# Blood Pressure: ALS v. BLS



## sirengirl (Jun 21, 2011)

Alright sooo.... Today I got a call for diarrhea at an indipendent nursing home. I get up to the patient and she's 89, A&Ox3, currently feels okay, diarrhea x3 in the past 30 hours. On meds for depression, insomnia, hypertension, and something else that was unrelated. Sitting in bed, ambulatory, pretty pleasant to talk to. So I get her vitals. BP machine is taking forever. Note that the county at this time is going insane with calls and our squad in fact turned down about 5 requests for assist from the county b/c our units were on calls already. BP machine finally gets back to me- 214/160 (or some other similar diastolic).

Immediately I take it on the other arm- it's the same range. Pt states she did in fact take her blood pressure medication this morning. I call for ALS, as my protocols state anything above 210 should be called in, and re-take manually as our BP machines have been known to be :censored:. Again, over 210. So we chill for about 10 mins until ALS arrives. It's the firemedics on the engine from the station closest us, as their truck and the second closest truck are already on calls. I explain that initial CC was diarrhea x3 and I called for BP over 210.

This is where my question starts. 

The medic took her BP, by this time it was just under 200/97 or so. Pt has no s/s, no complaints other than the diarrhea, no pains, aches, droop, slurring, aphasia, headache, tingling, tightness, sob, nothing. Medic 1 looks at Medic 2 and shrugs. Medic 1 then says to me,

"We don't treat unless it's over 220/140."

Then they pack their :censored: and vamos.

WITHOUT an ECG.

Was I wrong to call them? Or were they wrong not to check her cardiac? Should I have demanded that the medics run an ECG or was I right to let it slide and transport my patient for her initial diarrhea complaint? I discussed it with a fellow EMT at my station who believes I should have made them run the 12-lead, but as a general rule I don't question those with more training than me. I'm scared to death that this is going to come back as asymptomatic hemmoragic stroke or something- recently ALS turned over a call w/o SaO2 and w/o ECG to one of our teams and it turns out the poor man was having a silent MI. 

Thoughts?


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## bigbaldguy (Jun 21, 2011)

First of all I'm curious. You use machines to take BP and you're bls? What kinda a swanky outfit you running with lol. We do manual first here machine second and I don't know of many bls services that use auto bp at all.

Sounds like there is a disconnect between your bls protocols and your als protocols. If yours say to call als for xyz then you call als for xyz. You're just following your orders. That bp on a woman that age who should theoretically be dehydrated from the diarrhea and has her bp controlled by medication would set my alarm bells ringing as well.

I agree it seems like an ECG would have been a good idea just to be on the safe side. I can't see how this would come back on you though. You did what you were trained to do and called in the big boys and they poo poo'd your call. If anything comes of it then it will be on them not you.


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## sirengirl (Jun 21, 2011)

bigbaldguy said:


> First of all I'm curious. You use machines to take BP and you're bls?
> 
> ....should theoretically be dehydrated from the diarrhea...



Pretty swanky, I guess. All our units have auto BP machines which also have pulse ox. They have a very high rate of being crap, as I mentioned earlier, but we recently complained enough to get a bunch of new ones and they've been working good. 

And yeah she was mildly dehydrated- enought to tent a little when I checked turgor.

I talked with our education assistant chief, who said that getting all our protocols on with the county's has been an uphill battle; the county services 3 major cities and we service one small city. Our med director is local only an doesn't meet with the county. 

Like I said, I'm just worried about heart condition slipping through or the possibility of a cranial bleed somewhere. An 89y/o woman who has taken her BP meds and not been active, in fact has been sitting in bed, should not have a BO over 200....


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## LucidResq (Jun 21, 2011)

I think it's pretty simple... it's sad that they care more about a 20 mmhg difference in a systolic pressure than this patient or your request. Even if there's not much they can do treatment-wise, they have more assessment abilities... ALS was requested and this ain't for "my shoulder hurts" - a hypertensive crisis can lead to very severe consequences.


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## Lifeguards For Life (Jun 21, 2011)

There's 63 mmHg difference between your reported diastolic, and the diastolic obained by fire. 

140 may be worth a worry, 97, not so much.

You seem to think an ekg will show a brain bleed?

A 12 lead wouldn't hurt. I probably would of done one just as a courtesy to the BLS crew.


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## Lifeguards For Life (Jun 21, 2011)

You definitely  weren't wrong though. you did good kid.


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## sirengirl (Jun 21, 2011)

Lifeguards For Life said:


> You seem to think an ekg will show a brain bleed?



It's not that I think an ECG would show a bleed- I know it wouldn't. But being as the pt does have a cardiac history I wanted to make sure the BP wasn't indicative of a cardiac problem. OR there was the possibility of a bleed. Either way an ALS assessment would have helped.


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## Shishkabob (Jun 21, 2011)

Lifeguards For Life said:


> You seem to think an ekg will show a brain bleed?



No, and I don't think she insinuated as much, but a 12/15-lead COULD help with a differential.



However, without any S/S, highly doubtful anything would have been done for the patient at the ALS level.  We have 2 different Beta blockers, and multiple vasoactive drugs on my truck, but I'm not touching any of them just because I don't like a number.




Should a 12-lead have been done?  Yes.  Any treatments?  Don't know.


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## Lifeguards For Life (Jun 21, 2011)

Linuss said:


> However, without any S/S, highly doubtful anything would have been done for the patient at the ALS level.  We have 2 different Beta blockers, and multiple vasoactive drugs on my truck, but I'm not touching any of them just because I don't like a number.



Only S/S here is diarrhea 3 times over 30 hours, if fire correctly read the bp.

