# Assumed Wrong on a TIA



## JVEMT (Mar 12, 2009)

Again proving a fellow crew wrong. Dispatched for a possible CVA. Daughter states during dinner the mother’s face drooped for no apparent reason. BLS arrives and finds that patient is A&Ox3, no apparent distress. BLS does full exam, including stroke assessments and vitals, all comes out “normal”. BLS cancels ALS. Arriving at hospital, patient has another episode of one-sided of “drooping”. Based on the above happenings, BLS states she they think she was having a TIA. The cancelled medics due to their initial assessment, not because maybe they could have gotten to the hospital quicker. They claim medics could not have done anything to help her. Do you agree or disagree? And please inform me on ALS procesdires for CVAs. Thanks.


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## firecoins (Mar 12, 2009)

It was an ALS assessment that was needed initially.  BLS assessment was not enough. This woman needed to be put on a monitor amoung other things.  There people here who know more.  Ill let them answer.


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## Scott33 (Mar 12, 2009)

firecoins said:


> This woman needed to be put on a monitor amoung other things.



Why?

ALS standard of care perhaps. But what benefit does it do the patient?

CVAs are prioritized as ALS calls, but I wouldn't wait around for them, just so they can document a blood sugar, or start an IV which may or may not complicate things if they decide to infuse fluids. 

The patient needs a head CT.


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## firecoins (Mar 12, 2009)

Scott33 said:


> Why?
> ALS standard of care perhaps. But what benefit does it do the patient?


Because BLS crews might not recognize it.  Pt needs to be brought to a stroke center so recognizing it and alerting the ER saves alot of time. So yes, ALS standard of care.


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## medic417 (Mar 12, 2009)

OP says not closer to hospital so should have stayed and waited for ALS.  Again another arguement for a Paramedic on every ambulance.


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## Sasha (Mar 12, 2009)

medic417 said:


> OP says not closer to hospital so should have stayed and waited for ALS.  Again another arguement for a Paramedic on every ambulance.



Now from a potentially educational post this is going to deteriorate into "Everywhere should be ALS!" too which areas that don't have ALS will appear with the "Stop picking on us! We can't afford it!" argument and the thread will turn into fighting and be locked...

I agree, while this does deserve an ALS assesment and a paramedic present in case the patient decides to try and die, there is very little ALS can do for a stroke or TIA. The best thing you can do is hustle to the definitive care and not to delay on scene times. However, I'm operating under the assumption that a EMT in your area can preform a BGL check to r/o hypoglycemia. In that case, there would be a greater need for the paramedic.


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## firecoins (Mar 12, 2009)

Sasha said:


> Now from a potentially educational post this is going to deteriorate into "Everywhere should be ALS!" too which areas that don't have ALS will appear with the "Stop picking on us! We can't afford it!" argument and the thread will turn into fighting and be locked.



Everywhere should be ALS

Stop picking on us! We can't afford it!

punch!

kick!

gun shot!

FFEMT "thread is locked for 24 hours"

stab wound!

FFEMT "thread is closed permanently. 


By the way EMT-Bs in my area can not check BS.


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## Sasha (Mar 12, 2009)

> By the way EMT-Bs in my area can not check BS.



I don't get that. I understand some EMTs aren't smart enough to find their way out of a paper bag and tend to ruin things for the whole bunch (some medics, too!) but how can you possibly mess up a glucose check? Accidently stab them in the eye with a lancet? So in some areas instead of checking a BGL before giving oral glucose to a potentially hypoglycemic patient the EMTs are to just give it to them blindly. If they are trusted enough to assess for hypoglycemia they should be trusted enough to confirm their suspicion with a glucometer.


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## AJ Hidell (Mar 12, 2009)

Sasha said:


> ...how can you possibly mess up a glucose check? Accidently stab them in the eye with a lancet? So in some areas instead of checking a BGL before giving oral glucose to a potentially hypoglycemic patient the EMTs are to just give it to them blindly. If they are trusted enough to assess for hypoglycemia they should be trusted enough to confirm their suspicion with a glucometer.


That sounds good on the surface, but under closer scrutiny, it doesn't really bare out.  BGL is a single isolated sign.  It should not be evaluated as such.  It should be evaluated in the context of a complete, advanced assessment.  EMTs simply do not receive the education to complete such an assessment.  Consequently, there is too much risk of them getting tunnel visioned on the BGL, just like they do with SpO2, resulting in a botched assessment and incorrect treatment of the patient.  They see a BGL of 80 and get all hung up on getting the patient to down some glucose when the BGL was not the main problem, and they should have been on the road to a stroke center.  You simply cannot teach or learn good assessment skills -- and all the other crap they teach in EMT school these days -- in 120 hours.

ALS is an all or nothing proposition.  You can't piece mail out advanced "skills" a la carte and expect it to result in competent practice.  And, unlike something like defibrillation, there is not enough patient benefit realized from BGL determinations to dump it on minimally trained providers.

As to the original post, the only safe answer is the one that was already given.  The patient should have had an advanced assessment in the first place.  He was showing obvious neuro deficits, including altered mental status and disorientation.  It may have been a stroke.  It may have been one or two of a hundred other things that present similarly.  Whether he needed ALS care is not clear from the information you give.  Probably not, but the situation certainly may have quickly deteriorated to that point.  By the time that happens, it's too late to recall ALS to help you, and you're likely to get fired for that error.  On the other hand, if the patient was indeed having a stroke, then time is of the essence, so undue delays are not warranted.  If the ALS truck was on it's way and was going to arrive within a minute of when you were going to depart with the patient, then you should have waited.  If you were looking at sitting around and twiddling your thumbs for five minutes waiting for them, then your partner was probably right to hit the road.  It is sometimes a tough call, but that is the kind of dilemma that is placed upon providers in a tiered system.  That's why so many of us hate tiered systems.


