Just to start…
This facility sounds like many of the East Texas EDs that are not much more than a tech, RN and mid-level or an on call family practice MD. iSTAT labs and flat plate xray on film is usually all they have.
Now, to discuss everyone’s points.
I’ll get to the labs you have at the end of my post. TexRNmedic hit it exactly right on the description of the facility. You won’t get much out of them. His parents are Mexican, moved up from Mexico a few months ago. His dad is a farm worker and they live in a house on the farm. No abnormal religious practices to speak of.
Rectal Temp is 100.3 F. Capillary blood glucose is 104 mg/dL. Your RN partner (who was mine on this flight) is absolutely awesome and pops in a nice 18ga in the kid’s arm. No medical history that the parents are aware of. Our Spanish, between the two of us, consisted of “Where el hurto?” The little bit of information we got from the parents is that he had multiple seizures, and that’s why he was brought to the ER. The seizures were described as “violent, generalized seizures” by the PA in the ER.
No neuro workup, but I’ll hit a few details further down the post. Clear CXR , lung sounds clear, heart sounds = normal S1,S2, no murmur. We don’t have a urine dipstick available. Weight is approximately 22kg. The GCS and SpO2 are accurate.
We don’t have anyone available other than a security guard that answers “kinda” when you ask if he can help translate. No language line available. The father is very standoff-ish when asked to answer questions and will not give answers other than yes/no. The mother is obviously upset, says that the child just wouldn’t stop seizing. She didn’t know what to do other than bring the child to the ER. You are able to ascertain that he has no medical history and has been healthy until this recent “illness.” She says that the child was just sick for a day and she brought him to the ER the few days before. The RN that is taking care of him today said that the doctor just looked at him for a few minutes then discharged him home. She said he thought he just had a little virus. We thought it was rather abnormal that they sent a 4 year old home in diapers.
I see you clued in on his physical exam. What made you think twice about the handprint on his throat and the petechial hemorrhages?
Neuro Exam – Patient’s GCS is 6 as charted. He moans and exhibits decorticate posturing to deeply painful stimuli. No response to IV stick or glucose check. His pupils are sluggishly responsive at 6mm. They are equal. No abnormal reflexes noted.
Skin – Warm and Moist (Not diaphoretic, just moist)
While you’re setting up to manage this kid’s airway, you note that his heart rate has dropped to 106, his respiratory rate is 6 and ataxic in pattern. His BP is still around 90/50. Your partner starts assisting ventilations with a BVM. You also note a lot of secretions around the patient’s mouth and in his mouth that require suctioning.
You get one shot at an iStat cartridge. (I’ll go ahead and warn you, it’s not going to give you any enlightening information anyway)