OP what were the vitals, and did you take a manual bp?


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## sirengirl (Jun 21, 2011)

Lifeguards For Life said:


> Only S/S here is diarrhea 3 times over 30 hours, if fire correctly read the bp.
> 
> OP what were the vitals, and did you take a manual bp?



Forgive me but I can't remember the exact numbers :/ Initial vitals are BP (left arm) 214/160 (give or take on the diastolic), HR was in the 80s, RR was 16, GCS 15. RR and GCS never changed, heart rate at second assessment was 88 (I specifically remember that one) and BP on right arm 210/high150s, third BP taken manually on left arm was 211/high150s as well. Next set was done about 10 mins later by ALS with above results. By this time HR was 79.


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## Smash (Jun 21, 2011)

sirengirl said:


> It's not that I think an ECG would show a bleed- I know it wouldn't. But being as the pt does have a cardiac history I wanted to make sure the BP wasn't indicative of a cardiac problem. OR there was the possibility of a bleed. Either way an ALS assessment would have helped.



Actually although it's not necessarily used to diagnose a "brain bleed", ECG changes are very common with intra-cranial hemorrhage (reported ranges betwen 25% to 100%!)

However, with the scenario presented I don't think a 12 lead in the field is going to change things for the aptient.  
The trouble with any test (be it a 12 lead or an MRI) is that it is only as good as your pretest suspicion that something is going on that needs to be tested for.  The best example of that is probably the ballyhoo over PE and doing D-Dimers on all sorts of people.  We found that the incidence of PE was actually huge, but the significance was negligible; we just picked up that the lungs were doing their other job (clot catcher)

So for the scenario, I don't think a 12 lead really matters, and I certainly wouldn't be treating that blood pressure in the absence of any relevant symptomology.


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## Anjel (Jun 21, 2011)

I would of made ALS take them. 

Here if a basic doesn't feel comfortable taking the pt ALS cannot refuse to take them. We just have to have a really damn could reason not to.

With a BP that high and no explanation. I am not gonna risk the pt stroking out or something else happening.


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## Lifeguards For Life (Jun 21, 2011)

Anjel1030 said:


> I would of made ALS take them.
> 
> Here if a basic doesn't feel comfortable taking the pt ALS cannot refuse to take them. We just have to have a really damn could reason not to.
> 
> With a BP that high and no explanation. I am not gonna risk the pt stroking out or something else happening.




What reason do you have to not feel comfortable with this patient?

I doubt the BP was as high as the OP reported.(could of been but there is a huge discrepancy between her reading and the medics, as well as no accompanying signs, symptoms, complaints etc. of any real concern)


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## Lifeguards For Life (Jun 21, 2011)

Smash said:


> Actually although it's not necessarily used to diagnose a "brain bleed", ECG changes are very common with intra-cranial hemorrhage (reported ranges betwen 25% to 100%!)



Wouldn't a myriad of signs and symptoms come charging before any ekg manifestations in the case of a bleed? (I remember reading an old article discussing this, but haven't really ever heard anything else about it.)


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## Shishkabob (Jun 21, 2011)

Anjel1030 said:


> Here if a basic doesn't feel comfortable taking the pt ALS cannot refuse to take them.



That's the dumbest thing ever.  If a medic deems that a patient would be ok going BLS, that should be the end of it, as their clinical decision should outweight a BLS trucks non-clinical decision.




There are calls I'm not comfortable with, but I can't slink out of my responsibilities and shoo the patient to someone else.  Neither should a BLS provider.  Provider comfort really shouldnt be a factor in patient care.


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## Anjel (Jun 21, 2011)

Lifeguards For Life said:


> What reason do you have to not feel comfortable with this patient?
> 
> I doubt the BP was as high as the OP reported.(could of been but there is a huge discrepancy between her reading and the medics, as well as no accompanying signs, symptoms, complaints etc. of any real concern)



If it was as high as the OP says, and no EKG was done to clear the pt. I would not feel ok with taking that pt. Because if something happens I am screwed. 

I would have to be there to determine it too. Depending on the look of the pt, and other factors. Especially how close I am to the hospital.


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## Lifeguards For Life (Jun 21, 2011)

Linuss said:


> That's the dumbest thing ever.  If a medic deems that a patient would be ok going BLS, that should be the end of it, as their clinical decision should outweight a BLS trucks non-clinical decision.
> 
> 
> 
> ...



I wouldn't go as far as to say it is the dumbest thing ever. If the basic is really and truly not comfortable with babysitting a patient, I don't really know if it is fair to the patient to send them with such a provider (even if said care consists mainly of staring at them). Provider comfort shouldn't take priority, but care should be taken to ensure the patient feels that their provider is capable of caring for them.

But on the other side, is that really worth tying up an ALS unit with?

Regardless, being afraid to transport this particular patient, is weak.


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## Lifeguards For Life (Jun 21, 2011)

Anjel1030 said:


> If it was as high as the OP says, and no EKG was done to clear the pt. I would not feel ok with taking that pt. Because if something happens I am screwed.
> 
> I would have to be there to determine it too. Depending on the look of the pt, and other factors. Especially how close I am to the hospital.



What are you expecting this EKG to show?


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## SeanEddy (Jun 21, 2011)

There are a few things to consider here. If your transports time to a hospital is less than the als eta, then sitting on scene doesn't do much good. Of course, I don't know your rules or your area. 

Clinically speaking, you were absolutely right to call als. The risk of stroke or cardiac is significant with that bp. However, I would strongly advise against "directing" a paramedic to perform a skill that's outside of your scope. Your best bet is to document well and let the higher-ups deal with the medic.

Don't worry about this scenario. It sounds like you did the right thing.