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## MSDeltaFlt (Mar 12, 2009)

JVEMT said:


> Again proving a fellow crew wrong. Dispatched for a possible CVA. Daughter states during dinner the mother’s face drooped for no apparent reason. *BLS arrives and finds that patient is A&Ox3, no apparent distress. BLS does full exam, including stroke assessments and vitals, all comes out “normal”*. BLS cancels ALS. Arriving at hospital, patient has another episode of one-sided of “drooping”. Based on the above happenings, BLS states she they think she was having a TIA. The cancelled medics due to their initial assessment, not because maybe they could have gotten to the hospital quicker. They claim medics could not have done anything to help her. Do you agree or disagree? And please inform me on ALS procesdires for CVAs. Thanks.


 
It appears they followed their protocols.  They did fine.  No problems.


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## firecoins (Mar 12, 2009)

Sasha said:


> I don't get that. I understand some EMTs aren't smart enough to find their way out of a paper bag and tend to ruin things for the whole bunch (some medics, too!) but how can you possibly mess up a glucose check? Accidently stab them in the eye with a lancet? So in some areas instead of checking a BGL before giving oral glucose to a potentially hypoglycemic patient the EMTs are to just give it to them blindly. If they are trusted enough to assess for hypoglycemia they should be trusted enough to confirm their suspicion with a glucometer.



It isn't that EMT-bs will mess up. Originally EMTs were not allowed to do anything that breaks the skin. Protocols were changed for the possibility that EMT-Bs could do this. Up to now there this no money for the glucometers and in service training required.  Since we have ALS flycars with 2 medics on board that respond to most if not all calls, it is unnecessary for EMT-Bs and paramedic to check.  BLS treatments would not be altered by the glucometer reading anyway.


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## firecoins (Mar 12, 2009)

MSDeltaFlt said:


> It appears they followed their protocols.  They did fine.  No problems.



i don't think they did anything horribly wrong.  I just think it is an ALS call.


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## Sasha (Mar 12, 2009)

AJ Hidell said:


> That sounds good on the surface, but under closer scrutiny, it doesn't really bare out.  BGL is a single isolated sign.  It should not be evaluated as such.  It should be evaluated in the context of a complete, advanced assessment.  EMTs simply do not receive the education to complete such an assessment.  Consequently, there is too much risk of them getting tunnel visioned on the BGL, just like they do with SpO2, resulting in a botched assessment and incorrect treatment of the patient.  They see a BGL of 80 and get all hung up on getting the patient to down some glucose when the BGL was not the main problem, and they should have been on the road to a stroke center.  You simply cannot teach or learn good assessment skills -- and all the other crap they teach in EMT school these days -- in 120 hours.
> 
> ALS is an all or nothing proposition.  You can't piece mail out advanced "skills" a la carte and expect it to result in competent practice.  And, unlike something like defibrillation, there is not enough patient benefit realized from BGL determinations to dump it on minimally trained providers.



I get what you are saying... to a degree. But why do they have oral glucose at all, then? If you feel an EMT will get tunnel visioned, don't you feel that's still possible with or without the glucometer? If they feel it's hypoglycemia, they are still going to administer oral glucose if not contraindicated and still may botch the assesment.

And let's not limit this to just EMTs. Paramedics get tunnel visioned too with pulse ox and glucometers. I've been in the hospital too many times when there paramedic argues with the nurse or doctor, or vice versa "But her SpO2 read 96%!! She's breathing just fine!" "Yeah, this is the broken leg patient... no she didn't have AMS but I gave her D50 because her blood glucose read 54! No.. I don't remember when the last time the glucometer was calibrated... no.. we didn't do it this morning..."


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## mikeN (Mar 12, 2009)

If it was a new onset of facial drooping I wouldn't have cancelled medics. This thread kind of went into focusing more on glucose than the actual tia, but only BLS would do such a thing. ^_^.


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## AJ Hidell (Mar 12, 2009)

Sasha said:


> But why do they have oral glucose at all, then?


For empirical, symptomatic treatment of cut and dried diabetic situations, such as the diabetic who gives a clear history of insulin administration without adequate caloric intake.  Nothing wrong with that.  But neither the glucose nor the glucometer should be used for a fishing expedition by someone not adequately educated to perform a more thorough assessment.


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## medic417 (Mar 12, 2009)

JVEMT said:


> Again proving a fellow crew wrong. Dispatched for a possible CVA. Daughter states during dinner the mother’s face drooped for no apparent reason. BLS arrives and finds that patient is A&Ox3, no apparent distress. *BLS does full exam*, including stroke assessments and vitals, all comes out “normal”. BLS cancels ALS. Arriving at hospital, patient has another episode of one-sided of “drooping”. Based on the above happenings, BLS states she they think she was having a TIA. The cancelled medics due to their initial assessment, not because maybe they could have gotten to the hospital quicker. They claim medics could not have done anything to help her. Do you agree or disagree? And please inform me on ALS procesdires for CVAs. Thanks.




