Puzzle Pieces

It always makes you somewhat uneasy when the only details you have when being allocated a job are: 7 month old, short of breath, and significant language barrier - unable to get further details.

We are so fortunate in Australia to welcome people from all around the world into our country. Those of a different upbringing enrich our culture and community, broadening our often narrow view on the world and make us all more informed, understanding Australians. I would say that for the average mono-linguistic Australian, communication with someone who speaks very little english themselves is probably limited to rare tourist interactions at local points of attraction, and maybe the odd smile and a wave at a neighbour’s elderly relative. The challenge of trying to extract information around symptoms, timelines and medical details is a whole different beast we grapple with regularly in pre-hospital care. So as we walk toward this house with absolutely no information other than an infant is in apparent respiratory distress, it is understandable that one might experience a certain sense of aforementioned unease. It is at this point in time that experience in pre-hospital care can allow you to place the pieces of the puzzle together before even laying eyes on the patient. I take a moment to think of my previous experiences with those who have made a new start in our country and are still building their understanding of our language and culture. Generally speaking, Australia has a world class emergency healthcare system that is mostly accessible to all. This is not so much the case in many other countries throughout the world. In some countries it can be a crippling financial decision to access healthcare for some, such as can be the case in the United States. In other countries, it can take so long to be seen, and care so questionable that many would rather take their chances and manage their own. As a paramedic in Australia, I regularly see those who have recently emigrated here carrying their old sentiments about emergency care with them, unsure of what is available, who they need to call, and what the associated costs may or may not be. Consequently, many choose to only call 000 for an emergency ambulance when they absolutely feel they require it. Which, ironically, can be in stark contrast to many Australian citizens who have an innate understanding of healthcare in Australia and choose to abuse emergency ambulance resources and attend the emergency department when they otherwise shouldn’t. I think critically for a moment about the data I have been given. I have been told that the parents of this infant are unable to communicate effectively in English so we can assume their cultural heritage is that of another country. I know that those fitting this general profile often in my experience do not access emergency healthcare unless they absolutely need it. I know that they called 000 four minutes ago so whatever has happened, it has likely happened suddenly, and I also can suspect there is some level of respiratory distress. Placing all this together I can tell you the list of problems this is most likely to be: airway obstruction, convulsion (febrile or other), croup, anaphylaxis or sudden infant death syndrome. I acknowledge that this represents a certain degree of anchoring on a diagnosis prior to even assessing the patient. However, I personally believe it is better you mentally prepare yourself for the most unwell patient you can imagine before arriving then be surprised by how healthy they are, rather than be caught out the other way around. I cross the threshold and enter into a long entrance corridor where a highly distressed man, dad, appears. “My son, sick! Quick!”, he exclaims. From a distance, he truly does have a look of terror on his face, the look of someone who is horribly out of control of a situation. I walk the corridor and listen for the telling seal bark cough that can suggest croup. Only a woman crying and no baby crying, not a great sign. I round the corner and see mum cradling a mottled, limp infant. Not what you want to see. I remove the stethoscope that is around my neck and place the diaphragm just below the child’s left nipple. His skin is so hot. Mum is hysterical, trembling, I say very calmly, “I will help”, and offer a half smile in reassurance.

I hear his heart beating, albeit far too quickly for me to count with my watch. Moving my thumb from around the bell of the stethoscope, I push gently into his mottled skin on his sternum, then release. Central capillary refill is ok. His breathing is fast, but certainly not dangerously fast. I move the diaphragm of the stethoscope upward just below his left collar bone. No stridor. I move to the opposite collar bone, pause, then move the diaphragm under his right armpit, then his left. No wheezing, air entering on both sides.

I remove the stethoscope from my ears and look at the little guy’s face. Whilst his eyes are open, he isn’t taking in any of the stimulus around him, he is gazing into oblivion. I touch the bottom of his chin gently opening and peering into his tiny mouth, illuminating his uvula with my pen torch, then move the bright circle to each of his eyes. He shuts them promptly, but not before I can see a slight constriction of each of his pupils. A temperature is taken which reveals a fever of 40.0 degrees celsius, and a drop of blood is taken from his toe which shows a low blood sugar level. “My son - his breathing - his face blue then his arms and legs”, with her free arm she makes an erratic shaking motion.

At this point I’m fairly certain these two young parents have witnessed their first febrile convulsion. It’s a terrifying thing to witness the first few times. What is often described is that the child will pause their breathing for some period of time, or breath in short, sharp grunts, then become very stiff sometimes arching their back. This is known as the tonic phase of a seizure. What is then observed is the more typical shaky, convulsive movements often depicted in television. This is known as the clonic phase of a seizure. As the shaking ceases, and it almost always does so without intervention, what we then see is a period of abnormal, confused behaviour known as the post ictal period. The literature surrounding febrile convulsions is tenuous and often changing, but what is known is that they are almost always benign and self limiting, and represent a syndrome independent of that to epilepsy. My partner spends some time with the father attempting to clarify the exact timeline of events, which after a few back and forths, and much gesticulating, points us almost certainly in the direction of a resolved febrile convulsion. The mother’s previous statement about breathing, blue face and shaking arms and legs fits nicely into the category of typical tonic-clonic febrile convulsion. His limb body and distant gaze fit the profile of a post ictal period, which isn’t expected to have resolved yet, as we got here so quick after the beginning of the seizure. So what to do now? I spend a moment preparing then rubbing a small amount of oral glucose gel into the little guy’s mouth in an attempt to replace what was probably burnt by his body in the lead up to and during the convulsion. I move very deliberately and slowly, trying to reassure the mother and father with my movements that I have the situation under control and no harm will come to their son. Within five minutes he begins to cry, weeping at first, then moving to more of the ear-piercing variety. That’s more like it, crying is good.