Priority Calls

Late-afternoon house duties are interrupted by a call for a motor vehicle accident with possible injuries, and the location given is “in the vicinity of a rural address.” The Attack One crew knows being dispatched to somewhere “in the vicinity of” anything usually means a serious problem. If the excellent call managers in the 9-1-1 center can’t pinpoint a good location, there is often a bigger problem than the average call.

When they mark en route, the dispatcher is prepared with some additional information. “This call was originally reported through a vehicle-based security system in this rural area, based on GPS locating,” she reports. “An additional call from a bystander indicates there is a vehicle way off the road with an unconscious driver.”

The Attack One crew leader requests additional rescue resources, and the crew prepares for a trauma victim. On arrival, they find a single vehicle about 400 yards off the road, down an embankment in a field, with a single male driver belted into the driver’s seat, unconscious. Vehicle damage is relatively minor; the automobile had impacted a small tree, which triggered the air bags and the vehicle’s GPS-based emergency notification system. An operator is still on the vehicle’s integrated cellular phone system, and that individual reports he’s heard no response from any vehicle occupant at any time.

The paramedic initiates assessment, and the rescue resources set up for victim removal and transfer back to the street. The patient is diaphoretic and unresponsive to all stimuli, but has only small abrasions and contusions, which appear to have come from the air bag deployment. Crew members note no trauma to the head, chest or abdominal areas, and no visible extremity deformity. Pulses are regular and strong, and the victim is not tachycardic. The paramedic opens the victim’s eyes, and the pupils are midsize and reactive. There is no smell of alcohol. Pulse oximetry reveals good oxygen saturation.

The Attack One crew leader sets up for trauma care and rapid removal, and the crew slides the victim onto a backboard and immobilizes him. They administer oxygen and ask colleagues back at the road to prepare for intravenous fluid therapy. It will take several minutes to carry the victim back up the embankment.

The victim remains unresponsive into the ambulance, and yet his perfusion status appears adequate. He also remains diaphoretic, although the outside temperature is not overly warm.

A thought occurs to the paramedic: Altered level of consciousness plus diaphoresis means blood sugar assessment. The medic quickly inserts an IV line, takes a drop of blood out of the catheter, places it on the blood sugar measurement strip and inserts it in the glucometer. The reading is 23.

The patient has the intravenous line connected and receives a pressure infusion of 500 cc of normal saline as a 50% dextrose solution is prepared. The sugar is administered, and the patient’s diaphoresis clears quickly. His mental status slowly improves, and he begins to move around within his immobilization straps, but does not open his eyes or talk during transport to the trauma center. A secondary trauma assessment en route finds no additional signs of injury and no victim identification. The paramedic calls the hospital via cell phone to report on the patient’s mechanism of injury and altered mental status, as well as good perfusion and lack of signs of significant trauma.

As the team and victim arrive at the emergency department, the victim finally opens his eyes and asks, “Where is my phone?”

“We’re not sure what you’re talking about, sir, but fortunately you’re doing OK,” the paramedic reassures him. “It looks like your blood sugar dropped and you drove your car way off the road. Maybe your phone is in the car, so we’ll ask someone to try to find it.”

Just as the patient is being loaded onto the emergency department stretcher, a pair of very concerned parents arrives. They identify their son and provide a history of insulin-dependent diabetes. They tell the trauma team and EMS crew he has had problems controlling his blood sugar since he started a new job a couple of weeks ago, and problems often occurred at this time of day.

How did they know to come to the hospital? They’d asked their son to call them each day as he left work, and when he didn’t call today, they knew something was wrong. When they heard the number of sirens responding to a call in the vicinity, they tried repeatedly to call him. When that didn’t work, they got in the car and headed to the hospital.

The Attack One crew places another cell call to the rescue crews still working at the scene to bring the car back up the embankment. They ask if someone can find the missing cell phone. They also pass on information to allow police to find the victim’s wallet. Both are located, and a police officer who is coming to the hospital returns them to the young man.

The young man’s condition improves quickly in the ED. He has no recollection of the accident, but his workup for any serious injuries is negative, and his mental status clears completely. His blood sugar is 146 on repeat assessment, and after eating a full meal, he is released with his parents. He will not be able to return to driving until his primary physician releases him.

Case Discussion

This case demonstrated great patient assessment in identifying the cause of the patient’s altered level of consciousness, and the dramatic potential of the portable phone in public safety and emergency medical care. This patient was found unconscious and had a mechanism consistent with major trauma. But he did not show signs of blood loss and was perfusing well on assessment of skin, capillary refill, pulse rate and pulse oximetry. Unexpected diaphoresis is a common finding in hypoglycemic patients, and causes related to the intake of substances that alter level of consciousness (e.g., alcohol, opiates, sedatives) are much less likely with midsize pupils, no smell of alcoholic beverages, and a normal respiratory rate.

The mobile phone has had many positive effects on emergency medical service. The early version of the cellular phone was the portable phone, which could be used around the home within a short distance of its base. As these proliferated, fire and EMS providers in warm climates began to notice an association with reductions in pediatric drownings in home swimming pools. The reason? Many drownings historically occurred when parents stepped momentarily into their houses to answer phones. When those homes got portable phones, parents could bring them poolside and not lose sight of playing children. Another early benefit of portable phones was the emergence of services that assist those with mobility challenges and fall risks.

When cellular systems were built out into communities, there was a dramatic impact on notification systems for public safety. Now most 9-1-1 public safety answering points receive the majority of their calls from cellular phones. This challenges systems to implement technologies to automatically locate emergency callers. Vehicle-based emergency safety systems with automatic triggers are also becoming more common. Now 9-1-1 centers are also working to be able to receive text messages and camera images from cellular phones.

Cell phones allow 9-1-1 centers with trained call-takers to deliver prearrival instructions to bystanders with patients. Rescuers can utilize them at scenes for notification of other needed agencies (e.g., poison control), for contacting hospitals and/or medical direction, and as a backup system to communicate with dispatch. In some locations, cell phones may provide more reliable communication than an agency’s portable radios.

James J. Augustine, MD, FACEP, is medical advisor for Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.