They're BLS no way for them to do a full exam.  A BLS assessment leaves out way to much information.  

ALS can start process for that fancy new fangled thrombolytic drug.  Some even can administer it.  Also ALS can already have blood draws, IV's, 12 lead, etc saving time at the ER so patient can get to definitive care quicker.


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## Sasha (Mar 12, 2009)

medic417 said:


> They're BLS no way for them to do a full exam.  A BLS assessment leaves out way to much information.
> 
> ALS can start process for that fancy new fangled thrombolytic drug.  Some even can administer it.  Also ALS can already have blood draws, IV's, 12 lead, etc saving time at the ER so patient can get to definitive care quicker.



A lot of the process for new fangled thrombolytic drugs require labs and a CT confirming the fact it's an ischemic stroke, not a hemorrhage. The last I checked, a CT machine was not the standard of care, prehospitally, and there is no way to tell, in the presentation of a stroke if it's a clot or a bleed.

They need to get the patient to the hospital, not wait around for ALS to arrive so they can take the patient, waste time on scene getting their 12 lead and IV, and then head to the hospital with a stroke alert.


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## medic417 (Mar 12, 2009)

Sasha said:


> A lot of the process for new fangled thrombolytic drugs require labs and a CT confirming the fact it's an ischemic stroke, not a hemorrhage. The last I checked, a CT machine was not the standard of care, prehospitally, and there is no way to tell, in the presentation of a stroke if it's a clot or a bleed.
> 
> They need to get the patient to the hospital, not wait around for ALS to arrive so they can take the patient, waste time on scene getting their 12 lead and IV, and then head to the hospital with a stroke alert.



I'm hurt you reverted to basic thinking.


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## Sasha (Mar 12, 2009)

medic417 said:


> I'm hurt you reverted to basic thinking.



I'm hurt you can't seem to think past a blanket statement.

What does this patient need? I think we can all agree this patient needs a hospital.

Whoever can get them there the quickest should go ahead and take them. Soemtimes ALS gets so wrapped up in "ALS procedure" that they delay on scene time and getting them to that hospital.


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## medic417 (Mar 12, 2009)

Sasha said:


> I'm hurt you can't seem to think past a blanket statement.
> 
> What does this patient need? I think we can all agree this patient needs a hospital.
> 
> Whoever can get them there the quickest should go ahead and take them. Soemtimes ALS gets so wrapped up in "ALS procedure" that they delay on scene time and getting them to that hospital.



No delay.  OP even said they were not closer to hospital.  IV and blood draw in route.  12 lead ads 30 seconds to scene time.  wow we now call hospital with more complete details they gather stroke team.  We get checklist started.  Get there they complete checklist and boom.  By adding 30 seconds we saved minutes if not hours depending on the ER.  And again some services now administer.


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## triemal04 (Mar 12, 2009)

Sasha said:


> I'm hurt you can't seem to think past a blanket statement.
> 
> What does this patient need? I think we can all agree this patient needs a hospital.
> 
> Whoever can get them there the quickest should go ahead and take them. Soemtimes ALS gets so wrapped up in "ALS procedure" that they delay on scene time and getting them to that hospital.


This pt needs a particular kind of hospital, if at all possible.  The local community hospital that is 15 blocks away wouldn't be the best choice if there is a stroke center 30 blocks away.  While there isn't a lot that will be done by a paramedic for someone having a relatively uncomplicated stroke that will help fix the problem versus a basic, as happens normally, recognition of what is happening is key.  Knowing that they are having a stroke (or are at high risk for one) and being able to start going through inclusion/exclusion criteria (though this will get redone) is a better thing to do than just toss on a gurney and go.


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## Sasha (Mar 12, 2009)

medic417 said:


> No delay.  OP even said they were not closer to hospital.  IV and blood draw in route.  12 lead ads 30 seconds to scene time.  wow we now call hospital with more complete details they gather stroke team.  We get checklist started.  Get there they complete checklist and boom.  By adding 30 seconds we saved minutes if not hours depending on the ER.  And again some services now administer.



Thats with the assumption that ALS is not 20 minutes out. Perhaps they weren't closer to the hospital, but that doesn't mean they'll be there in 2-3 minutes. 

I agree they need to be taken to a stroke center (perhaps we're spoiled here, all but one hospital with in a 20 minute travel time from the area I do rides are stroke centers.) but what kind of genius does it take to recognize a stroke? If an EMT is not capable of that, then perhaps they should revisit EMT school.


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## AJ Hidell (Mar 12, 2009)

Sasha said:


> ...what kind of genius does it take to recognize a stroke? If an EMT is not capable of that, then perhaps they should revisit EMT school.


Practicing physicians -- with at least 9 years of education -- have a 75 percent success rate at accurately diagnosing strokes with only an initial physical examination.  Now, do you really think that 120 hours of technical training -- most of which is focused on trauma skills -- is likely to result in a more impressive competency rate?


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## Sasha (Mar 12, 2009)

AJ Hidell said:


> Practicing physicians -- with at least 9 years of education -- have a 75 percent success rate at accurately diagnosing strokes with only an initial physical examination.  Now, do you really think that 120 hours of technical training -- most of which is focused on trauma skills -- is likely to result in a more impressive competency rate?



Is a paramedic?


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## Scott33 (Mar 12, 2009)

medic417 said:


> ALS can start process for that fancy new fangled thrombolytic drug.  Some even can administer it.



