# Stroke?



## frdude1000 (Nov 28, 2011)

Dispatched for a stroke.  My BLS unit arrives on scene at an apartment complex to have the approx. 50 y/o M walk up to the unit.  Pt. stated he believed he had a stroke or is having one.  Pt. was placed on cot in back of unit and we began assessment.  Pt. stated he had been having a headache, one-sided weakness, minor facial droop (I didn't really see it but he said he felt it), and a few other stroke like symptoms.  Pt. said this started the day before and he had done research on the symptoms so he finally decided to call.  Performed Cincinnati Prehospital Stroke test: no real facial droop upon inspection (pt. reported feeling minor facial droop), arm test ok, speech normal, no slurring.  Pt. had normal grip strength in both hands, was able to push down and pull back on my hands with both feet. Patient was taking a long list of medications for depression, high blood pressure, etc.  Vital signs were 110 pulse, 99.2 temp, 162/102 BP, 96% SPo2.  pt. reports he monitors BP and it was higher than normal.  We transported to the local hospital, a stroke center, routine.  Upon arrival, the stroke team did not assess the Pt. at least while we were there.  Do you think this could be B.S.?  The patient seemed to have some Psych issues (he put in ear plus before we arrived because of the ambulance siren and loud noises, long history of depression, anxiety issues.  The driver thought it was BS, I took it seriously.  I know none of you were there, but I just want to hear your thoughts.


----------



## Anjel (Nov 28, 2011)

I think BS. 

He has psych issues and the internet. 

He had no signs of a stroke.


----------



## DrParasite (Nov 29, 2011)

honestly, I think the majority of people who meet us curbside are just looking for a ride to the hospital, or looking to be evaluated for a non life threatening issue..  that includes complaints of chest pains, diff breathing, and strokes.  not everyone, just the majority.

that all being said, people with psych histories (ie, the crazy people that we all blow off as just being psych related) do have cardiac problems, do have strokes, and can have medical problems.

Do I think this guy was having a stroke?  no.  could he have had a TIA, the symptoms of which resolves themselves already?  maybe.  

Treatment I would do?  transport to hospital, maybe low flow oxygen via N/C, give a report to the ER of your findings and what he was complaining about. let them decide if it's BS or not.  After all, you are supposed to advocate for your patient.


----------



## Melclin (Nov 29, 2011)

Doesn't seem at all like a stroke. If he wants a ride to hospital while I'm doing my paperwork, hes more than welcome. He can hop out and sit in the waiting room when we arrive. 

Perfectly reasonable to treat it as if it were a stroke.


----------



## Tigger (Nov 29, 2011)

I don't think I would call in a stroke alert or anything like that (and we don't really even have those in my area), but I would certainly not treat this call as a stroke. If my assessment finds nothing, I think I would just inform the ER staff of the contradictions between the patient's complaint and my assessment and let them take care of it. I certainly would not look at this like a psych transfer or anything like that.


----------



## fast65 (Nov 29, 2011)

Eh, perhaps he had a TIA, but with all your findings, I'm not real concerned about this gentleman having a stroke. Is it possible? Yes. Is your assessment showing any stroke specific signs? No. You've done all you can to rule out a stroke in the field, and with the info you've given so far, I think this guy might just be a bit of a hypochondriac. That being said, he's more than welcome to take a ride to the hospital with me, but he'll be going to triage when we get there.


----------



## mycrofft (Nov 29, 2011)

*TIA, depression, or CVA*

Want to take that risk?

Was his pulse regular? Your monitor doesn't have a little light that says "REG", you have to palpate or better yet listen. 

If it is fast and irregularly irregular you may be looking at AFIB which is prodromal for CVA.


----------



## systemet (Nov 30, 2011)

frdude1000 said:


> The driver thought it was BS, I took it seriously.  I know none of you were there, but I just want to hear your thoughts.



How do you rule out CVA prehospitally?  

You can't.

