# Stay-play / Load-go/ Upgrade?



## Shishkabob (Aug 30, 2010)

So as you all know, one of the BEST parts of being a brand new medic is always doubting yourself... and tonights has to do with Staying, loading, or upgrading.



It's common consensus that on a BLS truck, if the hospital is closer than the ALS intercept, just transport... but what if ALS intercept is there, but it takes less time to get to the hospital than to do ALS treatment?




Tonight we were dropping a patient off at a psych hospital.  As we were calling on, dispatch said "We have a BLS truck at that location with a hypertension call, would you mind sending your medic (me) to go check them out and see if they need help?"


So I go to where the BLS truck crew was, an Intermediate and a Basic.  The Basic is just about to finish his paperwork.  Quick rundown of the patient--- 40's male, BP of 198/118 hr of 58, headache, nausea (but no vomitting), seems a slight bit lethargic (but unable to tell if that's baseline, it being 2am, medications, or the BP) no CP, no SOB, pupils are fine, lungs clear, no other medical history aside from psych.  Nurse states his BP's been elevated since Friday.  (Keep in mind this is a generally good psych hospital).   They've given Norvasc with little change in BP.



Now comes the question.  This psych hospital shares a parking lot with a major hospital.  The transport from A to B takes less time than it would take me to set up a 12-lead.




So, considering his condition has been "stable" for atleast 24 hours, and you're literally THAT close to the hospital, what would your decision have been?  Stay and treat the BP, let the BLS crew transport, or start some ALS and ride in their rig and go?


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## Smash (Aug 30, 2010)

Why would you treat his BP?  Why has the basic been sitting on scene doing paperwork? What are you going to achieve for the patient by doing a 12 lead or other investigations given that you are literally on the doorstep of the hospital?


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## Shishkabob (Aug 30, 2010)

Meh, I don't know why they were sitting on scene for the length they did, and even though I didn't take over the call I hurried them up a bit.... which irked the Intermediate some.  His attitude with me made me chuckle afterward.

I was using the 12-lead as an example as to how close we were, not that I had done one.

I chose NOT to treat because A) we WERE so close...I wouldn't have even gotten the supplies for an IV out by the time we would have backed in to the ER.  and B ) he has been elevated for a while, so another couple minutes probably wouldn't cause more damage than has been done.  



I just let the BLS truck transport, which is why I'm seeing if anyone would have done differently.


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## Smash (Aug 30, 2010)

Linuss said:


> Meh, I don't know why they were sitting on scene for the length they did, and even though I didn't take over the call I hurried them up a bit.... which irked the Intermediate some.  His attitude with me made me chuckle afterward.
> 
> I was using the 12-lead as an example as to how close we were, not that I had done one.
> 
> ...



I'm sure someone would do different, but I wouldn't.


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## FFMedic75 (Aug 30, 2010)

You did the right thing,  treating a patient on scene is generally acceptable if you can provide definitive care, i.e. anaphylaxis.  This is not the case here, keep in mind you stated they had already been given a Calcium Channel Blocker with no change.  As far as not letting the BLS crew take it, there would probably be nothing different in treatment even if something catastrophic did happen due to the short ETA, but try to imagine defending yourself for turning this patient over to a Basic and finding out this is all caused by a slow Subarachnoid Bleed.  Always error on the side of caution and use common sense, that is usually the first thing to go when you get your card. Something I was told when I first got my medic that I will always remember, "If you are trying to talk yourself out of making an intervention you should have already done it."  "If you are trying to justify doing something you probably didn't need to do it."


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## Veneficus (Aug 30, 2010)

If I were there, I would have told dispatch to have the BLS squad take him.

he has uncontrolled hypertension, it takes a lot of work to figure out why and what to do about it. 

You can't do it on an ALS ambulance.

So what if the pt had a CVA? how does that change anything? I think:

"ladies and gentlemen of the jury, I told the BLS squad to take them to the hospital because they would have gotten better help faster than if I showed up and started a more detailed work up from the begining knowing full well from my education, training, and knowledge of commonly accepted medical practice that I would not been able to help in anywhere near the capacity of the hospital and would have put the patient in greater risk with my efforts."

The scenario doesn't even change if the CC was crushing substernal chest pain radiating to the arm and jaw. By the time you show up, start the workup and treatment, the patient could have been in the ED receiving heparin or starting a STEMI protocol that activates a cath lab.


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## FFMedic75 (Aug 30, 2010)

Veneficus said:


> If I were there, I would have told dispatch to have the BLS squad take him.
> 
> he has uncontrolled hypertension, it takes a lot of work to figure out why and what to do about it.
> 
> ...



Telling dispatch to go ahead and take them is fine and probably what I would have done, but once you as a medic are on scene with the patient, it is your patient, especially if your standing orders list hypertension as an ALS ride.  If he had told dispatch to have the BLS crew transport before arriving on scene that is different.


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## MasterIntubator (Aug 30, 2010)

In my protocols, in clearly states that any hypertensive crisis not presenting with CVA or AMI is to be BLS only.  If I were in that spot ( and I have )  I would probably use that as my guide and use common sense from there, just a transport.

Our BLS crew would have been at the ER already.


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## Veneficus (Aug 30, 2010)

FFMedic75 said:


> Telling dispatch to go ahead and take them is fine and probably what I would have done, *but once you as a medic are on scene with the patient, it is your patient, especially if your standing orders list hypertension as an ALS ride.*  If he had told dispatch to have the BLS crew transport before arriving on scene that is different.