Really? And which service is this that can rule out hemorrhagic vs ischemic stroke in the field?


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## triemal04 (Mar 12, 2009)

Scott33 said:


> Really? And which service is this that can rule out hemorrhagic vs ischemic stroke in the field?


None that I know of carries thrombolytics for CVA's.  Some for MI's although that has been called into question in the last 5 years or so.  Best thing a paramedic can do is recognize the problem, get them to the right place, and start screening them for thrombolytics.


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## Scott33 (Mar 12, 2009)

Precisely. 

A few places in the county, and many places in the world, routinely give thrombolytics prehospitally. For MIs not for CVAs.


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## reaper (Mar 12, 2009)

Look into the field trials of Factor VII. There are great trials going on with it. One of the flight services in FL has been testing it for a few years now. This is where thrombolytics for CVA's may come into the prehospital environment. It is interesting how the two work together on any type of CVA.


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## AJ Hidell (Mar 12, 2009)

Sasha said:


> Is a paramedic?


Depends on the paramedic.  I don't have a lot of confidence in the competence of most paramedics either.  But yes, there is a much greater possibility that they are more competent at physical examination and diagnosis than someone with three weeks of night school.


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## triemal04 (Mar 12, 2009)

reaper said:


> Look into the field trials of Factor VII. There are great trials going on with it. One of the flight services in FL has been testing it for a few years now. This is where thrombolytics for CVA's may come into the prehospital environment. It is interesting how the two work together on any type of CVA.


Got anymore info on that?  At a quick glance it seems like the initial results from testing Factor VII on hemmorhagic strokes weren't as good as was thought.  I can see how they could be used in conjunction with each other, but it seems like it'd be a touchy situation with the need for almost constant labs...not something we can really do unfortunately.


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## medic417 (Mar 12, 2009)

http://www.medwire-news.md/39/78534/Stroke/Pre-hospital_triage_boosts_stroke_thrombolysis_use.html

"MedWire News: Use of a pre-hospital stroke assessment tool by ambulance staff leads to a large increase in the proportion of patients receiving thrombolysis treatment, say Australian researchers.

Implementing the process resulted in a four-fold increase in stroke thrombolysis, Christopher Levi (Hunter Medical Research Institute, Newcastle) and colleagues report in the Medical Journal of Australia."

Guess ALS assessment is just not that important after all.


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## triemal04 (Mar 12, 2009)

medic417 said:


> http://www.medwire-news.md/39/78534/Stroke/Pre-hospital_triage_boosts_stroke_thrombolysis_use.html
> 
> "MedWire News: Use of a pre-hospital stroke assessment tool by ambulance staff leads to a large increase in the proportion of patients receiving thrombolysis treatment, say Australian researchers.
> 
> ...


Uh...did you actually read that or just post it?  Because...hate to tell you...it doesn't help your arguement about having paramedics available all the time.


> The Pre-hospital Acute Stroke Triage (PAST) protocol is based on four elements: the presence of hemiparesis, impaired speech, and normal glucose levels, and a time from symptom onset of less than 2 hours.
> 
> If ambulance personnel find a patient meets these criteria, is older than 18 years old, and is normally ambulant, then they activate the Stroke Intervention Protocol. This involves taking the patient directly to a hospital providing specialist stroke services, and pre-notifying hospital staff of the patient’s arrival.



All that is is another version of the LA stroke scale, with a couple things removed.  

While not knocking what they are doing, it isn't anything that extradordinary.

Edit:  If you want to argue for having paramedics treat a specific problem, you need to give out good, accurate reasons.  The above is not one unfortunately.


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## Scott33 (Mar 12, 2009)

Errr.

Your link to an Australian EMS piece of research is higlingting the need for a rapid neuro assessment. It is basically a modified Cincinatti stroke scale with blood sugar tagged on. No reference is given to ALS vs BLS interventions, and the use of prehospital thrombolysis for CVA is still noticably basent.

Nothing that most of us didn't already know.

Incidently, with the Australlian system, some of their BLS providers a referred to as Paramedics, depending on what part of the country they are in.


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## medic417 (Mar 12, 2009)

My point with that study is that EMS does play a part in improving patient outcome.  In the USA the basics are not educated enough to do the assessment.  Based on the assessment in the field patient care improved.  So common sense says having a Paramedic perform said assessment would improve patient outcome because even treatment at the hospital would improve by being activated much quicker.


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## reaper (Mar 12, 2009)

I have had no luck on finding a newer report on the Factor VII issue. This one is a few years old. All the articles I read, pretty much refer to this one article.

http://content.nejm.org/cgi/content/abstract/352/8/777


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## triemal04 (Mar 12, 2009)

reaper said:


> I have had no luck on finding a newer report on the Factor VII issue. This one is a few years old. All the articles I read, pretty much refer to this one article.
> 
> http://content.nejm.org/cgi/content/abstract/352/8/777


That was one I saw.

http://www.medscape.com/viewarticle/557558
Not definative, they just agree that more study needs to be done.  Definetly seems like something that could be beneficial for hemmorhagic strokes and potentially hemmorhage in general (couple studies on that had similar results as above; more research is needed)


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## bstone (Mar 12, 2009)

medic417 said:


> OP says not closer to hospital so should have stayed and waited for ALS.  Again another arguement for a Paramedic on every ambulance.



I was in New York City over the weekend and was a bystander to an elderly woman falling and fx her hip. The responding crew was BLS, two Basics. The lady needed fluids and pain meds. Yes, a medic on every bus.