Sent from my DROIDX using Tapatalk


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## Anjel (Jun 21, 2011)

Lifeguards For Life said:


> Regardless, being afraid to transport this particular patient, is weak.



It's not about comfort. It is about if something was to happen to this pt with that high of a bp for no reason and no ekg to say that it isnt cardiac related. There is nothing I could do for that pt. 

If the BP was that high. But everything else about the pt was perfectly normal then no I wouldn't have a problem taking them.

For the pt, I want them to have the best resources available to them in case they decided to take a turn for the worse.


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## sirengirl (Jun 21, 2011)

It weas never a question of being comfortable transporting this patient- she was having a perfect conversation with me, and like I said A&Ox3, my only concern was whether I should have pushed for the ECG to ensure the best patient care was being handles in order to minimize risk of improper care.


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## Smash (Jun 21, 2011)

Lifeguards For Life said:


> Wouldn't a myriad of signs and symptoms come charging before any ekg manifestations in the case of a bleed? (I remember reading an old article discussing this, but haven't really ever heard anything else about it.)



Absolutely, hence saying that it's not necessarily going to diagnose the sub-arachnoid.  There's no reason to expect any in this patient anyway.


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## Anjel (Jun 21, 2011)

Lifeguards For Life said:


> What are you expecting this EKG to show?



That there is nothing cardiac relating to the BP. 

If there isn't. Ok we are good to go. I will take her and "babysit" her to the hospital.


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## Lifeguards For Life (Jun 21, 2011)

sirengirl said:


> It weas never a question of being comfortable transporting this patient- she was having a perfect conversation with me, and like I said A&Ox3, my only concern was whether I should have pushed for the ECG to ensure the best patient care was being handles in order to minimize risk of improper care.



I'm not questioning the level of care you provided. I think you did perfect. 

To answer your question, while I don't think you should of "demanded" or "pushed for" an ekg, but you could of asked the medic about it. A simple "hey what do you think about an ekg" would of been fine. The medic may of done one for you, or more likely, nicely explained their reasoning to you.

Never be afraid to ask


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## Shishkabob (Jun 21, 2011)

sirengirl said:


> It weas never a question of being comfortable transporting this patient- she was having a perfect conversation with me, and like I said A&Ox3, my only concern was whether I should have pushed for the ECG to ensure the best patient care was being handles in order to minimize risk of improper care.


No one was questioning your comfort ^_^



As an add on to LFL, it's how you phrase it.

"Hey what did the EKG show?  Oh, you didn't get one?  Could you do one for me as I'm trying to learn EKGs"


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## Lifeguards For Life (Jun 21, 2011)

Anjel1030 said:


> It's not about comfort. It is about if something was to happen to this pt with that _high of a bp for no reason _and no ekg to say that it isnt cardiac related. There is nothing I could do for that pt.
> 
> If the BP was that high. But everything else about the pt was perfectly normal then no I wouldn't have a problem taking them.
> 
> For the pt, I want them to have the best resources available to them in case they decided to take a turn for the worse.




well if the bp is high for no reason, there is no reason to worry then.

Or if the BP is a little high(or even just plain high) because they have a history of hypertension, there is, again, no reason for worry.


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## sirengirl (Jun 21, 2011)

Linuss said:


> No one was questioning your comfort ^_^
> 
> 
> 
> ...



I was just clarifying in case anyone did. In fact I feel better about the pt being transported with me as she was because her history of depression- we had a nice long conversation in her ER room about her family and such while I waited for the long turnover time due to the high call volume at that time. I don't feel like said paramedic would have had the patience to sit down in a chair next to her and chat while waiting for the ER backlog to catch up. In no way do I say this should be done with every patient- but the situation and time seemed appropriate for it considering that I'd already been working with her for over 20 minutes in her home. A stranger may or may not have had the same compassion.


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## Anjel (Jun 21, 2011)

Lifeguards For Life said:


> well if the bp is high for no reason, there is no reason to worry then.
> 
> Or if the BP is a little high(or even just plain high) because they have a history of hypertension, there is, again, no reason for worry.



why is it high if they took their medication?

All I ask is for an ekg. And after that and the medic says ok you are good to go.  Then ok we will go. The medics here would never leave once on scene either. 

The way the OP stated it. Was the medics that showed up, checked a bp and said peace. 

Again if they took the time, assessed the pt, said that they were ok. Then ok I will take them. 

Better safe then sorry.

BTW...Just because I don't like what you are insinuating. I have never turned down a pt. Or said no because I wasn't comfortable. I am just saying that depending on the situation and ALS on scene. If I didn't want to take them. I wouldnt have to


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## Lifeguards For Life (Jun 21, 2011)

Can one of the basics posting in this thread (meaning not Linuss  ) explain to me what cardiac complications you believe may be underlying  in this particular patient?


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## Smash (Jun 21, 2011)

Anjel1030 said:


> why is it high if they took their medication?
> 
> All I ask is for an ekg. And after that and the medic says ok you are good to go.  Then ok we will go. The medics here would never leave once on scene either.
> 
> Better safe then sorry.



Why do you ask for an EKG?  What symptoms is this patient exhibiting that makes you suspect there could be a thrombo-occlusive event occuring?  I'm struggling to see a connection between essential hypertension and a 12 lead.

Edit:  Sorry, Lifeguard got in before me.


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## usalsfyre (Jun 21, 2011)

Hmmm, if I remeber the AHA guidlines correctly, a B/P of 200/97 would get discharged from the ED with a script for oral antihypertensives and a note to follow up with the PCP. 220/110 is where they begin to treat. Anything less than 180 systolic doesn't even get the script. 

