# Possible CVA



## RedAirplane (Mar 21, 2016)

I heard a call dispatched for Fire Department X, mutual aid into remote area Y, for a 78 year old female not behaving right, possible CVA per EMD. The response time is 45 minutes emergent, and the transport time would be 1 hour.

This probably sounds routine to some of you who work in rural areas, but I was a little shocked at the times on that.

What I wanted to know is-- what should the advice be to people who live in rural areas? On my ride-along here in a suburban/urban area, I saw one man who arrested while being driven to the hospital by his wife (CP), and another who we saved when he arrested even though we were slightly delayed, because he called 911 instead of driving. 

However, given the time sensitive nature of CVA, I'm not sure what I would recommend to a hypothetical rural friend. My standard advice is "always call 911, don't drive or be driven, it's safer." In the rural CVA case mentioned above, 911 would add almost an hour before arrival to the ER. 

OTOH if you decided to drive your CVA significant other to the hospital and s/he arrested en route, you're out of luck. Nobody's coming, you presumably don't have cell phone signal, etc.

If you were in a log cabin 45 minutes from the nearest traffic light (or fire station), would you drive your patient or call 911? If somebody asked you this question, what would you suggest?

(And as a responder, wouldn't a helicopter be appropriate if this truly was a CVA and the txp time was that long?)


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## Tigger (Mar 21, 2016)

We would certainly place a helicopter on air standby for this if the weather allowed. 

We have people fairly often that call 911 and tell dispatch which road they will be taking and we will intercept with them. It's not perfect and people do get missed. 

It's also important to remember that you sacrifice quite a bit of public service to live a rural area and this should be a known risk of living in the middle of nowhere.


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## Akulahawk (Mar 22, 2016)

Where I work, there are no prehospital CVA protocols for flying CVA patients from the scene, or MI patients for that matter. What we do is the patient is brought to the ED, the MD meets the patient at the door, does an initial assessment and the medics know it's vitally important to document the time the patient was last seen "normal" because that drives some of the treatment stuff. The patient is wheeled to the CT scanner, still on the ambulance gurney, gets scanned, and the back to the ED on the ambulance gurney. Once in the ED bed, a formal NIHSS is done while the CT is processing and the MD reads the images. Since our small hospital doesn't have its own neuro service, we use telemedicine for this. Once we know the patient doesn't have a bleed _and_ the patient is within the appropriate window of time, we administer TPA if the telemedicine neurologist gives the order, all the while we're arranging for an emergent flight to a full-up stroke center. When everything is working very well, we can have transport at bedside within 60 min of arrival at the ED and 30 min later the patient is rolling through the doors of a stroke center. Yes, time is very important but the most important factor is the public recognizing and calling for help early in these cases, even if the patient lives a significant distance from services.


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## DesertMedic66 (Mar 22, 2016)

Luckily for us we have a fire station in all rural areas or at least maybe 10 minutes away so the fire department will get on scene (all ALS) and if the patient appears to be having a stroke, MI, other serious issue they will launch an airship. Usually by the time the ambulance is arriving on scene the airship is already taking off with the patient.


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## SpecialK (Mar 22, 2016)

First, the correct term is *"stroke" *or "*brain attack" *and not "CVA", that is an outdated term which is no longer correct.

In practical reality, it is probably faster to transport by road as long as a hospital capable of CT and thrombolysis can be reached within three hours of symptom onset.  If this is not the case, i.e. symptoms began five hours ago then there is no role for flying these patients. 

For a patient who can easily be extricated (i.e. not trapped) and transport time is one hour by road; the amount of time required for a helicopter to get ready, take off, fly to the scene, land, crew to get out and go to patient, do a handover, load into helicopter, take off, fly back to hospital and take patient into ED is going to take the same amount of time as driving one hour by road.

The general rule of thumb is for a helicopter to be useful it must save more than thirty minutes travel time and that time must be clinically significant i.e. the patient must have a time critical problem.


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## SpecialK (Mar 22, 2016)

Whoops double post.


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## Carlos Danger (Mar 22, 2016)

SpecialK said:


> First, the correct term is *"stroke" *or "*brain attack" *and not "CVA", that is an outdated term which is no longer correct.



CVA is still the most commonly used term here.


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## COmedic17 (Mar 22, 2016)

I have never heard of a stroke being referred to as a brain attack.


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## johnrsemt (Mar 22, 2016)

I think putting a helicopter on 'standby' is crazy.  they are always on standby.  Put them in the air,  they don't charge until they take off with the patient (or they shouldn't).  Have them come help eval the patient.  Sometimes out here they get on the scene before ground trucks can,  and in remote areas they are the only way to get to the scene


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## Carlos Danger (Mar 22, 2016)

johnrsemt said:


> I think putting a helicopter on 'standby' is crazy.  they are always on standby.  Put them in the air,



Every place I flew, a "standby" request means getting dressed, checking weather and planning the flight, and pulling the aircraft outside. Versus being asleep in bed with the aircraft inside the hanger and having to pull up the current weather. So there's definitely a difference.

Requesting HEMS when you arent 100% sure you'll actually need them (i.e. You aren't on scene yet) is fine if the dispatch info indicates that you probably will (reports of MVC with ejection, crushing chest pain in a patient with an MI history, etc), but calling HEMS for things like helping to evaluate a possible CVA just because "they don't charge" is a clear waste of an expensive resource, and I'm guessing  most HEMS programs won't play that game too many times.


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