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## triemal04 (Mar 12, 2009)

medic417 said:


> My point with that study is that EMS does play a part in improving patient outcome.  In the USA the basics are not educated enough to do the assessment.  Based on the assessment in the field patient care improved.  So common sense says having a Paramedic perform said assessment would improve patient outcome because even treatment at the hospital would improve by being activated much quicker.





medic417 said:


> Guess ALS assessment is just not that important after all.


I'm pretty sure that was your point actually.  It's a stretch, I know, but still...

All that study showed is that when a caregiver sees one-sided weakness, impaired speech, normal blood glucose, and a recent onset they should transport them to an appropriate, predetermined hospital that can appropriately treat them.  Not rocket science I'm afraid.

If you want to show that having a paramedic perform care for specific problems is needed, you need to demonstrate why it is needed.  The above does not accomplish that.


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## Scott33 (Mar 12, 2009)

bstone said:


> The lady needed fluids and pain meds.



She probably got both within 10 minutes of the doors being shut, given the lack of transport time in NYC.

I do agree with the principle of a medic on every ambulance. Perhaps it would mean the end of the role of EMT-B in anything other than the driver / bag monkey role.


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## firecoins (Mar 12, 2009)

bstone said:


> I was in New York City over the weekend and was a bystander to an elderly woman falling and fx her hip. The responding crew was BLS, two Basics. The lady needed fluids and pain meds. Yes, a medic on every bus.



you were in NY and didn't call?  The shame!

NYC is weird but she was probably in the hospital in 5 minutes. It isn't a defense but....


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## bstone (Mar 12, 2009)

Scott33 said:


> She probably got both within 10 minutes of the doors being shut, given the lack of transport time in NYC.
> 
> I do agree with the principle of a medic on every ambulance. Perhaps it would mean the end of the role of EMT-B in anything other than the driver / bag monkey role.



10 minutes on the ground, 10 minutes to the hospital, 10 more minutes until she is assessed and treated= 30 minutes

vs

10 minutes on the ground, 5 minutes until a line with fluids and meds administered=15 minutes

If you fx your hip would you really want to be moved and driven on bumpy streets and then moved again and wait until you got the beginnings of treatment?


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## bstone (Mar 12, 2009)

firecoins said:


> you were in NY and didn't call?  The shame!
> 
> NYC is weird but she was probably in the hospital in 5 minutes. It isn't a defense but....



Hah! Sorry! I was in town for my cousin's engagement party. Had a blast!


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## AJ Hidell (Mar 12, 2009)

Scott33 said:


> I do agree with the principle of a medic on every ambulance. Perhaps it would mean the end of the role of EMT-B in anything other than the driver / bag monkey role.


Nah.  The majority of all EMTs in this country are either first responders, IFT techs, or unemployed anyhow.  Removing them from EMS ambulances would not significantly change that.  They should be on their way to paramedic school anyhow.


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## MSDeltaFlt (Mar 12, 2009)

firecoins said:


> i don't think they did anything horribly wrong. I just think it is an ALS call.


 
It may have been in your eyes.  It may have been in my eyes as well.  This whole thread is Monday morning armchair quarterbacking.  The OP said that the pt's face drooped, then did it again in the ER.  That tells me it wasn't doing it in their presence.  So there were *no signs of CVA* on their assessment; which is why they cancelled ALS.

If they* followed their protocols*, then no foul.


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## Scott33 (Mar 12, 2009)

bstone said:


> 10 minutes on the ground, 10 minutes to the hospital, 10 more minutes until she is assessed and treated= 30 minutes
> 
> vs
> 
> ...



Not disagreeing with you. I don't think we take pain management remotely seriously enough at any level in EMS. Even at the BLS level, N2O should be standard prior to stabilizing. 

Tell me, did they neglect to use the scoop, in favor of rolling her onto a longboard?


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## Sasha (Mar 12, 2009)

> The Pre-hospital Acute Stroke Triage (PAST) protocol is based on four elements: the presence of hemiparesis, impaired speech, and normal glucose levels, and a time from symptom onset of less than 2 hours.
> 
> If ambulance personnel find a patient meets these criteria, is older than 18 years old, and is normally ambulant, then they activate the Stroke Intervention Protocol. This involves taking the patient directly to a hospital providing specialist stroke services, and pre-notifying hospital staff of the patient’s arrival.



Perhaps I'm seriously misguided, but what part of this, bar the glucose check in places that do not allow for a basic to preform a BGL check, cannot be preformed by a Basic?

Sounds like a good history, and a "Squeeze my fingers, push on my hands, say such and such phrase" would take care of that.


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## alphatrauma (Mar 12, 2009)

*Bells Palsy*



JVEMT said:


> Assumed Wrong on a TIA



Sounds to me like *Bells Palsy*, which is commonly mistaken for a TIA by the untrained/unfamiliar. While it is unlikely the EMTs suspected Bells Palsy, this patient was STABLE, and ultimately their decision to forego ALS was appropriate. There is nothing a Medic, thrombolytics, monitoring, or ER treatment can do for this patient. Outpatient Neuro followup is what's needed.


