# TIA



## Alpha752 (Sep 7, 2004)

Hi, I am an EMT-B (in Medic School), but I am not currently working as an EMT.  I am working a security job, while in Medic school.  Today I had a call come in for a woman possible having a Heart Attack.  I called 911 and then went out to check.

(bear in mind I was acting as a Security officer/Good sam, not an EMT)

When I get outside, I find the PT (60yo F) sitting in a car, she is A&Ox4.  She tells me she thinks she is having a stroke.  I checked her ABC's.  Her pulse was fast but strong.  Her resps were good.  I got a GCS of 14.  She had weakness in the LT side, no response in the L leg, limited movement in the L arm, no strength in the hand, and droop in the L face.  She was talking the whole time.  She had symptoms for about 90 minutes.  She had a hx of open heart surgery and diabeties.  Her sugar this AM was >350.  The response time was about 4 minutes for the squad, so it wasnt long.

All I could do was watch her ABC's and make sure she didnt "crap out".  What else could I/should I have done in this situation with out any equiptment, and only BLS training?

I am going to talk to my boss about getting me a BLS bag, so at least I could take BP's and such.

Thanks,
Russ


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## Chimpie (Sep 7, 2004)

I have seven years security experience specializing in industrial fire protection and EMS.  One site I worked with had just about every piece of medical equipment you wanted as we all were medical first responders and some were EMTs and Paramedics.  

Another "site" I worked we were security but were also their "first responders" with only CPR/First Aid/AED certifications. (My MFR was from another state and had expired).  The "site" was actually a private retirement community with an expected population of about 500 including independent living, assisted living and a skilled nursing area.

I too have worked a TIA patients and without any equipment there's not much you can do.  You did the right thing by getting the trucks rolling and keeping an eye on the patient.  Do you have protocols written for medical emergencies?  What do they say?  If there are none maybe you should start writing some.  

What you did was fine.  You did a patient assessment and monitored vitals to the best of your ability.  Just give the ambulance crew as much info as you can and consider your job done.

Chimp
(currently writing a book on medical emergencies and training scenarios for security officers)


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## Alpha752 (Sep 7, 2004)

Hey Chimpie, thanks for the reply.  As far as protocals and such, I have none here.  We have AED's and are all trained in CPR/AED, but I am the only EMT.  EMT duties are not included in my job description.  Thats why I did not identify myself as an EMT to the PT, for all intents and purpuses, I was a civilian.  I have talked to my boss about adding some first responce/medical things to my job description, but he side tracked it.  I am going to readdress this with him, and try to get some equiptment.  This is not the first medical incident that I have worked here.  

I was concerned because once I got out there and saw her vitals were ok, I couldnt think of anything to do.  I know I should get a BP, give O2, start a line (once im a medic), but I couldnt do any of that.  I felt that I was kind of helpless.  

As an aside, Chimpie, as you seem to have some experience... how do you think I should address this with my boss?  With out giving too much sensative information, we are in a large building, about 500 employees on site, over 20 security officers, im the only EMT.  All are CRP trained, but over half I wouldnt let come near me with a stick, let alone an AED.  I work evenings.  Last time I talked to him, he said there wasnt enough going on to justify going through all the trouble.  This is the 3rd major (i concider it major) medical incident in 12 months.  Not counting the countless times maintenance cuts themselves or whatnot.  

I just dont like the idea of not being able to do what im trained to do.

Thanks,
Russ


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## Luno (Sep 7, 2004)

Alpha, hmmm, TIA/CVA are considered BLS atleast where I am, unless there is a compromise in the airway, or a cardiac event with them.  And treatment is pretty much the same, O2, vitals, monitor, txpt, consider OPQRST/pt condition/pre-existing conditions/MEDS/HX/Allergies, also some other things to note in your assessment, BP over time and HR, pt with a bleed (form of CVA) will exhibit a decrease in BP initially with sinus tach, before their BP skyrockets, and they go bradycardic.  This is just to give you a little insight into the event, but the treatment whether aneurism or blockage is the same at the BLS level.  The BP/HR example illustrate an acute CVA w/bleed, this is also applicable to closed head trauma.  Another indicator of CVA bleed with an increase of ICP is differentiation of the patient's pupils, i.e. R/L side "blown," or with a size disparity.  However, as I will again re-iterate, these are only to give you an idea of what's going on, but never delay treatment to get a better idea, we treat signs and symptoms, the MDs diagnose.