I'd be suspicious of the diastolic of 160 from the NIBP. It's also important not to get confirmation bias from the NIBP when taking a manual pressure. A big deal is often made of hypertension, when in reality, most people aren't waiting to stroke out on you. When was the last time this patient saw here PCP? EMS is trained to think zebra's when they hear hoofbeats, in reality 75% of the time it's just plain old horses.

I would probably have taken the patient, just because the BLS truck has shown themselves to be uncomfortable with the patient. However, I don't fault the medics for releasing the patient to BLS. Diarrhea is not exactly a sign of occult stroke or MI. It comes down again to education ("not this cr@p again usalsfyre!"). EMT-Basics (and for the most part medics) are taught and expected to overtreat to make up for knowledge gaps in their assesment to determine life-threatening from non-life-threatening.


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## Anjel (Jun 21, 2011)

Smash said:


> Why do you ask for an EKG?  What symptoms is this patient exhibiting that makes you suspect there could be a thrombo-occlusive event occuring?  I'm struggling to see a connection between essential hypertension and a 12 lead.
> 
> Edit:  Sorry, Lifeguard got in before me.



I want an assessment by the ALS I called. If I thought that pt needed ALS then I want them to assess. Not just take a BP. 

I am talking in general. Idk that I would of called ALS for that pt. But if I did, I want them to make sure they are ok before I take them. 

The OP provided HR, RR, and BP. and said they were calling ALS. SO if she thought they needed ALS I am just going with that decision and building from there.


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## Shishkabob (Jun 21, 2011)

A Paramedic level assessment is that level not just for the tools used to assess, but the education/ knowledge behind such assessment, with (hopefully) an understanding of not just physiology, but pathophysiology.


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## usalsfyre (Jun 21, 2011)

Anjel1030 said:


> I want an assessment by the ALS I called. If I thought that pt needed ALS then I want them to assess. Not just take a BP.
> 
> I am talking in general. Idk that I would of called ALS for that pt. But if I did, I want them to make sure they are ok before I take them.
> 
> The OP provided HR, RR, and BP. and said they were calling ALS. SO if she thought they needed ALS I am just going with that decision and building from there.



I can do a pretty good assesment without a 12 lead EKG. If the patient has no complaints, numbers aren't neccesarily a good reason to run diagnostic test.

"ALS" is not about the tools, it's about the knowledge. 

(Linuss beat me there)


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## Anjel (Jun 21, 2011)

Instead of attacking and thinking that I am absolutely ridiculous. Why don't you explain your decision in the hopes someone could learn something. 

I am a brand new basic. There isn't much that I am comfortable with. But I do my job. I've never had to call ALS. But if I do that means that I don't think I could handle it. And would like them to either take the pt, or assure me that it is ok.


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## Anjel (Jun 21, 2011)

Linuss said:


> A Paramedic level assessment is that level not just for the tools used to assess, but the education/ knowledge behind such assessment, with (hopefully) an understanding of not just physiology, but pathophysiology.



But from what the OP said they did not do a paramedic level assessment. They did a BP and said cya bye


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## Lifeguards For Life (Jun 21, 2011)

Anjel1030 said:


> I want an assessment by the ALS I called. If I thought that pt needed ALS then I want them to assess. Not just take a BP.
> 
> I am talking in general. Idk that I would of called ALS for that pt. But if I did, I want them to make sure they are ok before I take them.
> 
> The OP provided HR, RR, and BP. and said they were calling ALS. SO if she thought they needed ALS I am just going with that decision and building from there.



That's not good enough. Why do you think the patient needs ALS?

None of the medics here  mean to insinuate anything negative, but this level of thinking should be obtainable at the basic level.


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## Smash (Jun 21, 2011)

usalsfyre said:


> I can do a pretty good assesment without a 12 lead EKG. If the patient has no complaints, numbers aren't neccesarily a good reason to run diagnostic test.



Indeed, I have zero suspicion that this patient is having an acute ST elevation myocardial infarction, so I have no reason to do a 12 lead.  The blood pressure really doesn't concern me at all, and even if it did, it bears no relation to what I may or may not see on a 12 lead (i.e. probably nothing, maybe a strain pattern, who knows, and really...)


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## Lifeguards For Life (Jun 21, 2011)

Anjel1030 said:


> Instead of attacking and thinking that I am absolutely ridiculous. Why don't you explain your decision in the hopes someone could learn something.
> 
> I am a brand new basic. There isn't much that I am comfortable with. But I do my job. I've never had to call ALS. But if I do that means that I don't think I could handle it. And would like them to either take the pt, or assure me that it is ok.



Oh we will explain eventually. But this is something you can think your way through, even if you are a new basic. I have faith in you.

I am a firm believer that by not spoon feeding, and allowing you to struggle with this problem here, you will learn something that you can take with you to the field.


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## Anjel (Jun 21, 2011)

Lifeguards For Life said:


> That's not good enough. Why do you think the patient needs ALS?
> 
> None of the medics here  mean to insinuate anything negative, but this level of thinking should be obtainable at the basic level.



For this particular pt I don't know if they needed ALS. 

If it was only the BP that was out of the ordinary then I probably would of just loaded and go. 

But obviously there was something that made the OP call.


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## Smash (Jun 21, 2011)

Anjel1030 said:


> But from what the OP said they did not do a paramedic level assessment. They did a BP and said cya bye



It sounds like they did do a paramedic level assessment.  It sounds like the OP had done a good assessment, which would lead them to trust her findings.  They've confirmed the main problem that they were called for (hypertension), have recognised that there is nothing to be worried about, nor is there any reason to do a 12 lead, and have duly handed off.  Maybe they could have spent a bit more time with the OP to explain this better.  Other than that, I don't see a problem.