A Bells Palsy patient will *NOT* have any involvement of the extremities on the affected side. They will also have no memory deficit or behavioral changes, and gait will be normal. I think the EMTs got this one right... and when the heck did glucose come into this :sad:


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## triemal04 (Mar 12, 2009)

alphatrauma said:


> Sounds to me like *Bells Palsy*, which is commonly mistaken for a TIA by the untrained/unfamiliar. While it is unlikely the EMTs suspected Bells Palsy, this patient was STABLE, and ultimately their decision to forego ALS was appropriate. There is nothing a Medic, thrombolytics, monitoring, or ER treatment can do for this patient. Outpatient Neuro followup is what's needed.
> 
> 
> A Bells Palsy patient will *NOT* have any involvement of the extremities on the affected side. They will also have no memory deficit or behavioral changes, and gait will be normal. I think the EMTs got this one right... and when the heck did glucose come into this :sad:


This is where having only a little education can be dangerous.  Is it possible that was Bell's Palsy?  Yes.  Is it possible that was a TIA?  Yes.  And that the second occurence was also a TIA or the beginning of a full blown CVA?  Yes.

Some good references:
http://emedicine.medscape.com/article/791311-overview
http://www.emedicinehealth.com/transient_ischemic_attack_mini-stroke/article_em.htm
http://emedicine.medscape.com/article/794281-overview

And this is a good example of why having a proper, paramedic level assessment done is appropriate.  While this could be something like Bell's, it also could be more.  And it will be, given the situation, impossible to determine which with complete accuracy in the field.  So, while nothing will be done prehospital, the pt will still need to be taken to a hospital capable of treating CVA's in a rapid manner.  It would not be appropriate to assume that it's nothing, blow it off, and take them to a local hospital, or worse, tell them to ignore it and follow up with their PCP in a couple of days.

It's also worth remembering, or maybe learning for the first time, that not all TIA's (hell, not all CVA's either) will present with the classic signs of facial droop, slurred speech, and one-sided weakness.  Some may have slurred speech only, or facial droop, or only be complaining of a headache, or severe nausea.  But all are having the same problem.  Once again, recognition is the most important thing paramedic's do that EMT's don't.

And you may want to look up how thrombolytics are used in the treatement of CVA's.  And how hypoglycemia can present; might clue you in on why a cbg is neccasary.

Edit:  This is on CVA's in particular.  http://emedicine.medscape.com/article/793904-overview  You'll notice that under the differntial dx's that need to be ruled out, Bell's Palsy is one of them.


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## medic417 (Mar 12, 2009)

triemal04 said:


> This is where having only a little education can be dangerous.  Is it possible that was Bell's Palsy?  Yes.  Is it possible that was a TIA?  Yes.  And that the second occurence was also a TIA or the beginning of a full blown CVA?  Yes.
> 
> Some good references:
> http://emedicine.medscape.com/article/791311-overview
> ...



Very good response.  I am going to try to work on how I answer in the forums.  My methods seem to be leaving to many lost and confused.


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## Sasha (Mar 12, 2009)

medic417 said:


> Very good response.  I am going to try to work on how I answer in the forums.  My methods seem to be leaving to many lost and confused.



Because you don't explain things! You can't sit there and tell everyone that you're right with out explaining why you're right. Yes, you have more education than me, but that doesn't mean you're above being wrong and I'm going to blindly agree with you.

Guess what? I agree with you now, but in order to agree with you I had to ask Veneficious to explain to me how a BLS assessment for a stroke would be different from an ALS assessment and he explained it to me in detail. He also explained how one would differentiate possibly from a bleed and a clot. You didn't do that! Even when asked! 

Instead of just preaching about education why don't you try doing a little educating? You may be received better.


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## medic417 (Mar 12, 2009)

Sasha said:


> Because you don't explain things! You can't sit there and tell everyone that you're right with out explaining why you're right. Yes, you have more education than me, but that doesn't mean you're above being wrong and I'm going to blindly agree with you.
> 
> Guess what? I agree with you now, but in order to agree with you I had to ask Veneficious to explain to me how a BLS assessment for a stroke would differ in depth from an ALS assessment and he explained it to me in detail. He also explained how one would differentiate possibly from a bleed and a clot. You didn't do that! Even when asked!
> 
> Instead of just preaching about education why don't you try doing a little educating? You may be received better.



Well thank you grasshopper even an educator can learn how to use the intenet to educate.


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## alphatrauma (Mar 13, 2009)

triemal04 said:


> This is where having only a little education can be dangerous.



...or having too much




triemal04 said:


> Is it possible that was Bell's Palsy?  Yes.  Is it possible that was a TIA?  Yes.  And that the second occurence was also a TIA or the beginning of a full blown CVA?  Yes.




Agreed, but it doesn't take a medic to perform a competent assessment and safe/rapid transport. 



triemal04 said:


> And this is a good example of why having a proper, paramedic level assessment done is appropriate.  While this could be something like Bell's, it also could be more.



This is a terrible example of why Paramedic level assessment/intervention is needed... because it wasn't. Unless medics are now equipped with a GE Lightspeed or Siemens Somatom strapped to their backs, there is no need for them on scene (unless already there) for a patient presenting like the one described. 

Could it be more... sure. Just like an 19 year old male with chest discomfort  could be having an MI. We could play this game with any patient/complaint.



triemal04 said:


> And it will be, given the situation, impossible to determine which with complete accuracy in the field.



which can be said for just about any condition/complaint




triemal04 said:


> So, while nothing will be done prehospital, the pt will still need to be taken to a hospital capable of treating CVA's in a rapid manner.



