By Crystal Wallin, NREMT-P, CCEMT-P, Tri State Ambulance
He’s the center of attention and he’s trying to be brave. It’s hard to be brave though when you’re lying on your back on a shiny brown cot in the nurse’s station and the room keeps filling with more grownups. All of the grownups are gathered around him when I add my uniform to the room, and they’re all peering down at him. He’s valiantly trying to lock it down, but the hiccuping kind of sigh/crying kids do when they’ve been at it awhile is going on. The sad noise out and the kind of inhale that’s short and sad; sometimes the lower lip gets involved. His face is red and splotchy, and if I didn’t have the dispatch information, if I saw him sitting in a chair somewhere without the accouterments of grown up people, I might’ve chalked up the discoloration to long-term crying.
But we are all gathered here today in the presence of Mom and the school nurse, and I do have the dispatch information. So I come in with the knowledge that he has a tree nut allergy and he’s eaten walnuts in a muffin. The very capable and kind hosting nurse tells us he was given an EpiPen prior to any EMS arrival. She produces it and gesticulates with it, punctuating the close air for emphasis as she tells the story – or at least what she knows of it.
Someone brought a snack, and when you’re 7 years old, you like snacks. Honestly, when you’re a tall human you love snacks too but I drag my mind back to the gesticulating nurse and resolve not to think about how many double digit hours since my own last meal. My abdomen grumbles but I prevail.
So the snack was wrapped up and store-bought and (here he interjects) there weren’t any visible nuts. But as nuts sometimes do, they were hidden by their small size within the muffin and when he realized this fact, he was maybe four bites in. I’ve seen 7-year-olds eat snacks, so I know no assumptions can be made about the size of the bites. I hunker down by the small hiccuping sniffling miserable person on the cot and gravely introduce myself, shake his hand. I tell him he’s the star of the show, that nothing is going to happen that he won’t know about first, that I will explain anything he wants, and that he gets to choose what order we do things in. He’s intrigued but a tough sell. I press on. I am impressed that he didn’t cry from the shot, per the nurse. She nods and punctuates the air again with the depleted device. He nods. I ask him if he’d like to sit up so all these tall people aren’t looming over him, and we open the door and pretty soon he’s upright and looking like he feels a little more on even footing with the situation.
Vitals. Assessment during all of the above, because it’s reflexive and interacting with him affords me his mentation, his lack of drooling, his speech is clear, he stops being red and blotchy and turns out yep, it was long-term crying. Or at least somewhat.
Next step; Mom. Mom is at the feet of the man of the hour, and has been watching all of this with grave interest and no small worry. I establish with her number of times he’s been exposed to nuts (once before), and what happened (swelling, face and throat). Negative intubations, excellent response to medication. In fact, so good that there is no EpiPen with him at school. It might be at home but she isn’t sure. We all turn to look at the device which has been passed on to the first responders. It is expired. Is it the school’s? Unsure. The nurse is gone. To where, I’m not sure but I don’t see her again until we are exiting through the office.
Soon inside the ambulance, transport is beginning. I’ve let the patient choose whether he wants the blood pressure cuff on first or the light on his finger for pulse oximeter. It doesn’t matter which is first, what matters is that he is calm and is beginning to have a small rapport with me. He’s perked up, he giggles when I complement his bright and busy coat and matching boots. He’s acting like a regular 7 year old.
Mom and I chat on the way in. She’s a little frustrated that despite the numerous papers she filled out, there was this series of events. Little man’s brow furrows at this and he hangs his head. A lightbulb that thankfully no one can see goes off, and I put some of the nursing training to work – this is a teachable moment. So we discuss the honest way a tiny ground up amount of nuts could be in a banana muffin packaged from the store without anyone knowing. We aren’t even sure if the muffin was consumed in class or shared in a hallway in a free moment between structured times. She nods, shoulders relax.
She asks why I wanted to know how many times he’s eaten nuts and reacted, genuinely curious. I explain the initial response, the subsequent responses and the need for hospital evaluation even after an EpiPen is administered. We talk about reoccurrence of symptoms, the window of time in which they may return and need immediate treatment again. She is struck by all of this and we go on to have a productive dialog.
During the dialog I ask the patient questions both to keep him interested and so he understands the importance of telling someone each time he feels a symptom, even if he has been treated already that day or night. He is bright, asks appropriate questions, and throughout the conversation I am able to monitor his continued swallowing, breathing, as well as the pulse ox level, heart rate and blood pressure.
I give radio report maybe five minutes out. He says his throat is itchy and his belly hurts. Mom is asking about an EpiPen, she’s not sure where theirs is. I advise the ER physician can help with that, and she nods. Her shoulders slump though, and her face clouds. I tip my head and she tells me in a hushed voice that her husband’s company recently downsized and his position was eliminated. She doesn’t have $600, or insurance. I suggest an area free clinic, wondering aloud if they may have some resources with which I am unfamiliar. I am matter of fact, careful to keep any sympathy from sounding like pity to this proud, sad mama. My hands are busy, too, letting the patient pick which 18G needle he wants, which small syringe. I’m getting out our epinephrine vial, and he’s watching me with interest and some concern. Mom mentions the name of the doctor at the free clinic, whom I know well, and I tell her so. She’s struck by how small a world it is, and I’m able to explain to the patient that we might need to give him some more medicine. I remind him again though that he will know if I am and that he is the boss, applesauce. He grins. We’re stopping, now, and I realize we are in the garage bay.
Mom hops out, my partner comes around and we take the patient out. He is jacked up, riding the automatic cot lift and I see no signs that worry me. We go inside, walking with Mom I ask her permission to approach the staff inside about options for covering the cost of that oh so necessary EpiPen. She agrees, and then we’re in, I’m giving bedside report and the small human is checking out the inside of this new environment. I see a red spot by his ear, and point it out to the nurse.
Leaving the room, I find the most senior ER nurse I see, and quietly fill him in. He directs me to the social worker, who nods during my tale, then reassures me that I shouldn’t worry – the EpiPen can most likely be added to their ER bill for today. Which they aren’t going to be able to afford either, I think to myself. I ask if there are any programs, and she repeats that they will work it into the bill. I meet the eyes of another ER nurse who was once a street medic in my same uniform, and she smiles sadly. I nod, mutely, and head back to the truck in the garage so we can clear and enter the system, ready for the next call.