Edit:  And we aren't attacking anyone, it's just that as an educator (I lecture at a large university that runs a full degree in paramedicine) I prefer to get people to think things through themselves, find the information they need and use it to develop their own practice.  I find that this helps them conceptualise things better, rather than being spoon fed lists of numbers or "facts"


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## Shishkabob (Jun 21, 2011)

Anjel1030 said:


> Instead of attacking and thinking that I am absolutely ridiculous. Why don't you explain your decision in the hopes someone could learn something.



I don't want you to think we're attacking you, because we aren't.  (Well, I know for a fact I'm not.)  I'm one of the biggest fans of EMTs who want to learn more / do more / take their job seriously and be a help instead of just a gofer (Which you clearly do, as do most of the people who join a forum such as this).  I hate gofers.  Challenge yourself, challenge me, help the patient, do what you think is right (so long as you dont go over the no-no zone line)



Anjel1030 said:


> But from what the OP said they did not do a paramedic level assessment. They did a BP and said cya bye



I can ask questions that an EMT wouldn't know to ask.  Hell, I ask questions and do procedures that make other Paramedics confused.  (Ask the next medic you see when the last time they did a 15-lead was)  

Again, an ALS tool need not be used to do an ALS assessment.


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## Lifeguards For Life (Jun 21, 2011)

Linuss said:


> Hell, I ask questions and do procedures that make other Paramedics confused.



He says this like it's a good thing:lol:

Just kidding L


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## Shishkabob (Jun 21, 2011)

Good for my over-inflated, Para-God-ish ego.


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## Lifeguards For Life (Jun 21, 2011)

Linuss said:


> Good for my over-inflated, Para-God-ish ego.



I was going the other way with that one, but again, I kid, I kid.


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## Anjel (Jun 21, 2011)

So what would you of done if this was your pt. No BLS on scene. 

As you were taking vitals and gathering info.

Would you of started a line?

Hooked them to a monitor? Maybe not an EKG But a monitor?

I am just curious. 

Diarrhea 3 times in over 24hrs really isnt that big of a deal. I just am really curious as to why her BP was high. If it is supposed to be controlled by her meds. 

Are the two related? Or just coincidence.


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## usalsfyre (Jun 21, 2011)

Anjel1030 said:


> Are the two related? Or just coincidence.



Maybe, maybe not. The big thing I want to know is when has she seen her PCP last.


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## 18G (Jun 21, 2011)

I wouldn't have been excited with this patient pre-hospital. Hypertension is RARELY ever treated by ALS in the field. I still wonder why BLS even calls ALS for hypertension unless it is an extreme case. The patient was pleasant, non-distressed, and completely asymptomatic of the finding. If your transport time is short (<20mins) just transport. 

Maybe I missed it but what was the patient's history? She said she has been compliant with the HTN meds but was she really? Any dosage change? Has she been compliant with her diet? Any splurging on the sodium that increased fluid volume and contributed to increased BP? Does she also take a diuretic to help with control of B/P? Has she been compliant with that? Any renal issues? What's her output been like?

Primary hypertension can be from several different causes and its anyone's guess sometimes what causes BP to elevate in a person. It's certainly not for pre-hospital to diagnose the specific cause. Is she currently ill over all? Increased HR? Febrile? Stressed? Taken any stimulant meds?  

Here in PA the decision for ALS to release must be a mutual decision. Rarely, does BLS ever dispute the ALS release decision but if BLS feels that ALS is being lazy or just doesn't feel comfortable than ALS has to ride.


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## Lifeguards For Life (Jun 21, 2011)

Anjel1030 said:


> So what would you of done if this was your pt. No BLS on scene.
> 
> *It would still be a BLS call*
> 
> ...



replies in bold above


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## sirengirl (Jun 21, 2011)

usalsfyre said:


> Maybe, maybe not. The big thing I want to know is when has she seen her PCP last.



Here I will admit poor record keeping- I didn't think to ask when her last PCP visit was. And @ 18G, I got the impression that she is well enough mentally to be on top of her meds- of course there is no absolute way for me to know.


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## Anjel (Jun 21, 2011)

18G said:


> I wouldn't have been excited with this patient pre-hospital. Hypertension is RARELY ever treated by ALS in the field. I still wonder why BLS even calls ALS for hypertension unless it is an extreme case. The patient was pleasant, non-distressed, and completely asymptomatic of the finding. If your transport time is short (<20mins) just transport.
> 
> Maybe I missed it but what was the patient's history? She said she has been compliant with the HTN meds but was she really? Any dosage change? Has she been compliant with her diet? Any splurging on the sodium that increased fluid volume and contributed to increased BP? Does she also take a diuretic to help with control of B/P? Has she been compliant with that? Any renal issues? What's her output been like?
> 
> ...



This is the assessment I was hoping for. Great reply.


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## 18G (Jun 21, 2011)

sirengirl said:


> And @ 18G, I got the impression that she is well enough mentally to be on top of her meds- of course there is no absolute way for me to know.



I agree sometimes it's hard to tell for sure. You can always look at the bottles and see if they are empty or count to see how many are there to get an idea. Sometimes patient's say they are compliant just to pacify their providers and because they think they will "get in trouble" if they say they haven't been compliant.


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## Aidey (Jun 21, 2011)

sirengirl said:


> Alright sooo.... Today I got a call for diarrhea at an indipendent nursing home. I get up to the *patient and she's 89*, A&Ox3, currently feels okay, diarrhea x3 in the past 30 hours.





sirengirl said:


> And yeah she was mildly dehydrated- enought *to tent a little when I checked turgor.
> *



Just an observation, she is 89, her skin is going to be significantly less elastic naturally. Turgor generally doesn't show up unless the person has 10%+ fluid loss. Even if a patient develops tenting when they aren't that dehydrated they are going to have other obvious symptoms.


