Age: 33.0
Sex: M
Vaccine: COVID19
Symptoms: Muscle tightness, Muscle twitching, Pallor, Skin laceration, Unresponsive to stimuli
Clinical narrative: 14:05 (estimation) - Client sat down at vaccination, here for 2nd dose Pfizer with vaccinator. Vaccinator recognized the client from the first dose ? Vaccinator administered first dose, described 1st administration as ?he had no problems at all.? - Client did not mention any history of fainting after medical procedures (or needle fear) at this time. - Per vaccinator, client complained that today?s administration was ?more painful.? Stated that client sat in vaccination chair ?for another 1 or 2 minutes? after administration instead of moving directly to observation. Denies noticing any additional paleness or diaphoresis. Vaccinator asked client ?are you ok?? to client replying ?yes.? - Vaccinator stated that after telling client that he was free to proceed to observation, client was able to stand and walk independently, gait described as ?he was steady.? - Registration stated that client ?looked really pale when he stood up from vaccination.? - Observation Lead met client in observation area, states ?I thought he looked kind of pale so I asked him ?are you okay? instead of my usual ?welcome to observation.? He said he was okay. I asked ?are you sure?? and he said yes.? Client was given post-vaccination paperwork and directions.  14:16 - Client had been sitting in observation for about 10 minutes (per vaccinator). - Multiple staff members (observation and registration staff) witnessed client fall from seated position. Client did not attempt to stand up before fall. - Per Lead ?His back looked tense. I saw him take off his mask so I grabbed for the radio to call you and I saw him go face down [on the floor].? - Per Lead, fellow observation staff member ?stayed in her seat? and did not react after watching client fall. - Safety Officer called to observation area via radio by Lead. - SO arrived and witnessed client face down on floor, unresponsive to verbal stimuli. Bleeding/laceration from left side of head noticed, immediately asked staff to call emergency. Site Director and Lead Vaccinator called emergency? used lead vaccinator?s phone to communicate with EMS dispatcher.  14:17 - Emergency called. - SO observed witness have multiple ?twitching? motions, rolled client to site into recovery position while maintaining c-spine. Clean paper towels used to put pressure on head laceration. - Client began to regain consciousness. Airway clear, client rotated to supine position, supporting head/c-spine and maintaining pressure on head lac. - Client remained in supine. Patient observed to be pale and diaphoretic. - Client able to answer SO?s questions. Alert and Oriented x4 - to self, time, place, and situation. - SO and Lead vaccinator completed phone communication with EMS.  14:21 - Client sat up (remained seated on floor). Re-assessed, AOx4, breathing normal. Denied pain at this time. Oriented to situation, that EMS was called, client was agreeable to go with EMS to ER. - Client was in sitting position for 1 minute. SO noticed client suddenly rolled eyes back and laid back into supine position - head was supported by SO. - Client was unresponsive for ~20 seconds.  14:22 - Client regained consciousness, AOx4. - Client able to answer SO?s questions about health history. Denied chronic health problems that required medication - denied diabetes and history of fainting. - Client did attest to ?when I was younger, I used to feel really sick getting blood drawn, but not always. But when I get physicals with the doctor, I always ask to lay down.? - Client denies pain at this time. Remained in supine position until EMS arrived. Soft surface (towels) laid under client?s head. C-spine maintained.  14:32 - EMS arrives on scene - EMS attach patient to portable monitor. - Vital signs: HR 98, BP 133/82 - Client AOx4, able to answer EMS questions. - SBAR given by SO to EMS. - Client agreed to be transported by EMS via stretcher and ambulance. All belongings taken with EMS (keys, black coat, vaccination card, phone, wallet).   14:40 - SD and SO leads notified via phone of incident.  15:10 - SO notified that Observation staff failed to support Observation Lead in urgent situation. Per Observation Lead, ?she is telling everyone that she just came back from the bathroom but I looked right at her when it happened,? noting that she was not returning from bathroom, but completely present during event.  15:25 - Staff debriefed on incident, all questions from staff answered. Reoriented staff on signs of vasovagal reactions and following proper procedures. - All necessary observation protocols were followed by obs. staff.