I see what you are getting at, and I m not saying that you are not right, but I disagree.

I think that we both agree that the BLS crew should have just transported. Especially with the phrase "finishing up the paperwork." There was no reason for Linuss to even have patient contact.

But to discuss what I do not agree with. In any system I ever worked in (including the messed up one where the FTOs made up their own rules in contra to the protocols) There is usually a phrase in the protocol book that mentions something about "protocols being guidlines not meant to replace sound clinical judgement."

if a paramedic could never turf a patient, it could create all kinds of issues not only in mass casualty, but with day to day EMS operations. As soon as you looked at the patient, you would be obligated to take them if that is the case.Even if no interventions were done.

If your protocol book does mention that elevated BP is automatically an ALS response or transport, it might be time to exercise the sound clinical judgement when you are a stone's throw from the hospital.

There is also the issue of what "on scene" actually means.  If I am on the 11th floor of a hospital, and i need to see a patient on the 3rd floor. My being in the hospital does not mean I am "on scene." Any agency can have multiple calls to a particular address. If there is a room and contents fire in an apartment complex in room 502 and a medical emergency in room 101 with no connection to the fire, then neither responders in any given area are "on scene" of the service request in the other.

I would agree that in this case, once Linuss got to the patient, it would have been less of a gray area to just load up and go without performing anymore assessment or intervention than what could have been done while transporting. I think Linuss was right in there was nothing that he could have done further for the patient an in a round about logic, if there is nothing you can do for a patient that a bls unit can't, then logically, the patient doesn't need you. Then you keep an available medic unit in service and the patient still got everything they should have. 

But if there was any failure, I would blame the BLS squad. The initial call should not have been to dispatch, they should have had the situational awareness to either just transport or call med control to get permission to transport. If they were waiting on scene doing paperwork, they were not using sound clinical judgement. Not every situation can even possibly be written into a protocol book.

I would fault the dispatcher for not telling them to just transport. (having been a field guy with absolutely no time or interest in dispatch; an aversion actually)  dispatch can always be blamed somehow  

again, i don't think either of us are "wrong" just a different perspective.


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## firecoins (Aug 30, 2010)

With a stable patient, I would have done the 12 lead and line. You have to thinl how long it would take to transfer the patient over to ther ED before getting treatment.  

THe BLS crew called.  I will not 2nd guess them.


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## Shishkabob (Aug 31, 2010)

Eh, it wasn't the BLS crew asking for assistance (that they clearly should have) but dispatch wanting them to be checked up on because of the nature of the call (think of a paramedic fly car and that's the role I was acting in)... should have been an ALS call but dispatch screwed up by sending my unit for a BLS call instead of the BLS truck right next to us.




Apparently on arrival to the ED, just before they whisked him off to CT, his Bp was 258/152.


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## Too Old To Work (Aug 31, 2010)

No IV, no 12 Lead. Point the BLS crew in the direction of the appropriate facility and wave good bye.


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## gicts (Aug 31, 2010)

We don't have intermediates in our state, but couldn't he have started an IV and ran a strip? :wacko:

I think this call should have been well within his knowledge.


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## Veneficus (Aug 31, 2010)

gicts said:


> We don't have intermediates in our state, but couldn't he have started an IV and ran a strip? :wacko:
> 
> I think this call should have been well within his knowledge.



What is the point of that? 

So close to the ED, no matter what was on a strip, when the guy is still awake, the jaunt over to the ED is a better use of time.

Who cares about an IV, with that BP, unless you have labetalol or even better, esmolol, there isn't much that will go in that IV that will help. (if available you could set up a nitro drip) but really why waste time when better things are available next door?


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## Shishkabob (Aug 31, 2010)

We do have Lebetalol... but like 99% of our drugs, only at the Paramedic level.... and sadly it's only for Afib, Aflutter and SVT.


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## Too Old To Work (Aug 31, 2010)

Veneficus said:


> What is the point of that?
> 
> So close to the ED, no matter what was on a strip, when the guy is still awake, the jaunt over to the ED is a better use of time.
> 
> Who cares about an IV, with that BP, unless you have labetalol or even better, esmolol, there isn't much that will go in that IV that will help. (if available you could set up a nitro drip) but really why waste time when better things are available next door?



I agree completely. This is purely a BLS call.  Absent airway problems or unresponsiveness, CVAs are a BLS call for us too, but that's a different story.


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## rhan101277 (Aug 31, 2010)

Seems like a slow bleed/CVA to me.  It almost fits Cushings Triad, except for him not having irregular respirations.

A embolic stroke fits perfectly though.  I think you did right.


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## CAOX3 (Aug 31, 2010)

For a BLS point of view.

I would have simply waved you off before you even had the chance to lay eyes on him releasing you from any responsability.  Then again I would have already been at the ER, so it wouldnt have been an issue.


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## JPINFV (Aug 31, 2010)

Quick question for the "CVA's are BLS" crowd. Unless BLS can take (either themselves or by facility staff proxy for IFTs) a BGL, how are you expecting BLS to differentiate between hypoglycemia and a CVA?


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## Too Old To Work (Aug 31, 2010)

JPINFV said:


> Quick question for the "CVA's are BLS" crowd. Unless BLS can take (either themselves or by facility staff proxy for IFTs) a BGL, how are you expecting BLS to differentiate between hypoglycemia and a CVA?



Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts. 

When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.


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## JPINFV (Aug 31, 2010)

Too Old To Work said:


> Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.
> 
> When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.



On the other hand, imagine the outrage when that drunk actually is hypoglycemic? Provided appropriate education, I see nothing wrong with a finger stick as a part of a normal workup for any ALOC, even if the etiology seems clear. However, as with any other lab value, the context of the results needs to be understood. If a paramedic or the ED is going to get a BGL for a patient, an EMT who has been approved to use a glucometer should be getting one as well.


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## Too Old To Work (Aug 31, 2010)

JPINFV said:


> On the other hand, imagine the outrage when that drunk actually is hypoglycemic? Provided appropriate education, I see nothing wrong with a finger stick as a part of a normal workup for any ALOC, even if the etiology seems clear. However, as with any other lab value, the context of the results needs to be understood. If a paramedic or the ED is going to get a BGL for a patient, an EMT who has been approved to use a glucometer should be getting one as well.



I didn't say that they were unresponsive, I said they were drunk. As in sitting on the sidewalk requesting transport to a shelter.


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## JPINFV (Aug 31, 2010)

To be fair, I didn't say unresponsive (you can be altered and not be unresponsive), you did use the term "passed out," and you didn't say that they were just asking for a ride to a shelter.


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## reaper (Aug 31, 2010)

So what is wrong with checking a BGL on them?


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## Veneficus (Aug 31, 2010)

JPINFV said:


> On the other hand, imagine the outrage when that drunk actually is hypoglycemic? Provided appropriate education, I see nothing wrong with a finger stick as a part of a normal workup for any ALOC, even if the etiology seems clear. However, as with any other lab value, the context of the results needs to be understood. If a paramedic or the ED is going to get a BGL for a patient, an EMT who has been approved to use a glucometer should be getting one as well.



To just take this a bit farther, i am partial to checking a glucose on any patient as part of the normal vital sign workup. 

Abnormal glucose can cause some vague symptomology prior aloc. It can detect early changes in both young and old (though not usually in middle age) and in the event of a normal finding correlated to last intake can clue in other  metabolic or endocrine syndromes that admitidly may be of more use to the hospital staff than EMS, but also becomes a pertinent negative as well. 

from the financial point, if a BLS unit does a glucose check, it does not increase the BLS billing, but if the hospital does one, it does increase the patient cost. In patients it is not specifically "indicated" for in EMS, it can be basically a free screening.


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## JPINFV (Aug 31, 2010)

veneficus said:


> it can be basically a free screening.



tanstaafl


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## Veneficus (Aug 31, 2010)

JPINFV said:


> tanstaafl



? you are going to have to help me out with that one.


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## JPINFV (Aug 31, 2010)

There Ain't No Such Thing As A Free Lunch. Not saying it isn't valuable. Not saying that it isn't good patient care and community service for the ambulance service to donate a lancet and test strip, just that it's isn't truly free.


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## Veneficus (Aug 31, 2010)

JPINFV said:


> There Ain't No Such Thing As A Free Lunch. Not saying it isn't valuable. Not saying that it isn't good patient care and community service for the ambulance service to donate a lancet and test strip, just that it's isn't truly free.



I meant it doesn't cost the patient anymore. Not that it was totally free. Besides, with what is being paid for a BLS emergency ambulance ride, whoever is collecting could lose a few bucks and still make out quite well.

It is not like the horizontal tax ride with some o2 and a set of vitals is worth $300


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## Fox800 (Sep 1, 2010)

Too Old To Work said:


> Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.
> 
> When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.



You should be checking a BGL on these patients.


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## DrParasite (Sep 2, 2010)

Too Old To Work said:


> No IV, no 12 Lead. Point the BLS crew in the direction of the appropriate facility and wave good bye.


Speaking as a BLS provider, that's pretty much what I would expect.   

BLS (and often ALS) providers often forget the goal is to get the patient to definitive care, not ALS care.  Take them to the hospital, no need to wait for a paramedic to arrive, start an IV, take a 12 lead, and we all stare at the patient enroute to the hospital.  Rapid transport to definitive care is often the best medicine, esp in a stroke situations.


Linuss said:


> Apparently on arrival to the ED, just before they whisked him off to CT, his Bp was 258/152.


yeah, and?  The guy is having a stroke, what can you do in the field to help?  The patient needs a hospital/stroke center to fix the underlying cause of the HTN, not a paramedic that can only treat the symptoms.

The only thing that could have helped would be for the BLS to call the ER and advise them of the patient's condition, so they could have a bed waiting for them when they walked into the ER.  other than that, it's an asymptomatic HTN episode, which is a BLS call


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## reaper (Sep 2, 2010)

DrParasite said:


> Speaking as a BLS provider, that's pretty much what I would expect.
> 
> BLS (and often ALS) providers often forget the goal is to get the patient to definitive care, not ALS care.  Take them to the hospital, no need to wait for a paramedic to arrive, start an IV, take a 12 lead, and we all stare at the patient enroute to the hospital.  Rapid transport to definitive care is often the best medicine, esp in a stroke situations.
> yeah, and?  The guy is having a stroke, what can you do in the field to help?  The patient needs a hospital/stroke center to fix the underlying cause of the HTN, not a paramedic that can only treat the symptoms.
> ...



