Age: 8.0
Sex: F
Vaccine: COVID19
Symptoms: Anxiety, Body temperature increased, Headache, Nervousness, Respiratory rate increased
Clinical narrative: Patient (Date of Birth: 8/18/2013) is an 8-year-old female patient vaccinated at 12:23pm 1st dose Child Pfizer 5-11 (Lot #FK5618) by, LPN in her Left Deltoid. Per patient's Spanish speaking father who communicated with staff via Language Line Spanish video interpreter, the patient completed her post-vaccination observation period at 12:47pm and was fine when she left the clinic without issues.   Patient's father stated that his daughter was doing good when she left the clinic after observation and was playing outside the Outlet mall in the snow. She then started complaining of a headache while playing in the snow and he brought the patient back to our clinic door around 1:17pm. He did not report any injuries while she was playing in the snow. He did not have her vaccine card with him at the time.   With the Spanish interpreter (video) it was communicated by 8-year-old that she had a headache. Assessed by this Charge RN the patient appeared very anxious and nervous. Patient and her father both stated she was nervous and anxious before coming for vaccine that day. Patient and father reported to staff that the vaccinated minor did not have much to eat the day of vaccination and only ate some bacon for breakfast. Offered and accepted apple juice with parent's permission. Patient drank juice without issue.  This RN began a verbal assessment, patient reports she was nervous for the vaccine. As this RN continued to assess the patient, she appeared to become even more anxious and nervous, with visible increase in her respirations, and this RN could visibly see the patient shaking her hands and arms. Patient denied she was having difficulty breathing, she did not know why she was shaking, and she was able to continue to speak in complete sentences via video Spanish interpretation.   To further assess and evaluate, the guest and her father were safely escorted to the medical area via wheelchair. At this time the patient's father called the other family members around 1:30pm for the patient's vaccine card. Patient's mother (Spanish-speaking only), and other family members who both spoke English: (the patient's uncle) and (patient's Cousin), all arrived around 1:40pm. The mother and uncle began to attempt to calm the patient down encouraging her to breathe slowly in through her nose and out through her mouth as educated by RN staff.   Patient appeared to be very anxious, shaking her arms and hands, but she was alert, conscious, and oriented. She spoke with complete coherent sentences via interpreter.    Ice pack was provided with parent consent. Parents were informed via video Spanish interpreter that EMS/911 was activated for patient per Site Supervisor. Patient's parents both agreed.   Fire and Rescue/EMS Team- (Run # AF2114331) that his Spanish speaking EMS team member/partner would continue the assessment of the patient and Spanish video interpretation ended once they arrived. Parents agreed. EMS assessed the patient, and they reported the following patient vitals 132/20, HR 100, O2 Sat 99%, Temp 101.3F, Respiration Rate 20, MAP 5.   The EMS team also reported that the mother told them that she was a nurse in Mexico. The mother said the patient has no history of seizures or taking any other medications. Patient eventually began to calm down and was no longer shaking. The patient stated that her breathing was getting better and that she was feeling better. However, her hands and arms were still shaking intermittently.  EMS offered and encouraged the parents to allow them to call an aid car to take the patient to the emergency room for further follow-up. Both the parents refused EMS. This writer and the EMS team discussed with the parents the risks of declining transport for further assessment of their minor child. Parents understood education and still declined. The patient began to breathe normally, and following patient parent refusal of aid transport, the patient was stable, and EMS ended their clinical encounter and departed the facility.   As the family was leaving, the parents asked this RN to call the firefighters/EMS back to take her to the hospital as they had changed their mind. This writer went and relayed the parents request to the EMS went to retrieve firefighters/EMS but when the EMS team returned the patient Uncle listed above stated that the parents had left the vaccination facility to go to the mall restrooms. The Uncle escorted the firefighters with him to assess the patient. The firefighters/EMS then as they were walking by the vaccination clinic returning to their fire truck stated that the parents refused transport again when they were found at Outlet Mall public restrooms. Vaccination Site Nurse Supervisor aware.