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## Lifeguards For Life (Jun 21, 2011)

Aidey said:


> Just an observation, she is 89, her skin is going to be significantly less elastic naturally. Turgor generally doesn't show up unless the person has 10%+ fluid loss. Even if a patient develops tenting when they aren't that dehydrated they are going to have other obvious symptoms.



Actually now that Aidey brings it up, the other vitals given do not support the claim that this pt is dehydrated in the least.


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## Crunch (Jun 22, 2011)

I agree with Linus and the others as far as the reasoning behind the 12 lead not being necessary.

The other factor to "just in case" things like running a 12 in this situatio that most providers fail to take into account is cost to the pt. I know here the patient will be charged for the 12 lead, and the base charge and mileage fee will also be increased because it will become an ALS run. However, money should never be a factor in NECESSARY treatments and diagnostics.
It is unlikely even if the 12 lead showed something pathological that the course of the prehospital care would have been altered. The patient will likely get a 12 lead at the hospital, as I don't know anywhere that relys solely on ems ekgs. 
Even if the ALS crew had run a 12 lead for you, it would not have told you everything is okay. The electrophysiology of the heart is only one component of blood pressure. And an EKG can be normal even when there is an underlying problem.

Would have it hurt the patient to run the 12? No. 
Would there been any real gain in 99 out of 100 patients? Probably not


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## the_negro_puppy (Jun 22, 2011)

I want to know why a lady with 3 x diarrhoea in 30 hours and is ambulatory needs and ambulance....

In other news, I had a sorta similar case last night. Independent living facility 80 y.o lady had fallen and hit her nose. Bleeding had stopped. But started again a few hours later and couldn't be controlled (dripping). Pt was on Warfarin + aspirin. 2 x NiBP found the pt to be around 220/100, hx of atrial fibrillation, CCF etc. I did a manual and got 210/90. I straight away did a 6 lead ECG (1-3 + aug leads) 

Anyone with a cardiac hx with abnormalities such as high BP should really have an ECG done to rule out any problems or arrhythmias.


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## CAOX3 (Jun 22, 2011)

Hypertension is a priority 3 here, non emergent.

Even if the patient exibits signs of CVA upon your arrival and your medics dont have the ability to treat it, why waste window waiting for ALS to arrive, take them to the hospital.

If she has airway difficulties address them, control the airway and assist ventilations and take them to the hospital.

Your an EMT chances are at some point your going to encounter an emergency, and if the education and training wasnt provided the responsability lies with you to fill in the blanks.  Its easy to defer to the medics all the time but there will be a time when you will have to make a decision on your own do you feel confident in those abilities?

Its pretty simple theory, your not going to be able to treat everything, you wont understand everything and many things will beyond the reach of even the most educated and experienced providers.


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## boingo (Jun 22, 2011)

I'm wondering why the OP would call for ALS and then "chill" for 10 minutes waiting for them?  If you think the patient is ill enough to warrant ALS, perhaps driving towards a hospital would be a better idea.

With that said, the patient is w/o complaint.  I'm not in the habit of treating a number.  The patient needs a work up, but not by an ALS crew, IMHO.


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## sirengirl (Jun 22, 2011)

the_negro_puppy said:


> I want to know why a lady with 3 x diarrhoea in 30 hours and is ambulatory needs and ambulance....



Easiest answer: System abuse. My unit is BLS volunteer. Any call that comes in on our emergency line that the caller thinks is an emergency, we have to take. If we get there and they want to go, we have to take them. The nursing home that this particular patient was at, I was at 4 times yesterday. I actually transported a A&Ox3 58 y/o male, ambulatory, responsive, no pain, no discomfort, no n/v/d, no NOTHING, because he "felt a little off." Let it be known that this particular nursing home HAS SHUTTLE BUSSES.... and is an approximate 40 second drive from the hospital (given the light at the road being green). The simple answer, like I said, is system abuse- they don't want to deal with their own patients, they don't want to use their own resources, so they use ours instead for :censored::censored::censored::censored: that doesn't require an ambulance at all.




CAOX3 said:


> Even if the patient exibits signs of CVA upon your arrival and your medics dont have the ability to treat it, why waste window waiting for ALS to arrive, take them to the hospital.



Reminds me of a call I had recently. A&Ox2 female with severe confusion, aphasia, and right-sided grip loss that presented after ALS assessed and left. Rather than recall them I loaded her and made the two turns to the hospital for treatment. Ideal? No. But would they have been able to do anything different? Doubtable.


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## IAems (Jun 22, 2011)

If there is a hospital as close to you as you are making it seem, "approximate 40 second drive from the hospital (given the light at the road being green)", the only reason I would call ALS is when I need extra hands (i.e. cardiac arrest).  To our level of training and education as BLS providers, we can both agree that this patient _may_ have needed an ALS assessment, probably not but err on the side of caution.  That ALS assessment doesn't need to be in an ambulance.  If you get the patient to an ER, that too is an ALS assessment.  I'm a firm believer that if I can get the patient to the hospital in about the time that ALS can get to me, that's what I'm doing; the patient gets what the patient needs and my service area isn't deprived of ALS resources.  This also boils down to understanding what ALS can and can't help you with, and what interventions you need them for. 