Also as a medic, what would be your purpose for "starting a line?"


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## ffemt8978 (Sep 7, 2004)

I've done the security officer thing for several years now and share your frustrations in incidents like these.

What you did in maintainng the ABC's was probably the most important thing you could have done.  Even if you had been allowed to practice as an EMT, the treatment for a CVA/TIA is essentially the same as that of a bystander (with the exception of O2 and vitals).  What more are you allowed to do for a CVA/TIA victim?

As far as your boss goes, there are several issues that will probably need to be cleared up before your proposal goes forward:
1) Will you have a "duty to act" and if so, under what conditions?
2) What about liability insurance?
3) How will you fund the initial cost outlay?
4) Who is responsible for providing your CME's?
5) Which doctor will you go to for medical oversight, protocols, and equipment purchases?
6) How will you store these controlled items?

I don't mean to discourage you, because I think this is a worthwhile endeavor.  I am just trying to provide you with some of the possible obstacles in your plan, so that you can work on having the correct answers for them.


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## rescuecpt (Sep 7, 2004)

> _Originally posted by Luno_@Sep 7 2004, 07:13 PM
> * Also as a medic, what would be your purpose for "starting a line?" *


 Cuz I can...

In my County as a CC it is my option for O2, IV, Monitor on every patient I plan on escorting to the hospital.  Of course, I usually go O2/Monitor and avoid poking extra holes if I don't have to...  But you have to start a line to push meds, and it is preferred for nitro, aspirin, albuterol/atrovent, etc... because of allergies or other reactions that may occur.

But CVA/TIA/Stroke - whatever you want to call it - is a BLS job in NYS.  Clinically speaking though, whenever you could get ALS involved it is good because the stroke could be caused by a fibrullating heart that is throwing clots that may have been lodged in the heart... if you can calm the fibrullation you might be able to prevent further clotting - but the treatment is for medical control to decide.  It's not that common, but if you have the power to rule it out, go for it.

FYI:
NY State BLS Stroke Protocol
http://www.health.state.ny.us/nysdoh/ems/p...rokeprotcol.pdf


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## MMiz (Sep 9, 2004)

Alpha752,

I find that strokes / TIAs are one of the most difficult things an EMT can deal with, as there really are no pre-hospital treatments.  Besides nagging my partner for our ETA, there really isn't much I can do.  

My first stroke pt was with when I was working with a medic for the day.  Her partner didn't show up, so I picked up the shift.  They posted our ambulance with a supervisor (CCEMT-P), so we could convert into an ALS unit if needed.  The guy ended up faking a MI to get morphine.  As my partner whipped out the drug box, he started faking a CVA.  Needless to say, he didn't get anything beyond the four tylenol we gave him prior to his new symptoms.

Weird thing is, for a very short time he had a Septal MI.  We got him to the hospital where he tried one last time for some morphine.  He pretended to black out, but when the blad from the ET tube hit his mouth, he wasn't about to play the game any longer.

Needless to say, I was a bit frustrated with the whole situation.  

Besides the AED, I would try to push for an emergency O2 unit.  They're preset at 6 LPM, and you'll often find them in the same wall mounts with newer AEDs.  

As far as dropping a line, local hospitals expect all ALS calls to come in with at least one line.


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## Alpha752 (Sep 9, 2004)

Thanks everyone.  I talked to my medic instructor as well, and he said the same as y'all, theres not much to do.  Its frustrating not being able to do anything though.

mmiz- I thought O2 was a prescription drug?  How could we have that, and how could I dispense that with out a medical director?

oh well, 9 more months, and ill be a medic and get to do this stuff for real.

