# Elderly B/F with AMS, complains of headache BP>200/100



## DarknessEMT (Apr 7, 2014)

Hi, I'm still pretty new to EMS and I've only worked for a service tht does routine transports (dialysis, doctors appointments, hospital discharges, that kind of thing).  Got dispatched for routine transport of an elderly B/F with severe AMS from a doctors appointment back to her nursing facility.  In the unit her BP is >200/100, she denies chest pain and shortness of breath, but says her head hurts. Pulse was WNL but thready.  Her sister was riding along and says that her BP isn't usually that high and her mental status is worse than usual.  Performed Cincinnatti Stroke Scale and she passed except for repeating a simple phrase, but that could have been from her existing mental state, but since the doctor was right across the street from an ER, we just took her right over.

The nurses acted like it was nothing and dragged their feet about getting her triaged, and gave me attitude when I was giving them my report.  Needless to say I'm kind of doubting my judgement.  To me, it seemed like possible stroke symptoms, and my partner (she's just a responder, not an EMT yet) agreed and said we made the right call.  My field supervisor said the same thing.  But the way the nurses were acting about it, I don't know.  Got me thinking maybe I jumped the gun and made a mountain out of a molehill.

I don't know, just looking for another EMT's perspective on this.  Did I make the right call?


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## VFlutter (Apr 7, 2014)

Why was she going to the Doctor's office? Was her pressure that high in the office? What is her medical history?

Most importantly, Did you verify the pressure manually? Assuming you were using a NIBP. 

Without knowing more about the patient's history I would say that hypertension + AMS warrants evaluation. However she was just evaluated by her PCP. I am curious what occurred in the office and why she was being sent back to the facility. 

Many people with* chronic* hypertension live with blood pressures in the 200s. Is it detrimental to their health? Absolutely. Will it eventually result in organ dysfunction? Yes. Is it an _Emergency_? No.


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## DarknessEMT (Apr 7, 2014)

She was going to a wound specialist for diabetic ulcers, not her PCP.  I wasn't able to get a last BP from the staff when we picked her up.  (I'm sure you've heard the excuses "the computers are acting up and it's a little old you're better off getting a fresh one yourself."  That kind of run around.)  She was the last pt and they were waiting on us to pick her up so they could close up shop and leave for the day.

And the pressure was taken manually twice with the same results, we only have monitors for the ALS units, one for the field supervisor, and one extra in case one goes down.

The pt has a history of HTN and transient dementia, but her sister said the BP was a lot higher than usual and she wasn't usually so disoriented.  

Not sure if she is a permanent resident at the facility she was going back to, or just there short term for rehab.


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## mycrofft (Apr 7, 2014)

DarknessEMT said:


> She was going to a wound specialist for diabetic ulcers, not her PCP.  I wasn't able to get a last BP from the staff when we picked her up.  (I'm sure you've heard the excuses "the computers are acting up and it's a little old you're better off getting a fresh one yourself."  That kind of run around.)  She was the last pt and they were waiting on us to pick her up so they could close up shop and leave for the day.
> 
> And the pressure was taken manually twice with the same results, we only have monitors for the ALS units, one for the field supervisor, and one extra in case one goes down.
> 
> ...



Rule one: get your own vitals. Doesn't cut it when the pt rolls into the ED and the BP is way different than the one you report and you say you were depending upon the facility's BP.
Rule two: Serial manual BP's are golden. Single manual BP's are silver.Automated one are bronze. (Ask my cardiologist),


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## Brandon O (Apr 7, 2014)

Legit. Key is family endorsing a change from baseline mental status.


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## KellyBracket (Apr 7, 2014)

DarknessEMT said:


> ...
> 
> I don't know, just looking for another EMT's perspective on this.  Did I make the right call?



Well I _used_ to be a brand-new EMT! Those ED nurses can be pretty intimidating at first. Don't worry abut the grumbling, though. Keep being friendly and professional, and they'll take a shine to you soon enough.

Listen, you did great. You got a change in mental status + change in vital signs: What else are you going to do? Bring it to the ED to get sorted out, that's what we're there for, seriously. 

My guess, however, is that she didn't stay in the ED for long. Yes, there needs to be an exam, and her current and baseline mental status have to be teased out a bit more. But most often, it turns out that not much is going on. The first or second BP will decrease, the family will back-pedal and say that "Actually, this is kind of normal," or it turns out she has a urinary tract infection.

Of course, stuff happens! Did you get a chance to check in again?


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## EMSComeLately (Apr 7, 2014)

DarknessEMT said:


> In the unit her BP is >200/100, she denies chest pain and shortness of breath, but says her head hurts. Pulse was WNL but thready.



