Manuel is sitting on the floor. His wife called the emergency services because he suddenly started having convulsions while eating. He looks at us for help. Then it starts once more. The differential diagnoses rattled through my head.
When rescue service employees enter the scene of an emergency, they are ideally surrounded by a halo of emergency medical safety. The patient now feels safe, since the professionals are at the scene. The relatives who dialed the emergency call can hand over their responsibility to the professional helpers. However, if the paramedics are also groping in the dark, it becomes uncomfortable for both sides. This shows that emergency medicine often consists of unconventional solutions and pure improvisation. And from avoiding fixation errors.
One cramp following the other
I call the 28-year-old patient Manuel. Beads of sweat stood out on his forehead. The eyes looked like a character leaping out of hiding to scare passengers to death in the darkness of a ghost train. They fixed my colleague and me and would not let go of us. Manuel’s wife alerted us. Manuel had started convulsing in front of her during lunch. At first she thought it was a joke and asked him to stop, but he didn’t react. Her fingers snatched the phone from the cradle and flew over the keys. After the first spasm, he sat down on the floor so as not to injure himself further.
“Here we go once more,” he said. “Now!” The iris floated up until it was almost invisible and only the white of the eye was visible. The mouth formed an O, the hands curled like an O Hyperventilationstetanie. My colleague and I were still probing, and by then it was over. Manuel looked exhausted and anxious, probably wondering what was going on. As do I secretly.
And off you go: A-B-C-D-E
That had to a D problem be – and nothing else, I thought to myself. What should a patient have who suddenly starts having cramps? My colleague nodded and mumbled something regarding as well Epilepsy. But I started from scratch.
The stethoscope out. The airways were free – so no A-problem. Manuel spoke and had nothing in his mouth that might throw a spanner in the works for us later. I pressed the head of the stethoscope to the thorax and auscultated it. All free. Slightly increased breathing rate, as if Manuel was excited, but nothing else. My colleague had meanwhile put on pulse oxy and a blood pressure cuff.
The pulse oxy showed a value of over 97 percent, the pulse curve was rhythmic and indicated a normal frequency rhythm. Blood pressure was 130 over 80 that recap time was well under two seconds. The belly was soft. Manuel had no pain in his abdomen, chest, back or head. I might rule out B and C problem.
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The letter D kept floating around in my head. “We don’t need an EKG,” I said to my colleague. Nothing indicated a C problem there. So in the end, the only thing left was D: intermittent unconsciousness from seizures. Probably epilepsy, perhaps triggered by a tumor? I used this for anamnesis SAMPLER-Schema. The wife denied allergies, medication and previous illnesses. He has never had a headache before. Manuel did athletics every week. He had never needed a family doctor. There was nothing regarding epilepsy and nothing to suggest it.
When the penny drops
Then it started once more. Arms and hands spasmed, the pulse oxysensor flew off his finger, the blood pressure cuff handle slammed onto the floor. My colleague tore the vial out of his pocket and wanted Midazolam pour over the nasal spray. But before he might get to it, the attack was over. The situation didn’t taste good. I called for an ambulance to assist.
Almost twenty minutes passed before Manuel’s life-threatening situation was revealed. In the meantime, my colleague had established a venous access. The stretcher was in front of the door. Manuel lay down. “I’ll still do the ECG to be on the safe side,” said my colleague. He pressed the switch, a long beep signaled readiness. At that moment Manuel looked into space once more, hands clasped together. The deformed ECG curve raced across the monitor, and the penny dropped: The spasms were caused by a Hypoxia, which was triggered by a tachycardic cardiac arrhythmia without relevant cardiac output. Only this time it didn’t limit itself – the ventricular tachycardia flowed into a ventricular fibrillation.
The fixation trap
Manuel survived. He suffered from a previously unrecognized canalopathy called Brugada Syndrome. This disease is extremely dangerous. She just appears out of nowhere at some point without having caused any trouble before. Due to genetic modification of various ion channels and the associated reduction in sodium flow in the heart, it causes premature Repolarisation. Tachycardia arrhythmias through to ventricular fibrillation are the result – without any advance notice.
If I had consistently followed the ABCDE scheme and attached the ECG, I would have noticed the cardiac arrhythmia much earlier and the emergency doctor would have been called, antiarrhythmic drugs would have been administered and the patient would have been transported earlier. The fact that I was dealing with what appeared to be a prodromal seizure led me to avoid using an important diagnostic tool in order to save time. Though fog obscured my vision like a sauna infusion, I’d settled on the most likely option without looking over the edge. I ran into a fixation error.
First, it turns out differently, and second, than you think
And yes – sometimes it is not so easy to always keep the view of the patient fresh. This should always be done very consciously and following each use. Just following completing ten missions in which patients did not suffer from any medical conditions requiring intervention, one tends to blame the eleventh patient for something similar and then steer into a catastrophic fixation error.
Expect the Unexpected: Sometimes the first look at a patient just isn’t the one you should ultimately get caught up on.
Image source: Ahmad Diriniunsplash