You have an absence of physical examination findings, a negative CSS (sensitivity 40%), mild hypertension, a little tachycardia, (Neither of which are specific for CVA), and subjective complaints of hemiparesis (not exhibited upon physical exam), facial droop (not exhibited on physical exam --- both of these are objective signs, although I accept there's some subjectivity and interobserver variability in borderline cases), and headache (which certainly can be a sign for CVA, but is also very nonspecific, i.e. lots of other things can cause a headache).  Might be nice to have a blood sugar, but he doesn't sound altered, and if he's got no DM, it's unlikely to be an issue.

You took him to the hospital to get assessed, by someone with a higher level of medical education, because you couldn't rule out a potentially serious pathology.  Sounds just fine to me.

I'd resist the urge to try and decide whether it's BS.  It's probably more likely that the patient has a genuine concern, even if the probability of a CVA seems fairly low, than that he's deliberately misleading you or trying to waste your time.

Is he likely to get a CT scan?  Doesn't sound like it, to me.  But he might.  That's a decision for the MDs.  No one is going to support a medic who refuses to transport a patient who's called 911, stating concerns about a headache and possible CVA, on the basis of their physical examination.


----------



## usalsfyre (Nov 30, 2011)

It sounds BS, but remember that the Cincinnati is only particularly good at catching ischemic strokes in one of the hemispheres. There are other types of stroke (usually in the lower portions of the brain and occasionally ICH) that will present with a normal Cincinnati. Some things to look for:

Ataxia of any sort

Speech issues other than slurred speech

Persistent vertigo not relieved by rest

Disconjugate eye movement

Unexplained vision or hearing problems

Unexplained mental status change

All of these could be indicative of a stroke. The MEND exam assesses many of these and takes just a bit longer than the Cincinnati.


----------



## Medic Tim (Nov 30, 2011)

I had a pt very similar to this recently. his finger stick showed a low bs so a bit of oral glucose did the trick.

I have also had a pt stroke out and their only complaint was a slightly numb earlobe. the prehospital stroke scales are not the end all be all


----------



## Rettsani (Dec 1, 2011)

I find it difficult after all and everything what you see on the street as directly interpret hineinzu Mental illness ..

I once a patient with stroke symptoms, pre-registered 5 times in one day to the hospital and again he was dismissed as imaginary invalid. When I arrived the next day to the film I was then informed of the patient passed away at the 6th after hospital admission is of a stroke.:sad:


----------



## mycrofft (Dec 1, 2011)

*Nobody says mentally ill people can't have a stroke.*

In fact, since it is in the brain, couldn't a CVA be considered an extreme organic mental illness?


----------



## Rettsani (Dec 1, 2011)

I excuse no one wanted to step on the feet. Now I've probably made ​​unpopular. I just wanted to express something with it and show that it is a dangerous routine Permant look to consequences, and not left and right of the way there.:unsure:


----------



## mycrofft (Dec 1, 2011)

*I think I agree with you.*

It is too easy to dismiss people with a CVA as simply being mentally ill, but nothing protects people with mental illness from having a stroke.


----------



## MICP (Dec 1, 2011)

*"Real or Perceived"*

As most of the respondents have pointed out, we have no ability to be conclusive in the field, especially with intercranial events, complicated by potential for mental illness.  A critical thing to remember is that we respond to both real and perceived emergencies.  For your partner, he didn't see it as real, and so called BS on the stroke; however, this was "real" for the patient.

Either way, a more thorough assessment was necessary.  Could this have been some sort of mild dystonic reaction from the benzos he's taking?  Is he developing paranoia tendencies and needs his medications for his depression adjusted?  Hopefully when the ED receiving staff finally decided to clear this guy after the CT came back negative for hemorrhage, and no other signs pointed to stroke or other medical issues, that they got him some social services or mental health consult to make sure that he is not just being medicated into oblivion but being helped.

Maybe your partner should hang out with this guy for a bit and gain a touch of compassion.


----------



## medicsb (Dec 1, 2011)

> Vital signs were 110 pulse, 99.2 temp, 162/102 BP, 96% SPo2



CVA, TIA, or not... something was going on with him.   While some people may have a baseline BP like he had, they don't usually have a resting HR >100.


----------