I'm an EMT student, but will chime in to test my critical thinking skills on learning so far.

One, I'm not sure the Thready pulse and High BP are compatible findings...wouldn't there be a normal to bounding especially with a systolic that high?

Second, you mentioned Hx of Diabetic Ulcers for wound care, but didn't mention any BGL numbers.  In MO, an EMT can take a BGL so it might have been helpful for street cred with ED nurses to have factored that into the presentation especially if it either helped to pinpoint the AMS signs or move it closer to a stroke finding.

My .01 cents, since they aren't worth as much, yet.


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## VFlutter (Apr 7, 2014)

EMSComeLately said:


> One, I'm not sure the Thready pulse and High BP are compatible findings...wouldn't there be a normal to bounding especially with a systolic that high?



The OP stated she was at Wound Specialist for Diabetic Ulcers. I am willing to bet she has significant Peripheral Vascular Disease. I have had patients with pressures in the 180s that still had to have their DP/PTs dopplered.


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## DarknessEMT (Apr 7, 2014)

Thanks for your input people, I really appreciate it.  Like I said, I work mostly BLS discharges and transports (I've worked three whole shifts with a paramedic on an ALS unit), and this was only my second time having one turn into an ER call (the first being a pt seizing as we're pulling into his facility's parking lot).

I guess I'm just still feeling green in some situations and I don't want to make any stupid mistakes.


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## Brandon O (Apr 7, 2014)

DarknessEMT said:


> Thanks for your input people, I really appreciate it.  Like I said, I work mostly BLS discharges and transports (I've worked three whole shifts with a paramedic on an ALS unit), and this was only my second time having one turn into an ER call (the first being a pt seizing as we're pulling into his facility's parking lot).
> 
> I guess I'm just still feeling green in some situations and I don't want to make any stupid mistakes.



Very wise attitude all around.

Rule one in transfer work is that everybody's a mess, so the textbook "normals" don't much apply. Hone your ability to distinguish acute-sick from chronic-sick, but more than anything, rely upon the people who know the patient. Family, the patient himself... but mostly facility staff. Even if they're not worth a wooden nickel they're still gonna be a million times more knowledgable about what's okay for Ms. Smith than you are. (Just remember that you're bringing to the table a prejudice that everyone's having an emergency -- your job -- whereas they're bringing the prejudice that there's no emergency -- their job. Find the truth somewhere in between.)


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## DarknessEMT (Apr 7, 2014)

mycrofft said:


> Rule one: get your own vitals. Doesn't cut it when the pt rolls into the ED and the BP is way different than the one you report and you say you were depending upon the facility's BP.
> Rule two: Serial manual BP's are golden. Single manual BP's are silver.Automated one are bronze. (Ask my cardiologist),



Yeah, I always get my own vitals when we get in the back of the unit.  A lot of guys I work with will just use whatever the facility gives them no matter how old.  And our state requires two sets of vitals no matter how short the transport (or maybe my manager is just saying that), and I've been told a few times to just make up a second set that "sounds reasonable".  It takes like a minute, minute and a half tops to get a decent set of vitals, and I'm not risking my license and career just to shave a minute off my call time.


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## KellyBracket (Apr 7, 2014)

Brandon O said:


> ... Just remember that you're bringing to the table a prejudice that everyone's having an emergency -- your job -- whereas they're bringing the prejudice that there's no emergency -- their job. Find the truth somewhere in between.



Yes!


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## DarknessEMT (Apr 7, 2014)

Brandon O said:


> Very wise attitude all around.
> 
> (Just remember that you're bringing to the table a prejudice that everyone's having an emergency -- your job -- whereas they're bringing the prejudice that there's no emergency -- their job. Find the truth somewhere in between.)



Wow, that's a great way to look at it.  Thanks!


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## Ewok Jerky (Apr 7, 2014)

Was she stroking out? Probly not.  Did she need an AMS workup? Probly. 

Your role as an EMT is not so much to know WHAT is wrong with your Pt, but to know IF something is wrong with Pt.  You will bring a lot of people to the ED that don't need to be there, they would do better to see their PCP.  When you earn your "street cred" is when you ID the actual emergencies.

Remember, you have a scope and a tank of deisal, the ED has the lab, the CT scanner, and the hour to perform repeat neuro exams.

And I'm just throwing this out there, not sure if it is applicable to your case...you might get less attitude from the nurses if you focus less on "stroke" and more on "altered mental status".

Homework assignment: 5 things that cause altered mental status without localising symptoms?


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## mycrofft (Apr 7, 2014)

I forgot Rule Three: Stand your ground.
 Clause a: no matter how improbable, report the vitals you get.
 Clause b: repeat vitals!
 Clause c: know what you're doing.

Good on you.