Where are you getting that this pt was having a stroke? There is not any indication of this in the assessment. This pt is having a hypertensive crisis. How can you say it is a stroke and then say it is an asymptomatic HTN episode? This pt had plenty of symptoms, to go along with his HTN.

Based on being so close. I would have told to the BLS crew to transport him to ED. Any distance out, purely depends on protocols. Some systems can treat this on scene and treatment can be started right away.


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## clibb (Sep 2, 2010)

Linuss said:


> So as you all know, one of the BEST parts of being a brand new medic is always doubting yourself... and tonights has to do with Staying, loading, or upgrading.
> 
> 
> 
> ...



A question I would ask is if the patient has fallen. With that kind of a bp, hr, and nausea I would suspect Cushing's Triad or other head injury. What is his usual AAOx4?




Too Old To Work said:


> Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.
> 
> When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.



Of course you would check gluco on a DRUNK PASSED OUT patient. You want to eliminate and trouble shoot, it's a part of medicine. Here in our protocols we are required to get a gluco check on any patient who appears intoxicated, hyper/hypo - glycemic, AMS, falls, and any other incident that would scream diabetic emergency at you. It's pretty simple to rule out if the patient just needs d-25/50 or a full/limited - trauma team activated. 



Too Old To Work said:


> I didn't say that they were unresponsive, I said they were drunk. As in sitting on the sidewalk requesting transport to a shelter.



I've never heard a drunk person asking or requesting transport to a shelter. Maybe to the hospital due to a "medical emergency" so they could sleep at the hospital since the shelters won't take them in since they are intoxicated. But, we don't pick patients off the street and transport them back to their shelters. 
Also, if you would read above it will tell you that you DID say " Every drunk passed on out on the sidewalk gets his BG checked" and not " they were drunk. As in sitting on the sidewalk requesting transport to a shelter."

I would love to see that narrative. "Patient was drunk on the side walk and asked for transport to shelter. I decided that the patient was drunk, so I didn't need to check his gluco level (Even though I learned that in the first week of EMT-B class that a patient who "appears" intoxicated can be cause by many different medical reasons, such as diabetes)." I'm sure that goes well with you supervisor. 



Too Old To Work said:


> No IV, no 12 Lead. Point the BLS crew in the direction of the appropriate facility and wave good bye.



Would had done the same. 



FFMedic75 said:


> Telling dispatch to go ahead and take them is fine and probably what I would have done, b*ut once you as a medic are on scene with the patient, it is your patient*, especially if your standing orders list hypertension as an ALS ride.  If he had told dispatch to have the BLS crew transport before arriving on scene that is different.



Everyone has different protocols. After a simple blood sugar test we could see if this would be a BLS or ALS call for my area. If a Paramedic leaves the scene of an ALS call without having a refusal sign (On an ALS call you most likely wouldn't have a refusal signed to begin with) or leaving the patient in the hands of a person who has less medical training than the Paramedic, it's neglect. 

Linuss, you were the Paramedic at this scene and you have experience under your belt, so you made the best judgment. We can all argue for or against you, but you made the best judgment since it's your call.
It's all about the patient's well-being. Treat them like you would want your family members to be treated. Would you had wanted an BLS or ALS unit on this call if this was your son or father?


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## DrParasite (Sep 2, 2010)

reaper said:


> Where are you getting that this pt was having a stroke? There is not any indication of this in the assessment. This pt is having a hypertensive crisis. How can you say it is a stroke and then say it is an asymptomatic HTN episode? This pt had plenty of symptoms, to go along with his HTN.


Your right, I made an assumption that due to the fact that his BP was skyrocketing, especially from the time they found him to the time he made it to the ER despite the facility giving norvasc.  Plus the whole headache thing makes me think it's some type of issue with his brain (bleed, etc) that is causing his pressure to increase at an uncontrolled rate.  But there are no chest pain or diff breathing, so I doubt it would even be worked by ALS, since it's not really symptomatic (our ALS rarely treat hypertension without associated chest pain).

Your right, it is a hypertensive crisis, and left unmanaged, a stroke would probably result, but I did jump the gun based on the limited information presented.  I wonder if the CT did reveal anything.


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## Veneficus (Sep 2, 2010)

*the complications of simplicity*



Linuss said:


> So I go to where the BLS truck crew was, an Intermediate and a Basic.  The Basic is just about to finish his paperwork.  Quick rundown of the patient--- 40's male, BP of 198/118 hr of 58, headache, nausea (but no vomitting), seems a slight bit lethargic (but unable to tell if that's baseline, it being 2am, medications, or the BP) no CP, no SOB, pupils are fine, lungs clear, no other medical history aside from psych.  Nurse states his BP's been elevated since Friday.  (Keep in mind this is a generally good psych hospital).   They've given Norvasc with little change in BP.



As I follow the thread I see a lot of honing in on Cushing's triad and the potential for CVA. I would just like to kindly add a few words on this.

I would like to fist define what cushing's traid is:
1. irregular respirations
2. widening pulse pressures
3. bradycardia

Cushing's triad is seen in head injuries ( late stages), it does not mean there is a head injury.

It is also manifests in When chemoreceptors in the brain and baroreceptors are receiving mixed inputs. 

In hypertension patients the heart must overcome the resistance of the reverse flow in order to adequetely eject blood and achieve perfusion pressure.

