Under Parental Control

     Attack One gets a report of a child having a seizure on a winter Saturday afternoon. There's little time to prepare—the call is about a block from the station, so a short trip puts the crew on the doorstep. At this time of year there's typically an increase in calls related to febrile seizures in children, and this year has been even busier than usual with such cases. When the crew arrives, there are no frantic parents or siblings, and the mood is almost calm. The child is in his bedroom, unresponsive, and both parents are present. It appears Mom is the primary caretaker and spokesperson.

     "Our son has frequent seizures," she says. "We left him with a neighbor while we went to a school conference for our other children. He began to seize, and the neighbor called you."

     As they approach the child, he is on his side in his bed. He has occasional twitches and is breathing irregularly. His tongue and eyes are deviated to the right. He is breathing adequately enough to show 100% oxygenation on the pulse oximeter.

     The Attack One members consult with the mom about the boy's usual treatment.

     "This is a typical seizure," she says, "it's just lasting longer than usual. It's probably been ongoing for 12 to 15 minutes. I'd like to give him the medicine we've been prescribed for him."

     "What's that?" the paramedics ask.

     "His neurology specialist has prescribed medicine to administer in his nose when he has seizures. We had used medicine in his bottom previously, but it wasn't as effective."

     "Can we go ahead and start an intravenous line and prepare our medications?"

     "There should be no need for that," Mom replies, moving toward a safe in the parents' bedroom across the hall. "This medication is designed to work without an IV. That's a huge advantage, because he has very difficult veins."

     The medics maintain the child on his side and administer supplemental oxygen by holding a mask close to his face. From the safe, Mom retrieves a syringe of midazolam attached to a device for administering the medication into the child's nose. He has a preset dose of the medication for his size in the syringe. Mom quickly places the device into the boy's nostril and squirts the medication in. The device breaks the water-soluble medication into a fine spray, a process called atomization.

     "It typically works in 3–5 minutes," the father tells the crew. "We hold him on his side. He generally has a very short postictal period and wakes up without a problem."

     As they support the child, the paramedics complete his history. The child was born prematurely and has had disabilities to overcome. He has had seizures since an early age. He's been given a variety of medications to prevent them, the current one for about a year. His parents were still noting he had seizures about every 4–6 weeks, and his specialist educated the parents on giving the child medicine to stop any prolonged seizures. They originally used Valium (diazepam), administered into his rectum. That worked for a few months, but then failed over the next two events. The physician then stopped the diazepam in favor of Versed (midazolam) given nasally through the atomization device.

     Most of the child's caretakers know about the seizure disorder and call the parents when a seizure occurs, which allows the child to receive care without activating the EMS system. The neighbor who helped today was not familiar with the seizure problem.

     As the history was being completed, the seizure stopped, and the child entered the relaxed phase of the postictal period. His airway continued to be clear as he was supported on his side. The parents did not want the boy taken to the hospital, as this was not an unusual event. "Should we notify his neurologist?" the paramedics ask. The parents say they'll handle that.

     The Attack One crew places a call to medical control to report on the run and clear the nontransport. A few minutes later the child wakes up, and although a little drowsy, he interacts appropriately with his parents. His examination is normal but for a small bite mark on his tongue. He has no fever. The parents talk to the neurologist, and he speaks with the crew to confirm the child's normal vital signs and examination.

     The Attack One crew asks if any further service is needed, and the parents thank them and decline any additional care. The crew asks if they can call later in the day, just to make sure everything is still going well. A callback late that afternoon finds the child acting completely normal and back at his baseline level of activity.

     Learning Point: Children with serious and potentially life-threatening illnesses live in every community. When these children have sudden events, EMS providers must quickly gather enough information to address their emergency care needs. Parents, home health agency nurses and other caregivers may be the source of critical information necessary for quality treatment. At a minimum, they can provide care plans and contact information for usual care providers. Usual care providers, often physicians specializing in certain pediatric diseases, may provide information to guide appropriate care. EMS protocols should provide guidance about the use of information from sources beyond normal medical control authorities, and also regarding discharge of patients to caregivers. Phone followup is a great method of assuring better patient outcomes, and should be one option for EMS providers to complete a communication loop with patients and/or caregivers.

