# Right sided weakness - not a stroke?



## Emtkev22 (Jul 17, 2017)

I'm an EMT-B from California. I'm on a BLS crew, and today we were dispatched to a call for right sided leg, arm, and neck pain at a local SNF. 

Arrive on scene to find a 54 y/o female PT, A/O x 4, GCS 15. C/C is 10/10 pain in the right lower extremity radiating from her foot up to her lower back. She stated that it feels like something is moving up and down her leg, all the way down to her feet. She has abnormal sensation in the right foot, pedal pulses are strong, normal, and equal bilaterally. Her right leg seems to be very stiff, and she says that she can't move it. She can barely wiggle her toes in the right foot. 

She has right sided weakness when testing her grip strength, and apparent right sided facial droop. She has a Hx of TIA, and Diabetes type 2. We asked for a blood sugar from the facility, and we got 421. They said she had just eaten, and the last blood sugar of 176 was taken around 1200. We were on scene at approx. 1430. 

Her vitals were ... 
120/68
102 HR 
22 resp

We called our dispatch and requested an ALS crew to come out for a possible stroke. The medic and his partner showed up, asked us what was going on, and went in to start their assessment. 

The medic starts his stroke assessment, and finds that there is right sided weakness but left sided arm drift. He asks her to shrug her shoulders, and raise her eyebrows. The PT tells him that she has a plate in her chin, and that's the reason her, "mouth is crooked". The medic then proceeds to say, "I'm not thinking stroke, I'm gonna call this generalized body pain." He tells us that because the arm drift is left sided and not right sided, he's ruling out stroke because it's, "the opposite side of the brain." Also, I overheard the medic say that she had, "sinus tach" as a rhythm

I'd like to clarify, I'm posting this situation in order to receive some feed back, and learn from this. I didn't have a chance to talk to the medic much before they took off, and I want to understand more about the ALS crew's thought process. The hospital they transported to isn't a stroke center, which tells me that the medic was certain of his assessment and ruling out of a stroke. 

I know there are correlations between hyperglycemia and stroke, and I will admit I don't understand much about the relationship between the two yet, as I've only started researching it today after leaving the call. I would have figured that with a Hx of TIA, displaying what I considered to be stroke like symptoms, that they would have atleast transported to a hospital with stroke capabilities, just to be on the safe side. 

For reference, the closest ER was about 3 minutes away, and the closest ER with stroke capabilities was about 15 minutes away. 

To be honest, the ALS crew look displeased to take over patient care, and I'm sure they thought we could have handled the call seeing as how we were right around the corner from the ER. 

We get these calls like this quite often, coming out of a SNF, calling it, "General weakness" or "Altered mental status". I want to know exactly what to look for, and how to identify a potential stroke before upgrading to ALS, for future reference, since I'm sure it will happen again. I'm a fairly new EMT-B, and don't have much experience at all on the ALS side. 

Any feedback and/or comments are appreciated, thank you.


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## SpecialK (Jul 18, 2017)

Didn't you learn the FAST test? Go and talk to whomever your clinical support people are called and get some help on that one is my advice.

As for your mate's idea about hemiparesis; he's a tad misguided in this case.  The movements of one side of the body are generally controlled by the opposite side of the cerebral cortex but in general, pre hospital I don't think it has great clinical significance and there are exceptions.  It sounds like this lady had a lolly scramble of neurological signs and symptoms; it's a bit of a severe departure from what I would expect of clinical judgement to say "she's not having a stroke" because of a bit of wonky focal neurology; she might be having a TIA, she might have a dirty big subarachnoid bleed for all he knew? She definitely needs to be referred to ED for at the very least, a more detailed neurological workup and/or CT scan.  Having said that, his bad clinical decision making is on him, but, having said that, if you know he's leading himself up the garden path it's also the other clinical people's responsibility to say something to him!

Stroke can mimic hypoglycaemia, not hyperglycaemia; unless for example in the very rare instance somebody with hyperglycaemia has extreme DKA or HNNK or something and this has caused an altered level of consciousness, but I've honestly never seen it.

As for calling for backup vs transport; if you are fifteen minutes from a stroke centre; isn't it more expeditious just to transport once you have made the decision this is necessary (which didn't seem very hard in this particular lady)? What is backup going to do that you cannot do which has such high clinical utility waiting for them on the scene is going to benefit the patient? Back in the day it was common for crews to ring for backup just because they didn't know what to do, it was a bit of a knee-jerk reaction and lacked a bit of logical thought.  Determine what your patient needs, and how best to get it i.e. most efficiently.  If it's calling for back up so be it, if it's just going to hospital with an early notification if appropriate, then just do that.

