A Bad Way to End a Vacation

Scene

At 21:32, a BLS unit from the rescue squad and an ALS unit from county EMS were dispatched to a possible anaphylaxis call on the beach. Dispatch alerted both units that the patient was stung by a jellyfish while wading in the ocean. He lapsed into severe respiratory distress, and his friends pulled him up onto the sand. Their attempts to calm him did not work, so they called 9-1-1.

The rescue unit, staffed by two EMT-Bs, arrived first and placed the patient on oxygen via a non-rebreather mask at 15 lpm. Due to the darkness of the beach at night, the providers' initial assessment was limited to the breathing problem. Their report to the arriving ALS unit was a 15-year-old male, highly anxious, with severe respiratory distress. The patient was confused and unable to answer any questions. All patient information came from several of the patient's friends who were with him the entire time. Both crews later described the scene as a beach party, replete with bonfire and guitar-playing teenagers. In tourist areas, such a scene often raises the possibility that drugs and/or alcohol might be an issue.

Treatment

On arrival, the ALS crew maintained high-flow oxygen while the paramedic assessed breathing. The paramedic found wheezing in all four lung quadrants and prepared an albuterol treatment of 5 mg via nebulizer. It was difficult to administer the nebulizer because in his anxious state, the patient would not hold on to it. The patient's friends told the paramedic that the boy had no allergies but did have asthma and a prescribed inhaler, which could not be located.

The patient was carried on a long spineboard 200 yards from the beach to the ambulance. Due to the absence of any signs of trauma, he was not fully immobilized. A Stokes basket was unavailable.

Under the interior lights of the ambulance, a further assessment was performed. The patient had no urticaria, itching, edema or other systemic reactions that might indicate an anaphylactic reaction. A small erythematic area on his left leg, distal to the knee, was the only indication of a jellyfish sting. The patient was placed semi-Fowler on the stretcher, and the initial albuterol treatment was continued. At one point during transport, the patient had to be bagged via a BVM to control his escalating respiratory rate.

A second albuterol treatment of 5 mg via nebulizer was administered while the paramedics called for orders. A 16-gauge IV of normal saline solution was initiated and run at a KVO rate. Neither albuterol treatment had any effect on the patient's respiratory distress or level of confusion. The paramedic was given orders for 0.3 mg of epinephrine SQ by the on-duty physician at the receiving hospital. After administration of the epinephrine, the patient calmed down and relaxed. He was still unable to respond in full sentences, but was able to answer questions. The transport time from scene to hospital was seven minutes.

Hospital

At the emergency department, the patient was given oxygen via a nasal cannula at 4 lpm and was also administered steroid therapy via IV. The hospital released him later that evening. Although the steroids likely had some effect on inflammation caused by the jellyfish sting, there was no direct therapy administered for the sting.

Summary

Although EMS units are frequently sent to calls that differ from their radio description, the fault for this does not necessarily lie with the dispatcher. The dispatcher can only relay information given over the phone, which is often a frantic, indecipherable description of an event. Dispatchers should be careful to avoid a premature diagnosis based on that information. They should relate only a chief complaint, event or presenting symptoms to crews. A description of anaphylaxis as a chief complaint should instead be given as "respiratory problems following a jellyfish sting." Once given a proper description, an astute EMS crew can begin a mental and verbal process of differential diagnoses on the way to the call. This will allow the crew to prepare for patient contact and avoid any tunnel vision caused by the dispatcher.

Both crews in this situation performed admirably despite the darkened beach crowded with teenagers. They treated the presenting symptoms rather than focusing on the jellyfish sting and a possible anaphylaxis. An anaphylactic incident caused by a jellyfish sting is rare. The diagnosis at the hospital was an asthmatic attack induced by the anxiety of the sting. Ultimately, the sting only played a small part in the larger incident.