Also, let's put this whole level of training thing in perspective.  I would be a little ticked if a first responder "reminded" me to check a GCS for a patient A&Ox3 w/ no acute neurological deficits and a chief complaint of abdominal pain, when that first responder probably couldn't even tell me what a verbal response of 2 is or how that has anything to do in the least with a chief complaint of abdominal pain . . .



Anjel1030 said:


> If it was as high as the OP says, and no EKG was done to clear the pt. I would not feel ok with taking that pt. Because if something happens I am screwed.



By the by, if a higher medical authority _on scene_ clears a patient to your level of care, than whatever happens to that patient is on that _higher_ medical authority, especially considering you specifically called them to assist you (as opposed to mutual response via 9-1-1), so I wouldn't worry too much about liability on this one.  For gross negligence, I would call a Paramedic out, but for assessment preferences . . . sorry, they have more education, plain & simple.


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## sirengirl (Jun 22, 2011)

IAems said:


> If there is a hospital as close to you as you are making it seem, "approximate 40 second drive from the hospital (given the light at the road being green)", the only reason I would call ALS is when I need extra hands.



My protocols state anything above 210 should be called in to ALS. Their protocols state anything below 220 should not be treated. Obviously there is a disconnect, but I was doing what I have been told to do by the powers that be.


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## Lifeguards For Life (Jun 22, 2011)

sirengirl said:


> My protocols state anything above 210 should be called in to ALS. Their protocols state anything below 220 should not be treated. Obviously there is a disconnect, but I was doing what I have been told to do by the powers that be.



Protocols are made to be broken. They are more like guidelines anyway


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## sirengirl (Jun 22, 2011)

Lifeguards For Life said:


> Protocols are made to be broken. They are more like guidelines anyway



rofl I like that.


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## IAems (Jun 22, 2011)

*Hear Hear*



Lifeguards For Life said:


> Protocols are made to be broken. They are more like guidelines anyway



Cheers Lifeguards!


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## exodus (Jun 22, 2011)

Our protocols are guidelines, it even says so in the book. We have  protocol for protocol deviation as well!

To all BLS providers: What exactly would ALS do to help this patient? (The answer is nothing)


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## tacitblue (Jun 22, 2011)

Remember that an EKG or any other test for that matter is only going to show what a provider can see. From the information given by the OP, I would have not preformed a 12 lead EKG on a hypertensive patient free of complaint. I would have no pretest suspicion of a ischemic cardiac event underlying the problem so the results would not alter my differential or treatment. 

Now, perhaps I am a cardiologist seeing this patient in the clinic. EKG? yes. Lets look for LVH/strain/LBBB and have this on file to compare later. Perhaps will a BP like this LV failure is only a few years away.. But this EKG would not be preformed to rule out "cardiac causes" of hypertension.

EDIT: Field providers should also read the ACEP's new position on treating hypertension in the ED. Basically, dont do it. I think this can be extrapolated into the prehospital setting. See acep . org


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## johnrsemt (Jun 22, 2011)

For the OP:   Don't look at it as Protocols are meant to be broken; but think about it as they are Guidelines:  

  Your Protocols state that anything over a systolic of 210 needs and ALS consult; but you are closer to the ED than to ALS.  Transport, and document why you didn't call for ALS.  OR transport, requesting ALS from Dispatch as you mark transporting, and cancel them when you get to the hospital.
  Just be prepared to document and back up why you cancelled ALS.

  Talk to your Medical Director about changing the protocols:  so that if you are closer to the hospital than to ALS that you don't have to wait on scene.  He/she may never have thought about that situation; and it seems to happen alot in your area.

   Our Medical director in my old area would change protocols on suggestions of the EMS personnel, as long as we did the research to back up the reason that we wanted it done.


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## Lifeguards For Life (Jun 22, 2011)

johnrsemt said:


> For the OP:
> 
> OR transport, requesting ALS from Dispatch as you mark transporting, and cancel them when you get to the hospital.
> Just be prepared to document and back up why you cancelled ALS.



Don't waist a resource like this, whether that be ALS or BLS resources.

I would be more concerned about why you called ALS, than with why you canceled them.


Ambulances need to be available when people need them, not playing stupid political games.

If basics were tying up ALS trucks like this in my system, this issue would be immediately bought up with both the medical director and fire chief/ supervisor.

Calling ALS with the intent of having them chase you down, just to cancel them is absolutely horrible.

However, never be afraid to call anyone for assistance if you actually need it.


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## 18G (Jun 22, 2011)

If your less than one minute from the hospital why is this even being debated? When does common sense prevail?

You can drive your patient to definitive care in less than one minute, or wait on -scene for even longer until a Paramedic arrives who will do absolutely nothing to cause a difference in the patient.

As mentioned, protocols are just that, protocols. It is impossible to address every single patient care scenario with protocols. They are guidelines intended to integrate with clinical judgement and decision making. At the end of the day saying, "I was just following protocol" when it obviously wasn't the best choice won't win anyone over or look good in your defense. 

If your a new provider and still getting the hang of all of this I definitely understand and its okay. It's experiences like this that we all learn from when starting out and is what helps build decision making skills.


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## sirengirl (Jun 22, 2011)

18G said:


> If your a new provider and still getting the hang of all of this I definitely understand and its okay.



Thank you for noticing, this past Sunday was actually my 2-month birthday of being licensed


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## SeanEddy (Jun 22, 2011)

True, ALS would do nothing to treat the BP. I think the concern was regarding the possibility of a CVA or MI and the patient possibly deteriorating. If the transport time was long, then this could be a legitimate concern. 

Now, having said that. Numbers alone are nothing without some signs or symptoms to accompany them. I have always said that if you want to treat numbers, go be a mathematician.