In the findings posted by Linuss. There was no evidence of intracranial shift. Pupils were normal, a bit of lethargy (possibly baseline at 2 am) and no irregular breathing pattern. 

These findings (or lack of findings) rule out cushing's triad. As only 2 of the 3 criteria are met. The fact the pt is still conscious at any level also plays a strong role in this finding. There is also only one set of vitals so there is no way to tell if the pulse pressure is widening.

Now when we add a drug into the mix the dynamic completely changes.

Norvasc is a calcium chanel blocker that acts non specifically on both the heart and vascular smotth muscle. Depending on the underlying cause and patients level of compensation, norvasc is known to cause negative inotropic effect. (lack of contractility) In addition, as any CCB it can also produce negative chronotropic effects because Ca channels are part of the normal cardiac cycle. But I think the bradycardia in this case has a slightly different mechanism, more along the lines of something Dr. Cushing would be proud of.

In a well compensated patient with HTN, the body maintains perfusion to end tissues over the vascular resistence with increased inotropic or chronotropic response. (which opposes)

Decreasing the rate/pressure the heart beats at, decreases cerebral perfusion pressure. Which leads to a catecholamine response. (increased peripheral resistance to maintain central perfusion in addition to increased rate.) Having said that, the baroreceptor reflex in the carotid sinus would detect and attempt to regulate the arterial pressures by decreasing heart rate. All together central baroreceptor acting in contra to peripheral catecholamine, with chemical blockage of central catecholamine effect. Epi in particular affects cerebral arterioles.

Cushing's reflex + pharm.

Another important pharm finding is that headache is the most commonly reported side effect of norvasc. The peripheral HTN cold also produce the same effect and when adding in the nausea, it looks to me that norvasc is not the best choice here to regulate hypertension by trying to normalize numbers instead of patient condition. Norvasc is also not a first line therapy anywhere I have seen.

when you add in the nausea that is a nonspecific finding but I would think in this case it does point to a problem with cerebral perfusion and subthreshold stimulation of the vomiting reflex. Certainly a potential for CVA exists, but it seems more like an anoxic brain insult (from perfusion issues after chemically knocking out the patient's compensatory reflexes) than an ischemic or hemorrhagic insult from the limited information provided here.

But for all my musings, it doesn't change the EMS treatment... BLS ambulance to hospital where it can all be sorted out for sure.


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## Veneficus (Sep 2, 2010)

*just to be complete*

A decrease in renal perfusion from the lower bp secondary to the norvasc could decrease GFR and then activate the RAA cycle. This would leave the explanation of the bradycardia to negative chronotropic effect of the medications.

There catelcholamine release could aslo constrict pre and post renal arteiole sphincters decreasing GFR and activation of the RAA cycle, and an attempt at baroreceptor and chemical inhibition of the heart rate.

But in any event, I am thinking the problem arose with the norvasc, not a malignant hypertension in a patient with controlled HTN.


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## rhan101277 (Sep 2, 2010)

rhan101277 said:


> Seems like a slow bleed/CVA to me.  It almost fits Cushings Triad, except for him not having irregular respirations.
> 
> A embolic stroke fits perfectly though.  I think you did right.



Yeah I was saying cushings triad didn't fit.  As with any bleed you should have increased ICP which can lead to sluggish/dialated pupils.  Which wasn't present here.

Maybe it was just a chronic HTN


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## medicman90 (Sep 2, 2010)

Linuss said:


> Meh, I don't know why they were sitting on scene for the length they did, and even though I didn't take over the call I hurried them up a bit.... which irked the Intermediate some.  His attitude with me made me chuckle afterward.
> 
> I was using the 12-lead as an example as to how close we were, not that I had done one.
> 
> ...



IMHO: correct

source: http://wordnetweb.princeton.edu/perl/webwn?s=ambulance

Noun

S: (n) ambulance (a vehicle that takes people to and from hospitals)


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## Too Old To Work (Sep 3, 2010)

Fox800 said:


> You should be checking a BGL on these patients.



Defend that statement. Tell me that there is clinical benefit to it in a non diabetic patient.


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## Fox800 (Sep 3, 2010)

Too Old To Work said:


> Defend that statement. Tell me that there is clinical benefit to it in a non diabetic patient.



Tell me how you will rule out a glucose abnormality in a patient "passed out" without one and with no medical history available.

Are you seriously advocating withholding BGL checks on patients that are altered/unconscious due to an unknown cause?


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## JPINFV (Sep 3, 2010)

Too Old To Work said:


> Defend that statement. Tell me that there is clinical benefit to it in a non diabetic patient.



...because diabetes is the only thing that can cause a decreased blood glucose level? 

...because all diabetics have medic alert bracelets?


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## Too Old To Work (Sep 3, 2010)

Fox800 said:


> Tell me how you will rule out a glucose abnormality in a patient "passed out" without one and with no medical history available.
> 
> Are you seriously advocating withholding BGL checks on patients that are altered/unconscious due to an unknown cause?



I said that he was passed out when you found him, not that he was persistently unresponsive. 

How about using verbal or light painful stimuli to see if he wakes up? Then assess his mental status. Then if all of that is normal, don't even worry about a number. 

Let's say he wakes up when you do the "shake and shout" that you were taught on day one of EMT school. Or maybe it was day two. Anyway, he tells you that he's been drinking, drinks every day, and has no medical problems. 