On this point we both agree... and the EMTs did just that





triemal04 said:


> It would not be appropriate to assume that it's nothing, blow it off, and take them to a local hospital, or worse, tell them to ignore it and follow up with their PCP in a couple of days.



Where did I say, assume that it's nothing and tell the patient to ignore the symptoms or blow it off? The crew transported the patient to the facility, where (Physician) evaluation and diagnostic testing would ensue.



triemal04 said:


> It's also worth remembering, or maybe learning for the first time, that not all TIA's (hell, not all CVA's either) will present with the classic signs of facial droop, slurred speech, and one-sided weakness.  Some may have slurred speech only, or facial droop, or only be complaining of a headache, or severe nausea.  But all are having the same problem.  Once again, recognition is the most important thing paramedic's do that EMT's don't.



The EMTs "recognized" that the patient was *STABLE*, ALS was *NOT NEEDED* and transported appropriately.  I'm quite aware of atypical presentations, but this patient (according to the OP description) was not one of those cases. I agree totally that medics are needed in many situations where basics are not qualified, but this scenario is not the litmus test for that argument. 



triemal04 said:


> And you may want to look up how thrombolytics are used in the treatement of CVA's. And how hypoglycemia can present; might clue you in on why a cbg is neccasary.



I'm quite familiar with the application of thrombolytics/clot busters/heparin/tpa protocols etc... but all of this is academic. The patient was clearly not having a CVA. We can theorize all day about hypothetical/atypical symptoms and presentations, but at the end of the day the correct decision was made, and there was nothing that an ALS unit could have done to improve the patients condition or eventual outcome.




triemal04 said:


> Edit:  This is on CVA's in particular.  http://emedicine.medscape.com/article/793904-overview  You'll notice that under the differntial dx's that need to be ruled out, Bell's Palsy is one of them.



Read it and extracted the pertinent info

"Central facial weakness from a stroke should be differentiated from the peripheral weakness of Bell palsy. *With peripheral lesions (Bell palsy), the patient is unable to lift the eyebrows or wrinkle the forehead.*

Stroke mimics commonly confound the clinical diagnosis of stroke. One study reported that 19% of patients diagnosed with acute ischemic stroke by neurologists before cranial CT scanning actually had noncerebrovascular causes for their symptoms. *The most frequent stroke mimics include* seizure (17%); systemic infection (17%); brain tumor (15%); toxic-metabolic cause, such as hyponatremia (13%); and positional vertigo (6%).[/b] Miscellaneous disorders mimicking stroke include syncope, trauma, subdural hematoma, herpes encephalitis, transient global amnesia, dementia, demyelinating disease, myasthenia gravis, parkinsonism, hypertensive encephalopathy, and conversion disorders. A critical masquerading metabolic derangement not to be missed by providers is hypoglycemia"


According to this particular study... Bells Palsy isn't even on the map, when considering "stroke mimics". I'd be very interested to see more studies that would point to the contrary.


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## AJ Hidell (Mar 13, 2009)

alphatrauma said:


> Agreed, but it doesn't take a medic to perform a competent assessment and safe/rapid transport.


Nope.  But it does take a lot more education than is given in any EMT-B course I have seen in the last thirty-six years.  You can only do so much in 120 hours.  If there are EMTs out there who can perform a competent advanced assessment, it is because they learned elsewhere.  Therefore, whether it takes a paramedic or not, it still cannot be trusted to EMT-Bs.  And it takes more than the simple cookbook steps of performing the assessment to understand the results well enough to interpret them. 



> The patient was clearly not having a CVA.


Clearly?  You determined that strictly from the original post?  I think you just destroyed your own theory about EMT-Bs being able to perform competent assessments.


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## medic417 (Mar 13, 2009)

alphatrauma said:


> ...The EMTs "recognized" that the patient was *STABLE*, ALS was *NOT NEEDED* and transported appropriately.




This statement scares me.  Any patient that presents as described is not "stable".   They are in a potentially life altering or ending moment.  If I were a basic I would distance myself from you immediatly because you are providing proof that basics are not educated enoughed to be doing any assessment.  

They made a mistake by not choosing ALS but if you can not determine that based on the comments made by many others no need for me to waste time restating them.


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## Sasha (Mar 13, 2009)

medic417 said:


> Any patient that presents as described is not "stable". They are in a potentially life altering or ending moment.





> Daughter states during dinner the mother’s face drooped for no apparent reason. BLS arrives and finds that patient is A&Ox3, no apparent distress. BLS does full exam, including stroke assessments and vitals, all comes out “normal”. BLS cancels ALS. Arriving at hospital, patient has another episode of one-sided of “drooping”



It appears that at this time the patient was "stable". No neural defict, vitals normal, patient is alert and oriented. Of course, this could all go down hill, but EVERY patient could go down hill. Everyone is at a potentially life altering or ending moment. 

They did this patient no harm, they got her to the hospital which is the ultimate goal of any EMS level. 

I agree, this could have and should have been ALS, but you can't fault someone from following their protocols.


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## medic417 (Mar 13, 2009)

Sasha said:


> It appears that at this time the patient was "stable". No neural defict, vitals normal, patient is alert and oriented. Of course, this could all go down hill, but EVERY patient could go down hill. Everyone is at a potentially life altering or ending moment.
> 
> They did this patient no harm, they got her to the hospital which is the ultimate goal of any EMS level.
> 
> I agree, this could have and should have been ALS, but you can't fault someone from following their protocols.