Thanks again,
Russ


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## Luno (Sep 9, 2004)

RescueLT/Mmiz, I was writing the "why would you drop a line anyway" to Alpha as a security guard, even if you're medic trained, you're still a security guard, invasive medicine is different than basic first aid.


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## Alpha752 (Sep 9, 2004)

Luno- as a security guard I would NOT do any invasive or ALS procedures.  In my current capasity I am limited to BLS only.  However, I am trying to get myself in the mindset of a paramedic.  Thats where that comment came from, I was trying to think of what would happen if I were a medic on duty.  Sorry for the miscommunication.

Just to reiterate- NO ONE should do any ALS type procedures if they are not on duty, and working for a medical director....thats a good way to get sued for practicing medicine with out a license.

Russ


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## MMiz (Sep 9, 2004)

> *mmiz- I thought O2 was a prescription drug? How could we have that, and how could I dispense that with out a medical director?*



The O2 is no different than an AED in that respect.  An AED actually requires a MD's prescription with medical direction.  The O2 is set at 6-7 LPM, which I can't see doing any harm to any patient.  Just as you have protocols for using an AED, you would have similiar standing orders for use of O2.

I think the combination of O2 and an AED can't be beat.


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## Alpha752 (Sep 9, 2004)

Thanks Matt, Ill suggest this to my boss.

Russ


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## rescuecpt (Sep 9, 2004)

> _Originally posted by MMiz_@Sep 9 2004, 08:01 PM
> * The O2 is no different than an AED in that respect.  An AED actually requires a MD's prescription with medical direction.  The O2 is set at 6-7 LPM, which I can't see doing any harm to any patient.  Just as you have protocols for using an AED, you would have similiar standing orders for use of O2.
> *


 6-7LPM for a nasal cannula, right?

The rule NYS teaches is if someone needs O2 they should be given between 10 and 15LPM via non-rebreather.  A nasal cannula is used if they cannot tolerate the mask for some reason.

O2 can be toxic for infants and small children when given in large doses, but in ths situation we're talking about (O2 for a few minutes while moved to the ER) is usually not long enough to cause problems.


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## Luno (Sep 9, 2004)

> *O2 can be toxic for infants and small children when given in large doses*



Okay, I know about the newborns and blindness, and I am familiar with COPD and suppression of secondary resp. drive, but I had no idea about the toxicity of O2 with infants/children.  Would you please elaborate?


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## MMiz (Sep 14, 2004)

> _Originally posted by rescuelt+Sep 9 2004, 09:19 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>*QUOTE* (rescuelt @ Sep 9 2004, 09:19 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-MMiz_@Sep 9 2004, 08:01 PM
> * The O2 is no different than an AED in that respect. An AED actually requires a MD's prescription with medical direction. The O2 is set at 6-7 LPM, which I can't see doing any harm to any patient. Just as you have protocols for using an AED, you would have similiar standing orders for use of O2.
> *


6-7LPM for a nasal cannula, right?

The rule NYS teaches is if someone needs O2 they should be given between 10 and 15LPM via non-rebreather.  A nasal cannula is used if they cannot tolerate the mask for some reason.

O2 can be toxic for infants and small children when given in large doses, but in ths situation we're talking about (O2 for a few minutes while moved to the ER) is usually not long enough to cause problems. [/b][/quote]
 The 6-7 LPM is given via a Simple Mask.  In EMT school we learned there was:

NC - 1-4 LPM - 22-44%
Simple Mask - 6-12 LPM - 35-50%
NRB - 80-95%
BVM - 80-100%

I've never seen a Simple Mask in the field though, only on these special units.

We carry NC and NRB on the units, in Peds and Adults sizes.  We also carry both in our jump kits.  Many medics like NC instead of NRB for unknown medicals.  Personally I love to see everyone on a NRB.

Peds are provided O2 via blow-by oxygen, I've only done that once.  While we dont have them, many places have cute little things for ped blow-by oxygen administration (here)

COPD patients can be placed on O2 at 15 LPM for emergency situations.  Protocol states that COPD patients should be placed on O2 @15 LPM if experiencing significant breathing difficulties.  Being on high-flow O2 for such a short period will do significantly more good than harm.


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