He consents to let you stick a sharp object into his flesh and you find his BG is 69 mg/dl. What do you do now? Force him to go to the hospital? Buy him a sandwich? Call the paramedics so they can buy him a sandwich?

Use your clinical judgment, well if you have any, to make a decision based on your exam. 

I think a lot of people don't have any idea what "altered LOC" means.


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## Too Old To Work (Sep 3, 2010)

JPINFV said:


> ...because diabetes is the only thing that can cause a decreased blood glucose level?
> 
> ...because all diabetics have medic alert bracelets?



A decreased blood glucose level does not necessarily mean altered mental status. Non diabetics can generally handle low blood glucose levels that diabetics can't.


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## clibb (Sep 3, 2010)

Too Old To Work said:


> A decreased blood glucose level does not necessarily mean altered mental status. Non diabetics can generally handle low blood glucose levels that diabetics can't.



Oh really...?

People without diabetes.
http://diabetes.webmd.com/tc/hypoglycemia-low-blood-sugar-symptoms

With diabetes.
http://www.emedicinehealth.com/low_blood_sugar_hypoglycemia/page3_em.htm#Low Blood Sugar Symptoms

I'd say a lot of those symptoms are AMS. And of COURSE they can handle low blood glucose levels that a diabetic can't. That's why those "other" people are called DIABETICS. 




Too Old To Work said:


> I said that he was passed out when you found him, not that he was persistently unresponsive.
> 
> How about using verbal or light painful stimuli to see if he wakes up? Then assess his mental status. Then if all of that is normal, don't even worry about a number.
> 
> ...



If his bgl is 69, I don't worry about it. Would I take him to the hospital if he had AMS? Of course. It's in my protocols. I can't out rule a head injury just by looking at him.


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## Too Old To Work (Sep 3, 2010)

clibb said:


> Oh really...?
> 
> People without diabetes.
> http://diabetes.webmd.com/tc/hypoglycemia-low-blood-sugar-symptoms
> ...



So, what is the instance of treatable hypoglycemia in non diabetic patients? Non diabetics have compensatory mechanisms that diabetics don't. And again, what is "AMS"? If someone wakes up easily to verbal or light painful stimuli, answers all of the questions in your screening exam appropriately, denies any history of trauma, and has no evidence of a head injury, what to you do then? How do you claim AMS to justify taking them to the hospital? Especially how do you do that if they adamantly refuse to go?


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## clibb (Sep 3, 2010)

Too Old To Work said:


> So, what is the instance of treatable hypoglycemia in non diabetic patients? Non diabetics have compensatory mechanisms that diabetics don't. And again, what is "AMS"? If someone wakes up easily to verbal or light painful stimuli, answers all of the questions in your screening exam appropriately, denies any history of trauma, and has no evidence of a head injury, what to you do then? How do you claim AMS to justify taking them to the hospital? Especially how do you do that if they adamantly refuse to go?



If they have AMS they wouldn't be AAOx4, would they? If they check out alright, they aren't going. But if they are showing any symptoms of a head injury, I will beg them to go.


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## Shishkabob (Sep 3, 2010)

Sure they could be.


You're telling me someone can't know their name, location, date and events and not be extremely lethargic, mentally retarded, slow, or one of many psych conditions that WOULD make them altered?


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## Fox800 (Sep 3, 2010)

Too Old To Work said:


> I said that he was passed out when you found him, not that he was persistently unresponsive.
> 
> How about using verbal or light painful stimuli to see if he wakes up? Then assess his mental status. Then if all of that is normal, don't even worry about a number.
> 
> ...



OK, I'll bite. You find a patient "passed out", using your EMT skills that you learned on day one of school, you perform a "shake and shout". They are slow to wake up. They can answer all of your questions appropriately but have slurred speech, unsteady gait and are slow to respond. He admits drinking heavily all day and has a history of alcohol abuse. Being the astute prehospital practitioner that you are, you check a BGL and it comes back 20. Now what?

Are you comfortable letting this patient sign a refusal? Would you decline to check a BGL in the first place?


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## Too Old To Work (Sep 3, 2010)

Fox800 said:


> OK, I'll bite. You find a patient "passed out", using your EMT skills that you learned on day one of school, you perform a "shake and shout". They are slow to wake up. They can answer all of your questions appropriately but have slurred speech, unsteady gait and are slow to respond. He admits drinking heavily all day and has a history of alcohol abuse. Being the astute prehospital practitioner that you are, you check a BGL and it comes back 20. Now what?
> 
> Are you comfortable letting this patient sign a refusal? Would you decline to check a BGL in the first place?



It this guy can do all that at 20, better to toss out the glucometer. My point is that it's the clinical signs, not the number that's important. Which too many people don't seem to get. 

Slurred speech? Lot's of things cause that. Could be baseline from a previous injury or stroke. A lot of factors go into the decision of what might be wrong with a patient and what we can do about it.


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## reaper (Sep 3, 2010)

Little bit of light reading!

http://pubs.niaaa.nih.gov/publications/arh27-2/134-142.htm


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## Fox800 (Sep 3, 2010)

Too Old To Work said:


> It this guy can do all that at 20, better to toss out the glucometer. My point is that it's the clinical signs, not the number that's important. Which too many people don't seem to get.
> 
> Slurred speech? Lot's of things cause that. Could be baseline from a previous injury or stroke. A lot of factors go into the decision of what might be wrong with a patient and what we can do about it.