Based on what you've written, my number one not to miss diagnosis would be a stroke or cerebral haemorrhage, if it's not that, then I'd be quite worried about the possibility of some sort of evolving limb ischaemia; definitely, needs an ultrasound to make sure it's not that.

I hope she was given some pain relief too, being in 10/10 pain!


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## VentMonkey (Jul 18, 2017)

1. Don't take any of it too personally.

2. You did your job, it's now on the medic to decide how sure he is re: his "diagnosis".

3. By no means am I telling you to upgrade every patient you get you think meets stroke criteria to a BLS "code 3", but aside from a blood sugar, and (2) IV's, there isn't a whole lot more ALS will be doing treatment-wise in the field. Don't be fooled by their "awesomeness", it's hardly that awesome.

Thee biggest point I can emphasize whether it is BLS or ALS is last known well time. In other words, the last time they had been seen prior to the onset of any neurological deficits. This alone is what the EM physician will try to get to the bottom of prior to continuing to treat for, or pull the plug on the patient meeting Stroke Alert criteria.


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## NomadicMedic (Jul 18, 2017)

I would second the above. Stroke is really the only time I think BLS should be transporting emergent. It's not an ALS call, but they do need to get to a hospital with a quickness.


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## EpiEMS (Jul 18, 2017)

Emtkev22 said:


> Arrive on scene to find a 54 y/o female PT, A/O x 4, GCS 15



Really quickly...why is this 54 y/o female in a SNF? A bit of history may help elucidate whether this is related to an underlying/pre-existing problem.


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## harold1981 (Jul 21, 2017)

Emtkev22, first of all I think you had legitimate reasons not to rule out a stroke, being a BLS-crew: you had a compromising history of TIA and DM2 in combination with what you believed at that moment to be a facial droop and a hemiparesis.
Based on the rest of your story though, if I came in as an ALS crew, I would probably end up not thinking stroke: Apart from the sensory symptoms and motoric weakness,  you´re also describing a 10/10 pain radiating from the feet to the lower back, which is not common in acute stroke patients, and a ´stiff right leg´, which can happen in stroke, but also opens the door to other possible causes.
It makes me curious about the past medical history of this lady, and the reasons why she is in a nursing facility. In this case it is the history that is going to give you important clues. How mobile is she normally? What happened and did anything change after the TIA (some people downgrade small strokes and prefer to call it a TIA). Is she known to have muscle atrophy or contractures? Does she have any history of sciatic nerve pain or spinal stenosis? Did these symptoms start out of a sudden or did they progress slowly to the point that they sought medical help? What medication is she taking and why? Then you do your assessement: does the facial droop also go with a speech disorder? Was her face symmetrical before and since when did the facial droop occur? What else is wrong, other than what she considers to be the chief complaint?

Now, not thinking stroke, does not mean that I can rule it out (still being the ALS-crew that arrived). Signs and symptoms can be very subtile and will require much more than a FAST-test to identify. Sometimes you´ll take in people with vague complaints, based on their risk factors: Afib, valvular pathology, metabolic syndrome, age or family history of stroke. Sometimes a FAST-test will reveal nothing but you´ll find the patient to have coordination or balancing problems when assessing their walking pattern. Sometimes all you´ll have will be complaints of a sudden headache, nausea and vision problems. Sometimes it will be confusion, desorientation or a family member being worried about ´odd behaviour´. Sometimes it will be dizziness, a visual neglect or unexplained incontinence, a fall or a seizure. 
I think that in this particular case it would be a bit worrying if your ALS-crew says: there is no stroke, while the neurologist in the ED will probably need a CT-scan, a CT-angiogram and an observational admission on the stroke unit, before he can finally say...no it wasn´t a stroke. 
Now, another thing is that maybe I can´t rule out the stroke, but you can find that the probability is very low and maybe there are also contra-indications for trombolysis and these could be reasons to transport to a hospital with a neurologist and a stroke-unit, but not necessarily to a stroke center. There is a whole list of criteria for that decision-making. For example if the time of onset is unclear, or if you´re dealing with a ´wake up CVA´, you don´t call for the stroke alert. 
However if the time of onset is less than 4,5 hours ago (and there are no other exclusion criteria from the list), we will load and go code 3 to a stroke center for intraveneous trombolysis. We´ll do the same up to 8 hours after the time of onset, for arterial trombolysis and embolectomy. 