Of course, this is not meant to be offensive to the BLS providers. I try not to blame them for being cautious. I think the training requirements for basics is absurd. I think they should do internships - even if not the same length - as paramedics. But then again, I think educational standards for paramedics if embarrassing. But I guess that's another topic for another thread.


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## JPINFV (Jun 22, 2011)

SeanEddy said:


> True, ALS would do nothing to treat the BP. I think the concern was regarding the possibility of a CVA or MI and the patient possibly deteriorating. If the transport time was long, then this could be a legitimate concern.


Paramedics, in general, can't do much for a CVA either.


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## mike1390 (Jun 22, 2011)

treat the pt not the monitor.


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## Lifeguards For Life (Jun 22, 2011)

mike1390 said:


> treat the pt not the monitor.



If the monitor shows a massive MI, but the elderly diabetic patient has no complaints, do you treat the monitor, or the patient?


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## the_negro_puppy (Jun 22, 2011)

Lifeguards For Life said:


> If the monitor shows a massive MI, but the elderly diabetic patient has no complaints, do you treat the monitor, or the patient?



I try to treat the patient. Last time I tried to give apsirin and GTN (nitro) to the monitor, my partner looked at me is if I was crazy.


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## EMSrush (Jun 22, 2011)

Linuss said:


> Again, an ALS tool need not be used to do an ALS assessment.



^ well said!


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## sirengirl (Jun 22, 2011)

Lifeguards For Life said:


> If the monitor shows a massive MI, but the elderly diabetic patient has no complaints, do you treat the monitor, or the patient?





the_negro_puppy said:


> I try to treat the patient. Last time I tried to give apsirin and GTN (nitro) to the monitor, my partner looked at me is if I was crazy.



+1 to you both :lol: lol


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## 18G (Jun 22, 2011)

JPINFV said:


> Paramedics, in general, can't do much for a CVA either.



True. But it's the field triage and early entry into the proper segment of the healthcare system that makes the difference. If a CVA patient can be recognized in the field and taken straight to a Stroke Center that is much better for the patient. This is in comparison to taking a CVA to a small little hospital who can't handle them.

EMS can't directly resolve the CVA, but the assessment, triage, supportive care, and rapid transport to a facility that can makes a world of difference.


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## exodus (Jun 22, 2011)

18G said:


> True. But it's the field triage and early entry into the proper segment of the healthcare system that makes the difference. If a CVA patient can be recognized in the field and taken straight to a Stroke Center that is much better for the patient. This is in comparison to taking a CVA to a small little hospital who can't handle them.
> 
> EMS can't directly resolve the CVA, but the assessment, triage, supportive care, and rapid transport to a facility that can makes a world of difference.



And why exactly can't a BLS unit call a stroke code? They can in SD and have many times...


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## Lifeguards For Life (Jun 22, 2011)

exodus said:


> And why exactly can't a BLS unit call a stroke code? They can in SD and have many times...



It's probably in their :censored:'s.


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## exodus (Jun 22, 2011)

Stupid. Then I'd call the hospital and be like, this is what i got, I'm not allowed to say stroke code, but you sure can based off of my assessment I'm giving you.


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## MrBrown (Jun 23, 2011)

OK so we have an old lady with known hypertension and she is .... hypertensive, Brown is gobsmacked.

Did we actually ask this lady what her blood pressure is normally? Could it be that such numbers are usual for this patient? Did the nursing home have any more history on her?

In the absence of any sort of symptoms that she is having a stroke Brown cannot help but wonder if we are getting our knickers in a twist over .... nothing.

For example, Brown and Black picked up a bloke from a medical centre whose primary problem was asthma, but his blood pressure was 240 systolic, but, that was normal for him and he had no headache, visual or other sensory abnormality or neuro symptoms and he was on a bag of blood pressure lollies so we didn't think of it as clinically significant.


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## 18G (Jun 23, 2011)

MrBrown said:


> Did we actually ask this lady what her blood pressure is normally? Could it be that such numbers are usual for this patient?



Brown makes a great point. 

I had a patient once who was being treated for hypertension and was walking around with a BP of low 200's over 100 something. She was on a few anti-HTN meds and her doctor couldn't get the pressure down. She was undergoing more testing and what not but at the time she was baseline hypertensive with medication. 

From my experience most nursing home staff have no clue what a patient's baselines are when you ask. Yesterday I had a call that was a perfect example of that.


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## 18G (Jun 23, 2011)

exodus said:


> And why exactly can't a BLS unit call a stroke code? They can in SD and have many times...



I never said BLS couldn't.


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## sirengirl (Jun 23, 2011)

MrBrown said:


> Did we actually ask this lady what her blood pressure is normally? Could it be that such numbers are usual for this patient? Did the nursing home have any more history on her?



Pt stated normal for her on her home NiBP was 136/90s. Had recently moved into the home, nursing staff was typically clueless and didn't even know if pt takes meds as religiously as the pt says she does.


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## slb862 (Jun 23, 2011)

When I get called into a Basic's area, allowing them to give me a good report, and I ask questions if needed, I will then make a decision as to whether it is ALS or BLS.  

Also, sidenote about taking blood pressures, when I take a BP via machine, and I think it is abnormal (high or low), I will follow it with a manual BP.  And then if time allows, I have one of my partners take a manual BP.


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## AnneHathaway (Jun 24, 2011)

good post I like it


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## tom.watkins (Jul 17, 2011)

As a good rule of thumb you should try to start taking your first pressure manually, and then use your machine for trending. Also, HTN is something that typically kills you over 10 years, not 10 minutes. Still, a basic should never be afraid to tell a medic that they aren't comfortable with certain situations; I have a real aversion to sending my partners with anything that could use ANY kind of ALS treatment.


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