Did He Say ‘Clear’?

We were cleaning up from our last call, restocking the rig and doing paperwork at the hospital. The tones dropped for an elderly male having a seizure. It was only a short haul to the address, an upscale apartment building overlooking the lake. Police and fire were already on scene when we arrived. We grabbed our stuff and headed up to the second floor apartment.

Our patient’s wife told us she had sent her husband out with a broom to sweep off the balcony in preparation for a reception they were hosting. (I guess that would explain the tables laden with various delicacies and beverages.) The fire guys had already started working on him when we elbowed our way out onto the already crowded porch.

Joe, our patient, was lying supine, breathing in short gasps, pulse rapid and thready. He was unresponsive, and he appeared to be having focal motor seizures with rhythmical twitching especially of his face. His eyes were deviated up and to the left with nystagmus. Definitely seizing. Stroke, maybe? We had a medic student with us that day, so we put him at Joe’s head to take care of the airway while a first responder bagged. I moved down his left arm to start an IV.

I was busy ripping open the bag of saline, spiking, flushing, swabbing, tearing, sticking and taping the IV and thinking ahead to getting the Valium out of the drug box, when I heard my partner bark “CLEAR!” My mind went blank. “CLEAR?” I thought, what do you mean “CLEAR?” What does “CLEAR” have to do with a seizure? There’s no “CLEAR” in the seizure protocol, is there? Did I miss that class? Are we shocking seizures now? Do we stick the defib pads on the head? Did I miss the memo on prehospital electroconvulsive therapy (ECT)?

I looked up from my IV. My partner had hooked up the monitor, and it was sitting on a little garden table about eye level. Son of a gun! V-tach. So that’s what that “CLEAR” was all about. But there was still a moment of cognitive dissonance, as I tried to process the fact that our patient was not actually having a primary focal-motor seizure or a seizure secondary to a CVA. He was having what used to be called a “cardiac seizure” seizure activity brought on by cerebral hypoxia secondary to cardiac insufficiency.

I let go of Joe’s arm and raised my hands in the pre-shock-I’m-clear-you’re-clear “I surrender” position, so my partner could see I was not in contact with the patient. He looked around one last time, and then he hit the red buttons simultaneously. Shock delivered, pause, then sinus tachycardia on the monitor. “You got a pulse with that?” he asked. I always chuckle to myself at that one. I know, it’s dumb, but it sounds like “you want fries with that rhythm?” Anyway, fingers flew to the nearest artery me femoral, medic student carotid, first responder radial. Yes, strong pulse, regular. Great. Let’s get moving.

Joe had converted before our medic student had a chance to intubate, and now he was actually coming around and hurling, if my memory serves me. We oxygenated and monitored and suctioned and vital signed him to the hospital. He was pretty responsive by the time we arrived. After cleaning up, restocking and finishing paperwork, I stopped in to see how he was doing.

Joe was sitting up in bed, and his skin was no longer pale. His eyes were no longer dull and twitching, but sparkling and full of life. I went over to his bed. He reached out and grabbed my hand. I said how glad I was to see him feeling better. Born in Italy, Joe hadn’t let decades of New England winters dampen his enthusiasm for life. He pulled me to him, reached up, put his hands on my cheeks and kissed each in turn. “You are a good boy, a very good boy, thank you,” he said.

Don’t thank me, I thought. Thank my partner. If it had been up to me alone, you might not be sitting here with that big smile on your face. Of course you’d have gone to your reward happy with 10 mg of Valium on board. Well, at least you wouldn’t be seizing.

Tunnel vision. The power of suggestion. Jumping to conclusions. Making assumptions. Relying on experience. Complacency. One of these, all of them or any combination thereof can lead you down the wrong path. Pilots die from these very same maladies. That’s why they are trained to follow checklists scrupulously. They say there are two kinds of pilots: those who have landed with the landing gear up, and those who will. There is a mnemonic commonly used just before landing GUMPS. Gas (to both tanks); Undercarriage (gear down); Mixture (full rich); Props (full forward). It’s like a mnemonic I try to drill into my medic students’ heads OTWOIVMONITOR (O2/IV/Monitor). But mnemonics and checklists and protocols are only useful if they are used. In this case, O2/IV/Monitor saved the day.

The power of suggestion. Dispatch sent us to an elderly man having a seizure. Of course, I know dispatch can only tell us what they know, and that what is found on scene is notoriously different from the information received from dispatch. But he looked like he was having a seizure, right? Since what I found matched what I expected, I jumped to a conclusion seizure before all the facts were in, and I made the assumption his seizure was focal motor or secondary to CVA. After all, I relied on my experience that an unresponsive guy twitching with nystagmus is having a seizure, right? And that assumption could have made me complacent. Without all the help we had on scene, I might have delayed attaching the monitor until I had gotten the IV in and Valium on board, since that would solve the problem if the seizure was focal, and would do no harm if it was due to cerebral ischemia, right? And even with the evidence right there, the v-tach waveform on the monitor, I had tunnel vision, trying to get that IV so I could give that Valium.

By following procedure O2/IV/Monitor we quickly found out what was really going on, even though the evidence was unexpected. Cardiac seizure who knew? First one I had seen in 20 plus years as a medic. But there it was, plain as the ventricular tachycardia on the monitor screen.

So that’s why there are procedures, and protocols, and mnemonics and checklists. That’s why vigilance is required to avoid the traps of tunnel vision, the power of suggestion, jumping to conclusions, making assumptions, relying on experience and complacency. Experience is valuable when it helps us see what the neophyte might miss. It is dangerous when it lures us into inaction, because, after all, we’ve seen it a thousand times before. That’s why we don’t train for the routine, we train for the exceptional. We don’t need to practice the skills we do well every day. We need to practice the skill we almost never get to perform. That is our lot in EMS hope for the best, train for the worst. Be an optimist in your heart, but a pessimist in your practice.

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