometimes the aggression can come from physically being held down, the patient is confused and frightened, and all they can feel is people holding them down – so they struggle. I suggested that the security guards let him go, which only resulted in the patient trying to stand up, only to fall over again (don't worry, we caught him) and unfortunately the centre medic got a head butt for his trouble. I managed to get a blood glucose reading, which was normal, and a work colleague phoned the patients mother, so I could get a bit of history. The patient is normally fit and healthy, not diagnosed with epilepsy, but has had two fits in the past two years. All during this phone conversation the mother could hear her son shouting in the background. He had never been violent before.

We resigned ourselves to a bit of a wait, so we managed to get him over to a leather couch, and held him down there – after ten minutes there was no change in the patients condition, normally they get a bit tired or they start to have a change in their condition. So we started to think about other ways in which we could help the patient at the scene. We couldn't get him to the ambulance while he was so combative, and so we thought he might need some form of sedation. I ran back to the ambulance and asked control to get us a BASICS doctor, or at least someone who could give some form of sedation.

Instead after about 10-15 minutes we got the Physician Response Unit, which is a new service where a doctor from the Royal London Hospital covers medical emergency calls, it's a bit like HEMS only without the helicopter, and instead of going to Trauma, they instead deal with medical emergencies.

The doctor (who is a very nice man) and paramedic crew with him took one look at the patient, listened to the patient's history and decided that sedation was a very good idea.

Cut forward 40 minutes worth of trying to sedate the patient with increasing amounts of medication. For the medically trained out there, the patient needed 10mg Haloperidol and 17mg of Midazolam. At one point the doctor was thinking about knocking the patient completely out and intubating him (something that has it's own risks). But luckily the patient was sedated enough for us to get him out of the conference centre, and into out ambulance, where we 'blued' him into Newham hospital just in time for him to wake up (the sedation lasting only around 15 minutes) where the doctors there did paralyse and intubate him.

We have few ideas why the patient was so violent and so deeply confused – it's something that will be investigated in hospital. We were considering epilepsy, head trauma (from when his head hit the floor), meningitis (so antibiotics were given on scene) or some form of brain insult. I'm asking my crewmate to find out what happened to the patient.

The reason why I am off sick? Well after holding the patient down for an hour and ten minutes, I managed to sprain my thumb. As I can't be considered safe to carry a patient downstairs, I'm taking today off (plus two days of leave) so that my thumb can heal and I can get back to saving lives picking up drunks again on Monday. Oh, and it's my birthday tomorrow – 33 is such a young age don't you think?

26 thoughts on “Sedation”

  1. Happy Birthday!And thanks for such an interesting and regularly updated blog – definately one to check daily.

    Cheers,

    Andy

  2. It's a hell of a call. I know if someone was trying to hold me down for an extended period of time, they'd need some bloody serious drugs to calm me down. Had a guy in a bed next to me a while ago who was wrecking the whole bed – the nurses were just telling him to stop in case he hurt himself. Poor guy was tring to explain that it was out of his control but they didn't seem to hear. This was about a 4 session – it amazed me he lived through it.

  3. thanks foR your blog – it hAS BECOME ONE OF MY DAILY FIXES =happy birthday – hope you get to celebrate it with some fun friends, sprained thumb and all!

  4. Happy birthday Hope the thumb doesn't hurt too much as you are holding a glass of whateverAny more news from the bosses re your blog?

  5. Happy birthday for tommorrow, i shall have one for you tonight. Would shake ur hand, but i might damage your thumb more!

  6. thank god it's only your thumb, when I read 'combative' I thought you'd been slammed in the face or something. Hope it feels better soon. And happy birthday :-)Cheers,

    Arwen Lune

  7. Happy brithday! Great blog.Regarding the confused chap, I am a medic (SHO in neurosurgery and neurology) and it certainly sounds like my territory. I would list DRUGS as first probable cause. Next, seizures is a possibility, although it sounds like an atypical one (ie. frontal lobe non-convulsive seizures). Or it could be something like encephalitis.

    That was a lot of midazolam. I suspect he was intubated in the end because of the suspicion of non-convulsive status epilepticus or encephalitis.

    Get well thumb

  8. Happy birthday – Thumbs Up (groan deserved) on your elegant & impressive way of including us in your work and life. dab/Chicago

  9. Happy Birthday Tom!Sorry I missed meeting you when you were here in Toronto – I managed to come down sick with a nasty cold that weekend. I was glad to read you got to meet some of our local residents (including the racoons).

    FYI – one of the reasons you see so many fire engines about is when you call 911 with a serious issue (e.g. 5 year old with status seizures and suppressed respiratory) they send everyone – police, fire and paramedics. Usually the fire guys are the first on the scene and handle things until the paramedics/ambulance show up. They often also help out with other family members so the paramedics can concentrate on the patient

  10. Have a thumbs-up birthday. Gees, your blog is a bit of a downer – sorry, I'm feeling a bit melencholy today!Cyalayta

    Mal :o)

  11. You are one third of the way to the ton of life, put this blog on to CD [ leave out the odd ones with sand buckets], then review it when ye be resigned to watching others blue lighting the way. dungbeetle [PS congrats to ye Mum for giving your genetic inheritance and ye old bro for letting ye blog..]

  12. Happy birthday! In Copenhagen we've had physician response units for years and they seem to be a very good idea. I'm glad to see that your experience is the same. I hope your thumb gets well quickly and am glad to see that it doesn't hinder your typing too much πŸ™‚

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