OK, lets say no history of TBI or stroke. Only significant history is alcohol/drug abuse and "they told me I was probably diabetic".


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## Too Old To Work (Sep 3, 2010)

reaper said:


> Little bit of light reading!
> 
> http://pubs.niaaa.nih.gov/publications/arh27-2/134-142.htm



That's why we still give thiamine to all hypoglycemics that we give D50. That's supposedly more pronounced among the alcoholic population, but I've never seen hard numbers on it. Most other systems don't seem to give thiamine. At least when I tell medics from other areas that we still use it, they think we're weird. Which of course we might be, but for many other reasons.


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## Too Old To Work (Sep 3, 2010)

Fox800 said:


> OK, lets say no history of TBI or stroke. Only significant history is alcohol/drug abuse and "they told me I was probably diabetic".



I would contend that this is meaningless because people say things like that all the time. I work with a guy that had one set of elevated LFTs and now he tells everyone that he has "Stage II Liver Disease". 

You're also changing the scenario from what I presented quite a bit, so the answer isn't valid to the original point that I made. 

BTW, I wouldn't do a 12 lead ECG on this guy either to rule out cardiac related syncope. Well, not if his heart rate and BP were withing the expected range for a patient of his age.


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## Fox800 (Sep 3, 2010)

So are you comfortable forgoing a BGL on this patient?


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## Too Old To Work (Sep 3, 2010)

Fox800 said:


> So are you comfortable forgoing a BGL on this patient?



Yup. The hypoglycemic patients that I've seen, which would be a few thousand over the years, don't wake up and talk to you coherently if when you use BLS to get them up. If they can do that, chances are a couple of Twinkies and  20 oz Mountain Dew (not the diet kind) are all they need. Chances are they'll tell you that, too. 

Also, I don't recheck a BG after giving D50 and thiamine. If the patient wakes up, and demonstrates a "normal" mental status, the BG is not telling me one thing that I need to know. If the patient doesn't wake up, the BG is still not going to tell me anything other than something else is probably going on. 

If you have a patient who has been treated with D50 who is still disoriented, what are you going to do when you find out that their BG is 250? You're not going to rebolus them with MORE D50. What you're going to do is take them to the hospital so that they can figure out what's going on. Similarly, if the patient wakes and their BG is now 65, but they are oriented, what are you going to do? Give them more D50? I think not. You're going to do what you would do if their BG was 120. You're going to have them eat something. You're going to try to convince them to go to the hospital, warn them that their BG might drop again, make sure that they have someone who will stay with them and advise that person to recontact 9-1-1  (or 999 or whatever number). You're going to document your findings and get a refusal. The number on the glucometer is not going to help you decide what to do with this patient. 

How about if someone is complaining of dyspnea and chest pain, but has a diabetic history? Are you going to focus on that if they have a normal mental status? Use your clinical judgment to help you sort things out. If you don't have clinical judgment and are more worried about protocols and meaningless numbers than you are in treating the patient's problem, you're probably in the wrong field.


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## reaper (Sep 3, 2010)

Too Old To Work said:


> That's why we still give thiamine to all hypoglycemics that we give D50. That's supposedly more pronounced among the alcoholic population, but I've never seen hard numbers on it. Most other systems don't seem to give thiamine. At least when I tell medics from other areas that we still use it, they think we're weird. Which of course we might be, but for many other reasons.



Why do you give Thiamine to all Hypoglycemics? Are you still treating with coma cocktails?

Between your answer with BGL and 12 lead, you would not last a week in a progressive system. You are paid to treat pt's. Any AMS pt deserves to be treated to the full extent. If you haven't learned this over the years, there is a problem there.

BTW- Passed out drunk is AMS!


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## Too Old To Work (Sep 3, 2010)

reaper said:


> Why do you give Thiamine to all Hypoglycemics? Are you still treating with coma cocktails?
> 
> Between your answer with BGL and 12 lead, you would not last a week in a progressive system. You are paid to treat pt's. Any AMS pt deserves to be treated to the full extent. If you haven't learned this over the years, there is a problem there.
> 
> BTW- Passed out drunk is AMS!



I'm in a pretty progressive system, at least it seems so. I've lasted over 30 years, so I'm not too worried. I think you mean that I wouldn't last a week in a cook book medic system, which is probably where you work. 

The thiamine thing is a hold over from the old days, I don't know why it hasn't been changed, but it hasn't. The rationale back then was similar to  your AMS rationale because of the relatively high number of homeless we see. However we've PROGRESSED past that in most regards. 

Passed out drunk is passed out drunk. It's not a hypoglycemic emergency. Now, if you or someone would invent an easy to use BAL meter that functioned like a glucometer I'd use that. If for no other reason than to establish a betting pool for the highest per shift, per week, per month, and per year. As with the Price is Right, if someone could guess the highest BAL without going over, they'd win fabulous prizes.


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## Fox800 (Sep 3, 2010)

Too Old To Work said:


> Yup. The hypoglycemic patients that I've seen, which would be a few thousand over the years, don't wake up and talk to you coherently if when you use BLS to get them up. If they can do that, chances are a couple of Twinkies and  20 oz Mountain Dew (not the diet kind) are all they need. Chances are they'll tell you that, too.
> 
> Also, I don't recheck a BG after giving D50 and thiamine. If the patient wakes up, and demonstrates a "normal" mental status, the BG is not telling me one thing that I need to know. If the patient doesn't wake up, the BG is still not going to tell me anything other than something else is probably going on.
> 
> ...