I do agree that if you call for an ALS-intercept it has to have added value. The way to go once you´ve decided that you are dealing with an acute CVA is: 
get two IV´s in, get a glucose check and a BP, be sure about your time of onset and the complaints (be assertive and ask questions untill you are sure about it), get a good history, especially around previous neurological and cardiac problems and the use of anticoagulants or salycilates. While you are doing that, loose as little time as possible (time is brain). While you are enroute, get a stroke alert out. I would say that the ALS-intercept will only have added value if you have reasons to believe that your patient will become unstable enroute and need an intervention that you cannot provide. 
Oh, one more thing...your decisions (for example to call for ALS back-up) are always based on your own findings at the time that you make that decision. Then it doesn´t  matter if ten minutes later the patient stands up and dances the lambada in front of the ALS-medics. It´s so easy to play cocky on the new EMT on the BLS-crew if you´re carrying more experience and heavier training, while they KNOW that they deal with the same issues all the time at the ED for example, because patients will change their stories along the way, new facts will arise each time you involve a higher skill level and in our field of practice, patient presentations are dynamic and evolve contineously. You´ve got this picture now...you act on it. Then the picture changes, you adapt your approach. As you gain more experience, you´ll become better and better in dealing with all the pieces of the puzzle. But even if you´re a hundred years on the bus, you won´t always know for sure what´s wrong. Even the guys on the ED won´t always know with all the diagnostic tools and specialists that we don´t have. Diagnosis is a dynamic process that will often take much longer than the time that we have to play our part of the game.


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## Akulahawk (Jul 21, 2017)

harold1981 said:


> Even the guys on the ED won´t always know with all the diagnostic tools and specialists that we don´t have.


I'm going to "+1" this, so to speak. I'm an ED nurse and it's rare that we actually are able to provide a definitive diagnosis. The vast majority of the time we basically exclude the "bad stuff" and provide symptom relief to the patient along with a strong advisement to the patient to call their primary provider for follow-up. One of the reasons why we have the primary care provider follow up is they've got better access to resources than we do in the ED, one of those resources is time. We don't have the time to run a diagnostic tree all the way to the end and determine exactly what the problem is. If a patient needs surgery or needs hospitalization for some reason, once we figure the basics of what the patient needs, we send the patient to that resources and out of our department. In effect, we let the specialists do their magic and determine the definitive diagnosis.


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## DrParasite (Jul 21, 2017)

I can do the stare of life as well as any paramedic.... the only reason I ever called ALS for strokes was to do a BGL check (not all states allow EMTs to check BGL because it's considered invasive.....), because hypoglycemia can mimic stoke symptoms.  It's a time sensitive emergency (if within the window), so an emergent transport could be justified, but the patient needs an ER for a CAT scan and possible TPA,, not two IVs in the field.  I am not saying don't call for ALS (especially if your protocol says to, and in case your agency only allows them to call stroke alerts), but keep in mind what the best thing is for the patient.

You made the right call, some lazy medics would get mad if you called them for a cardiac arrest.  others would rather you handle any questionable calls solo, so they don't have to get off the couch.  

I am not saying you shouldn't call them, especially if your protocols, supervisor, and medical director says to, but you have a job to do, and so do they; if they decide not to treat the patient, that's on them, you did your job.  I wouldn't have waited on scene for them to arrive, but I want to be able to say "yes i called them as you directed me to, but since they weren't there yet, I went to the closest appropriate facility to get them definitive care, vs delaying treatment until the paramedics arrived."


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## vc85 (Jul 21, 2017)

I thought the reason ALS was called for strokes usually had more to do with the potential for airway issues more than anything 

Also as an EMT I probably would have called for ALS in the same case depending on one thing. Was the facial droop and arm drift new?  If it was pre existing I probably wouldn't


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## VentMonkey (Jul 21, 2017)

vc85 said:


> I thought the reason ALS was called for strokes usually had more to do with the potential for airway issues more than anything


Do you not have the ability to effectively handle a patients airway at the BLS level?


vc85 said:


> Also as an EMT I probably would have called for ALS in the same case depending on one thing. Was the facial droop and arm drift new?  If it was pre existing I probably wouldn't


Define "new", the EM physician will ask. I saw a particularly snarky doc laying into some poor EMT a few weeks back for such vague details.

Honestly, if you're around the corner from an ED, and the ALS unit is equal distance, or further your patient is most likely best served by your rapid transport. Check with your supes though I suppose //shrugs//

Put it this way- most of our scene calls come down to one of two things: advanced airway management, or time savings. Strokes almost always fit the latter, unless the former presents as an acute decrease in mentation, and/ or an exponential risk for aspirations with an airway that cannot be controlled by other less invasive means.


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