Age: 15.0
Sex: F
Vaccine: COVID19
Symptoms: Pallor, Skin warm, Weight bearing difficulty
Clinical narrative: Client received her first dose of the Pfizer Covid-19 vaccine (Lot # EW0187 Exp. 08/2021) at 12:38 PM on Wednesday 6/16/21. EMTs and Lead RN responded to the incident. Lead nurse signaled over EMT at approximately 12:44 that she needed the gravity bed for a client. The client was found lethargic when EMTs arrived with a gravity bed. The client was a 15-year-old female with a chief complaint of dizziness. Client?s older brother was present during incident. Interpreter translated information between EMTs/RN and client/client?s brother. The client was alert and tracking to voice. Per the lead nurse, the client was complaining of dizziness after the administration of her first Pfizer vaccination. The client had no known allergies or medical history. The client also did not take any medication. The client's brother stated that ?she had chicken nuggets and a smoothie? to eat at approximately 10:00. The client's brother also stated that ?they had been standing at the border crossing under the sun? for an extended period of time. The client's airway, breathing, and circulation were intact. The client was negative for hives, swelling, shortness of breath, or other signs of anaphylaxis. The client was nauseous, dizzy and complained of numbness on both arms.  The client was unable to bear weight and not following simple commands before she was assisted to gravity bed by EMT and RN. The client then briefly lost consciousness for less than a minute before becoming alert to person, place, date, and event.  EMTs assessed vital signs every 5 minutes for a total duration of a 45-minute observation. Vital signs were taken by EMT with client lying supine immediately after losing consciousness (12:45) and were reported as follows: Blood Pressure (BP) 92/64, Pulse (P) 66, Oxygen Saturation (O2) 99%, Temperature (T) 98. Skin was intact, pale, and cool to touch immediately following patient regaining consciousness. Patient remained lying flat on gravity bed for approximately 10 minutes before she was assisted to a seated position. Patient was in a high-fowlers position when she was given a juice and granola bar. Client then stated that she was ?feeling better?. After an additional 10 minutes sitting on the gravity bed in high-fowlers position, the patient was assisted by RN and EMT from vaccination station to EMT/observation station. The client remained seated in the EMT/observation station for an additional 15 minutes. Vital signs were taken every 5 minutes during this time by EMT. They were reported as follows:  12:51- BP 112/78, P 69, O2 97%, T 98. 12:55- BP 108/78, P 77, O2 99%, T 97.9. 13:00- BP 104/78, P 66, O2 98%, T 98.1. 13:05- BP 96/62, P 83, O2 95%, T 98.1. 13:10- BP 92/68, P 76, O2 98%, T 98.1. 13:20- BP 90/70, P 92, O2 99%, T 97.6. 13:28- BP 92/72, P 93, O2 99%, T 97.9.   After a 45-minute observation, client stated her condition was improving and was observed walking normally. Client?s skin color returned to a pale pink and became warm to the touch. Client denied dizziness or any other symptoms. Lead RN educated the client about what to do if symptoms returned. The client was provided with the V-Safe form and EUA form with highlighted portions pertaining to symptoms to be mindful of. The client was also instructed to call 9-1-1 if symptoms of anaphylaxis, also known as a severe allergic reaction, presented. These symptoms include difficulty breathing, shortness of breath, hives covering body, facial swelling and more. Client and client?s brother acknowledged understanding of information. The client?s brother stated that he would ?drive her straight home?. The client then left facility at approximately 13:33 with her older brother in positive disposition with steady gait.