Sigh.

Let's say you find a pt. with a BGL of 10. You give them D50, and they wake up. You don't recheck a BGL. If you did, you'd find that their BGL was now 130. If you'd recheck it again in another 15 minutes you'd find that it's 80. Congratulations, you've just signed a refusal on someone who's sugar is continuing to fall because they took too much insulin. You leave and they're now unresponsive again.

You used the example of a pt. with a BGL of 65 after administering dextrose. I'd be seriously worried about a pt. with a BGL of 65 if I just gave them D50.


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## JPINFV (Sep 3, 2010)

Too Old To Work said:


> So, what is the instance of treatable hypoglycemia in non diabetic patients? Non diabetics have compensatory mechanisms that diabetics don't.



Oh, really?

http://tinyurl.com/36n49ho

This is, of course, ignoring the fact that untreated diabetes is not the loss of the ability of a patient to elevate their blood glucose level. For that, we can thank the medications.


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## Too Old To Work (Sep 3, 2010)

Fox800 said:


> Sigh.
> 
> Let's say you find a pt. with a BGL of 10. You give them D50, and they wake up. You don't recheck a BGL. If you did, you'd find that their BGL was now 130. If you'd recheck it again in another 15 minutes you'd find that it's 80. Congratulations, you've just signed a refusal on someone who's sugar is continuing to fall because they took too much insulin. You leave and they're now unresponsive again.
> 
> You used the example of a pt. with a BGL of 65 after administering dextrose. I'd be seriously worried about a pt. with a BGL of 65 if I just gave them D50.



System wide we don't transport 80% or more of diabetics we wake up. We've been doing that for about 20 years. You think maybe our medical directors know a thing or two about how this works. The key is to make sure that they eat after you give the D50. Their BG is going to fall even if they didn't OD on insulin, because that's what the insulin does. It metabolizes the Dextrose that we just gave them. Do you know what the hospital is going to do if you transport this person? Give them a meal, watch them for a couple of hour and then send them home. As I said, feed them, explain what happened, make sure that they are not alone, instruct the patient and whoever is with them what to do if symptoms re-occur. 

I really have to wonder about some of the people here who think that they work in progressive systems. Does that mean that you don't have to call in to medical control before you start an IV on a cardiac arrest?


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## Too Old To Work (Sep 3, 2010)

JPINFV said:


> Oh, really?
> 
> http://tinyurl.com/36n49ho
> 
> This is, of course, ignoring the fact that untreated diabetes is not the loss of the ability of a patient to elevate their blood glucose level. For that, we can thank the medications.



And that's pretty common in your area is it? Don't make the rules by the exceptions, you'll waste a lot of time and resources.


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## JPINFV (Sep 3, 2010)

So you're willing to let a patient with ALOC secondary to hypoglycemia go untreated because you want to assume that because he doesn't have a diabetic medic alert bracelet (which is, of course, ignoring that insulinomas are not a form of diabetes) and smells of alcohol that he must just be drunk?

edit: If the symptoms can be explained by hypoglycemia and a provider has the ability to test a BGL, then they should rule in or out Whipple's Triad.


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## Too Old To Work (Sep 3, 2010)

JPINFV said:


> So you're willing to let a patient with ALOC secondary to hypoglycemia go untreated because you want to assume that because he doesn't have a diabetic medic alert bracelet (which is, of course, ignoring that insulinomas are not a form of diabetes) and smells of alcohol that he must just be drunk?
> 
> edit: If the symptoms can be explained by hypoglycemia and a provider has the ability to test a BGL, then they should rule in or out Whipple's Triad.



No, I'm saying if he's easily arouseable, is alert and oriented once he's up, has no signs such as diaphoresis, tells you he's not a diabetic, and has no other signs or symptoms that make me suspicious, I'm not going to do a BG check. 

Which is where I started before we got off track. If you do a good assessment and it reveals absolutely nothing to suggest a metabolic disorder other than an elevated ETOH level, then there isn't much reason to do a BG check. 

Maybe it's my city, but I just haven't seen a lot of occult hypoglycemia masquerading as hyperETOHia. I have seen hypoglycemia in drunk people, but it didn't take a glucometer to figure it out, just to quantify the number. 

It's like a Heroin user who ODs. Once I give them the Narcan, provided they wake up, I'm not going to do a BG. 

How about everyone that gets punched in the head and goes down? Do you do a BG on them?


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## Veneficus (Sep 3, 2010)

I just have to join the fray I guess.

I spare no effort working up ETOH patients. The alcohol can mask a great deal of problems. Some chronic, some acute.

doing nothing for the chronic frequent flyer drunk is like playing Russian Roulette. 

The reason places have progressed passed thiamine is because it is generally wise to decide the patient doesn't have b12 deficency before giving the thiamine.

bedside blood glucose on all "altered" patients. Just like chem 10. Including on the patient who I have seen 3 generations of his alcoholic family rather frequently and know he is theraputic at 300.

When charting, I see a lot of value in pertinent negatives.

What happens where you do the CBG on the chronic ETOH and it comes back "hi" for the first time?


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