Since I'm the one who ran this "ejected" call, I thought I'd bring give you some clarification of the scenario.

And, by the way, neither I nor the hospital staff, figured this out either, so....

When we got the initial call, we were about 5 minutes away from the scene. The call came in as accident, person ejected. As we closed in on the scene, the situation kept being upgraded to "multiple cars 
involved," "multiple patients," "five cars involved," "five critical patients." As more information came in, our service continually upgraded the response, including dispatching a supervisor who 
happened to be nearby to the scene. This particular supervisor has vast experience and is very competent so this was a great asset. I arrived no more than thirty seconds before she did. There were 
several pieces of fire equipment on the scene and I was directed to the ejected patient.

RETROSPECTIVELY, I now realize what was probably happening. But let's take a look. I was advised the patient was unresponsive, which was 
true, but his eyes were open and he was staring straight ahead, though he didn't respond to pain or movement. For whomever it was who pointed out that we (Jeff and I) somehow managed to put "soft and non-tender" re the abd exam, you were right...sometimes you just get used 
to using certain phraseology, and I/we did. Obviously, we didn't know if the abdomen was "tender" or not. The only thing that happened on 
the scene that was odd was that the patient reached over his abdomen with his left hand and seemed to be feeling his RLQ. It was a kind of "absent-minded" motion, not specifically purposeful to watch, but 
curious. It was the only movement of any kind that the patient made. 
He was unresponsive to any stimuli. Of course, now we know that this patient may have had a seizure and this resulted in the accident (the police investigation of the course of the accident confirms this possibility/likelihood). The patient, as he presented to us was probably post-ictal. He had medical bracelets for "cardiac" and "diabetic." The auscultated BP was elevated, pulse normal, 
respirations normal, pupils equal, slightly dilated, sluggish (of course, now that we know the secret).

Remember, we had an ejected unconscious patient, so my primary concern, other than airway and breathing, was to deliver this patient to a surgeon. The presumption MUST BE that this patient has sufferend some kind of head trauma, and other life-threatening internal injuries must be considered as well. And this is where it got a little complicated. The level two trauma center which was about 3-4 
miles away provides adequate to good care, but often is on neuro diversion. With neuro patients, I am diverted away from them more often than not. So I had already put the helicopter, which was about 
15-20 minutes away including ground warmup, on hot standby, before I arrived on the scene. They were in the helicopter and cranked up. I was able to complete an extended primary survey in about a half a minute and called the level 2 center from a portable radio while I was still assessing the patient on the ground. They agreed to accept him, meaning they were available for neuro. The fire service was in 
the process of packaging the patient even as I was doing my primary survey (which agreed with the report they gave me when I arrived) and the patient was rapidly packaged. We were on the scene probably less than 5 minutes, since the supervisor was able to handle triage of the other patients (none of whom were critical). Once in the ambulance, 
we were probably no more than 4-5 minutes from the hospital. Seeing all this in process, I elected not to wait for the helicopter, since I was confident of the ability of the level 2 to care for this patient.

So here's the progress so far:

Quick primary survey
ABC's apparently OK for the moment, oxygen at 100%
Patient unresponsive
Approval by level 2 center 4 miles away to accept this patient, 
Packaged and in the ambulance, probably no more than 5 minutes has passed.

Once in the ambulance, I repeated the extended primary survey (ABCDE) and did a chemstrip on the patient, which was in the 120 range (the 
hospital glucometer read 138, so the 120 was pretty close). I had cardiac monitor leads already hanging so I put them on while I was waiting for the chemstrip and the monitor showed basically NSR/ST. 
And I started setting up an IV. About the time I was ready to stick, the patient started seizing, so I immediately moved to the patient's head and begin suctioning. He maintained good color throughout and his saturation never dropped below 92, if I remember correctly. I could not get an oral airway in -- teeth clenched. I timed the seizure at 2 minutes, 45 seconds, and when it stopped, we were 
pulling up on the ramp at the hospital with a trauma team waiting in the bay.

You can see that we were quite close to the hospital.

The hospital administered ativan and then more ativan once they found out the patient had a seizure history. They ended up paralyzing the patient and intubating him because his seizure activity kept breaking through.

I did no followup on this patient, except to note that he was admitted in critical condition. 

Points: someone suggested removing the nitro patch. According to the information you were given, our initial estimated BP, this probably would have been correct, however, we got an actual auscultated BP while we were packaging him that was something like 180/100, which might also be consistent with a postictal status. Therefore, with 
that high a BP, I didn't worry about the nitro patch. Neither did the hospital.

Did I ever consider seizure as the underlying cause? No, not really.

Why not? Well, I did consider hypoglycemia as a possible cause of the AMS, though the patient did not have the s/sx for that condition. 
But we did check his sugar. I did check his cardiac rhythm. Had this patient presented with this AMS and NO medical bracelets, I would have considered seizure as a possibility, though my treatment would 
have been the same, given the circumstances and the time frame I faced. However, frankly, it just didn't occur to me that someone would be so diligent as to put medical ID for two conditions but leave off a very relevant third one. So, I suppose "seizure history" 
probably entered my mind and left it at about the same moment, ruled out because of the lack of a "seizure" medical bracelet with the others.

Not unreasonable, but...

Over two decades plus in EMS, one sees all sorts of things. This was a new one (incomplete medical history in bracelets) and thus I learned something on this call: that people actually might do something that thoughtless (my old Captain used to point to his head with his forefinger and say, "Think, Larry, THINK"). So now I know that this sort of omission can happen, which is what learning is all about, and is the reason I shared this case with Jeff -- so you can share my experience and vicariously learn what I learned. 

Which, considering that none of you figured it out, is probably good. 
But, again, neither did the hospital nurses and doctors. 

I enjoyed all of your responses and comments and actually learned a few things from you all as well. Thanks for participating.

Larry Davis

Brief quiz related to the  'I feel so ejected' case (opens in a new window)
NOTE about the quizzes: Valerie writes the quizzes to accompany the cases. I got  a few comments on the last quiz. In almost all cases the problem was the tester not reading closely. Read carefully- but if you feel the quiz answer is incorrect or incomplete, do feel free to send your comments to me. ;-)