Case Discussion
     This case depicts a relatively common scenario for prehospital providers: patients with medical problems, simple or complicated, who live at home and are cared for by family members or visiting healthcare professionals. Sometimes they receive care using sophisticated infusions, ventilators and nebulizers. Sometimes there are family members knowledgeable about the patient's condition and treatments. Sometimes, as in this case, they have the necessary care tools and experience using them.

     When the patient has an acute medical issue or their equipment fails (common in events like power failures), EMS is called to provide acute care. An appropriate EMS response is to provide any obvious supportive therapy, work collaboratively with the family or home caregiver, communicate with any specialists necessary to resolve the event and stay in contact with online medical control if there are conflicts in care or communication. The family or caregiver may need basic support from the EMS crew, but if they are able to resolve the problem using familiar resources, it will usually result in the best care for the patient.

     In this situation, the family was accustomed to the seizure disorder, had a reasonable treatment plan worked out with the specialist and could communicate that effectively to the crew. There was nothing about the process that would take the EMS crew out of their scope of practice, and they were prepared to manage any complications.

     Here are some other common scenarios with a similar theme:

• A young asthmatic patient uses a nebulizer, but it has failed. A new one can be delivered in six hours, but the parents say the patient needs a treatment now. The EMS crew may work with the family and medical control to provide a nebulizer treatment and make sure the child does not need further care.
• A patient with a home infusion setup has bleeding at the catheter site in her arm. EMS evaluates the bleeding and the infusion setup, communicates with the home infusion nurse and primary care physician, and works with the family to allow the patient to stay at home with timely followup by the nurse.
• A patient with an implanted defibrillator believes the device shocked him, but isn't sure. EMS is activated, and the paramedics assist the patient in attaching the phone device that analyzes the defibrillator. They help the patient contact his cardiologist, and an immediate report indicates the defibrillator did not fire, and the patient does not need to go to the hospital.

     When these patients have sudden medical events, it is appropriate for EMS to be activated. EMS providers will need to gather enough information to address immediate emergency care needs, then utilize the resources the patient and family use to determine the best management of the patient.

     Children with complicated medical problems often have someone close by who is knowledgeable about their disease and its treatment. Their contribution to care should be invited. Parents, home health agency nurses and other caregivers (teachers, coaches, babysitters) may be sources of critical information necessary for quality treatment. At a minimum, they can provide care plans and contact information for the usual care providers.

     Seizure activity in a child is a frightening experience for families as well as care providers. Because the duration of seizure activity impacts morbidity and mortality, effective methods for seizure control should be instituted as soon as possible, preferably at home. Fortunately, there are new ways to administer medications that have been proven effective and allow rapid care without the need for an intravenous line. Intranasal midazolam, which delivers antiepileptic medication directly to the blood and cerebrospinal fluid via the nasal mucosa, is safe, inexpensive and easy to learn, and provides better seizure control than rectal diazepam.

Bibliography
Wolfe T. Intranasal midazolam more effective than rectal diazepam in seizures. Letter. Emerg Med News 27(10): 3, Oct 2005.
Wolfe T, Macfarlane T. Intranasal midazolam therapy for pediatric status epilepticus. Amer J Emerg Med 24(3): 343–46, May 2006.
Joyce S, Neff C, Allred A. Efficacy and Safety of Intranasal Midazolam Administration by EMS Personnel for Seizures and Sedation. Paper presented at the annual meeting of the National Association of EMS Physicians, Oct 2006.

Jim Augustine, MD, FACEP, is the medical director for a number of fire services in the Atlanta area, including Atlanta Fire Rescue. He is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, and a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

EMS EXPO™
Jim Augustine is a featured speaker at EMS EXPO, October 15–17, in Las Vegas, NV. For more information, visit www.emsexpo2008.com.