I'm no faulting the OP for following protocol if ALS would have taken longer then fine get them to hospital.  I am faulting the poster calling this "stable".  There are to many unknowns when a patient has an episode as described. They may have a bleed, they may have something else happening, but regardless until a patient with theses symptoms gets a complete exam including cat scan they should be classified unstable.  Honestly it is a disservice to the patient to even think stable as you let your guard down your tone in your report makes hospital go hey another patient that is not in need of immediate attention.  So because a basic or medic said patient was stable patient waits and then turns out they had something serious happening.  

I have had patients that were having acute MI's yet all vitals were normal were they stable?  No they were dieing body just hadn't told them yet.  Stable is over used in EMS.


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## JPINFV (Mar 13, 2009)

MSDeltaFlt said:


> It appears they followed their protocols.  They did fine.  No problems.



Befehl ist Befehl


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## Veneficus (Mar 13, 2009)

alphatrauma said:


> Sounds to me like *Bells Palsy*, which is commonly mistaken for a TIA by the untrained/unfamiliar. While it is unlikely the EMTs suspected Bells Palsy, this patient was STABLE, and ultimately their decision to forego ALS was appropriate. There is nothing a Medic, thrombolytics, monitoring, or ER treatment can do for this patient. Outpatient Neuro followup is what's needed.
> 
> 
> A Bells Palsy patient will *NOT* have any involvement of the extremities on the affected side. They will also have no memory deficit or behavioral changes, and gait will be normal. I think the EMTs got this one right... and when the heck did glucose come into this :sad:



You guys have to bait me with this stuff don't you?

I'll leave the glucose comment for everyone who has beaten into their brains to check glucose on all suspected strokes. (though I don't think it is a bad idea)

Bell's palsy isn't going to clear up in a few minutes. According to Harrison's internal medicine, Kumar's pathologic basis of disease, and my own anecdotal experience. It takes months to clear up, if it clears up at all. As a differential dx you must also rule out:

Borrelia (aka lyme disease)
Ramsay hunt syndrome
Gullian-Barre

sarcoidosis
facial neuropathy 2nd to DM
amyloidosis
Melkersson-Rosenthal synd.
local infarcts
MS
acoustic neuromas
cholesteatoma (aka a tumor)

The first 3 represent acute conditions that require emergent treatment. But my point is that the Dx of Bell's palsy prehospital without a prior hx is impossible. Even with history, it is still possible to be suffering from these conditions as well.

as for the OP since I am now commenting. In a suspected CVA, if the hospital is closer than ALS, hospital is the right choice. If ALS is closer than hospital, ALS is the right choice. 

Forget TPa and all that crap. A CVA can affect respiratory as well as cardiac function, both of which can be supported by ALS until something that can better resolve the root cause can be implemented. Sure a Basic can bag as well as anyone, but i would rather some cardiac support other than CPR and an AED be available to help maintain perfusion prior to an arrest.


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## triemal04 (Mar 13, 2009)

alphatrauma;131065Agreed said:
			
		

> No, but as has been said it takes a hell of a lot more than an EMT learns.  Which has been shown allready as you've decided this was nothing more than Bell's Palsy.[/COLOR]
> 
> This is a terrible example of why Paramedic level assessment/intervention is needed... because it wasn't. Unless medics are now equipped with a GE Lightspeed or Siemens Somatom strapped to their backs, there is no need for them on scene (unless already there) for a patient presenting like the one described.
> Actually, this is a good example.  Where did these EMT's take the pt?  Was it a community hospital, or one that was a little better equipped for someone having a CVA?  What did they say in their report when they arrived; was it enough to get a bed right away, or where they stuck in triage for awhile?  Did they get a good history from the pt while enroute, including risk factors for strokes, get a med list to rule out blood thinners and check inclusion/exclusion criteria for thrombolytics?  Don't know, but I do know what most paramedics would do...  More on that in a bit.
> ...


What so many people here, both EMT and paramedic alike tend to forget, or more likely never learned in the first place, is that the most important tool a paramedic has is their brain.  And the most important skill we have is our assessment capability.  It doesn't matter how many cool flashy things you can do if you can't figure out what is wrong with your pt and determine the need for them.  People seem to forget that, or never learn in in the first place.

Anybody who was been out of the classroom for any length of time will have realized that there are huge numbers of illnesses that we come across that we will be able to do exactly nothing for in the field.  None of the meds we have, none of the toys we use will help a lot of these people.  But what we can do that may make the difference is use our most important tool, properly assess the pt, and RECOGNIZE what the problem is.  And that is where the vast majority of EMT's will fail.  Can an EMT recognize someone having a stroke with all the classic symptoms?  I hope so.  But what about the person with an atypical presentation? Or the cardiac pt with atypical presentation and no ecg changes?  Should they go to whatever hospital they want, or maybe somewhere that is capable of treating them for what could be wrong?  For the situation here, knowing the person could have had a TIA and is at risk for a CVA and taking them to a stroke-capable hospital is the most important thing to be done.  For other times it'll telling the attending doc's and RN's what you've found and what you think it is...plant that idea in their heads early, don't just toss them off with a big "I dunno I'm just an EMT."  Recognition is, and always will be key to what we do.

There are far to many people out there who can't do any of the above; yes, at all levels.  But when the lowest, leaast taught level only get's taught things like, "high-flow O2 and rapid transport" for almost ALL problems, it makes sence to have someone who is just a little bit more competant assess the pt.


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