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## mycrofft (Apr 7, 2014)

" Originally Posted by Brandon O 
Very wise attitude all around.

(Just remember that you're bringing to the table a prejudice that everyone's having an emergency -- your job -- whereas they're bringing the prejudice that there's no emergency -- their job. Find the truth somewhere in between.)"



KellyBracket said:


> Yes!



Yes squared!


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## DarknessEMT (Apr 8, 2014)

beano said:


> Was she stroking out? Probly not.  Did she need an AMS workup? Probly.
> 
> Your role as an EMT is not so much to know WHAT is wrong with your Pt, but to know IF something is wrong with Pt.  You will bring a lot of people to the ED that don't need to be there, they would do better to see their PCP.  When you earn your "street cred" is when you ID the actual emergencies.
> 
> ...



I wasn't really pushing "stroke", really just emphasizing higher BP than normal and headache, which I guess makes it sound like I was focusing on stroke.  Something to remember next time.  Just got to treat it as a learning experience.

And 5 possible causes of AMS off the top of my head:
Hypoglycemia
Intoxication
Reaction to a new medication/reaction to absence of a current medication
Fever/infection
Trauma


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## Brandon O (Apr 8, 2014)

DarknessEMT said:


> I wasn't really pushing "stroke", really just emphasizing higher BP than normal and headache, which I guess makes it sound like I was focusing on stroke.



One thing I noticed is that EMT class seems to really like hypertension as a sign of badness. Elevated blood pressure isn't a sensitive or specific sign for anything, really... as a rule it's just a generic component of the body's stress response, just like tachycardia, sweating, and so on.

So sure, some elevation is common in MI, and stroke, and other nasties. But it's often absent. And loads of people walk around with hypertension too. Just not super useful. (Degree doesn't correlate with severity, either; it's not like sicker people get higher blood pressures, but higher blood pressures do make sweatier EMTs.)

One big exception is probably rising ICP from something like a head injury, because a climbing BP is the first and most useful component of Cushing's triad. In this case, it truly is a directly compensatory response. So yes, a spontaneous bleed is theoretically on the table on your case, but probably not where to start given the subtle symptoms (unless they worsen).


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## GoldcrossEMTbasic (Apr 8, 2014)

In response to Kelly Brackets comment, " I agree ED Nurses are intimidating." I think lazy at some times too.  I would've also gotten a GLUCOSE reading too. If that is what you did too? Since the PT has a HX of diabetes. I am really anal about using manual BPs and I think they are more accurate than the monitors. I also like to do the palpating BPs too. But monitors do come in handy in urgent situations where you don't have time for a manual BP.


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## Tigger (Apr 8, 2014)

EMSComeLately said:


> I'm an EMT student, but will chime in to test my critical thinking skills on learning so far.
> 
> One, I'm not sure the Thready pulse and High BP are compatible findings...wouldn't there be a normal to bounding especially with a systolic that high?
> 
> ...





Chase said:


> The OP stated she was at Wound Specialist for Diabetic Ulcers. I am willing to bet she has significant Peripheral Vascular Disease. I have had patients with pressures in the 180s that still had to have their DP/PTs dopplered.



This is an important lesson in tunnel vision for a student. There isn't really such thing as "compatible findings." In fact findings that don't fall as you expect them to are probably an important clue as to what is going on in regards to the patient's condition.

Do whatever you can to avoid tunnel vision. Actually be objective when collecting your objective signs. If you get one number for a pulse, don't let that affect how you continue your assessment. Put everything together once you have it laid out.


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## Tigger (Apr 8, 2014)

GoldcrossEMTbasic said:


> In response to Kelly Brackets comment, " I agree ED Nurses are intimidating." I think lazy at some times too.  I would've also gotten a GLUCOSE reading too. If that is what you did too? Since the PT has a HX of diabetes. I am really anal about using manual BPs and I think they are more accurate than the monitors. I also like to do the palpating BPs too. But monitors do come in handy in urgent situations where you don't have time for a manual BP.



Maybe wait till you have some experience before you go bashing on profession that you don't yet have much if any understanding for. Piling on ER nurses doesn't make you one of the cool kids and it's not a way for you to build credibility in the absence of bona fide experience. 

Also monitors are generally quite accurate if you understand their limitations, i.e. using them on a bumpy road probably isn't the greatest idea. A new LifePak costs nearly what I make a year. You better believe I am going to believe the numbers it gives me unless I have a reason to suspect otherwise and I can confirm by other means.


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## mycrofft (Apr 9, 2014)

Pulse monitors and automated BP cuffs need to be used cautiously. You can tell when you are unable to get a reliable reading, but the machines will report some of their boo-boos with utter confidence.

Smug little buggers.


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