Again proving a fellow crew wrong. Dispatched for a possible CVA. Daughter states during dinner the mother’s face drooped for no apparent reason. BLS arrives and finds that patient is A&Ox3, no apparent distress. BLS does full exam, including stroke assessments and vitals, all comes out “normal”. BLS cancels ALS. Arriving at hospital, patient has another episode of one-sided of “drooping”. Based on the above happenings, BLS states she they think she was having a TIA. The cancelled medics due to their initial assessment, not because maybe they could have gotten to the hospital quicker. They claim medics could not have done anything to help her. Do you agree or disagree? And please inform me on ALS procesdires for CVAs. Thanks.
Assumed Wrong on a TIA
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firecoins
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It was an ALS assessment that was needed initially. BLS assessment was not enough. This woman needed to be put on a monitor amoung other things. There people here who know more. Ill let them answer.
Why?
ALS standard of care perhaps. But what benefit does it do the patient?
CVAs are prioritized as ALS calls, but I wouldn't wait around for them, just so they can document a blood sugar, or start an IV which may or may not complicate things if they decide to infuse fluids.
The patient needs a head CT.
firecoins
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Because BLS crews might not recognize it. Pt needs to be brought to a stroke center so recognizing it and alerting the ER saves alot of time. So yes, ALS standard of care.
medic417
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OP says not closer to hospital so should have stayed and waited for ALS. Again another arguement for a Paramedic on every ambulance.
Sasha
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Now from a potentially educational post this is going to deteriorate into "Everywhere should be ALS!" too which areas that don't have ALS will appear with the "Stop picking on us! We can't afford it!" argument and the thread will turn into fighting and be locked...
I agree, while this does deserve an ALS assesment and a paramedic present in case the patient decides to try and die, there is very little ALS can do for a stroke or TIA. The best thing you can do is hustle to the definitive care and not to delay on scene times. However, I'm operating under the assumption that a EMT in your area can preform a BGL check to r/o hypoglycemia. In that case, there would be a greater need for the paramedic.
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Everywhere should be ALS
Stop picking on us! We can't afford it!
punch!
kick!
gun shot!
FFEMT "thread is locked for 24 hours"
stab wound!
FFEMT "thread is closed permanently.
By the way EMT-Bs in my area can not check BS.
Sasha
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I don't get that. I understand some EMTs aren't smart enough to find their way out of a paper bag and tend to ruin things for the whole bunch (some medics, too!) but how can you possibly mess up a glucose check? Accidently stab them in the eye with a lancet? So in some areas instead of checking a BGL before giving oral glucose to a potentially hypoglycemic patient the EMTs are to just give it to them blindly. If they are trusted enough to assess for hypoglycemia they should be trusted enough to confirm their suspicion with a glucometer.
AJ Hidell
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That sounds good on the surface, but under closer scrutiny, it doesn't really bare out. BGL is a single isolated sign. It should not be evaluated as such. It should be evaluated in the context of a complete, advanced assessment. EMTs simply do not receive the education to complete such an assessment. Consequently, there is too much risk of them getting tunnel visioned on the BGL, just like they do with SpO2, resulting in a botched assessment and incorrect treatment of the patient. They see a BGL of 80 and get all hung up on getting the patient to down some glucose when the BGL was not the main problem, and they should have been on the road to a stroke center. You simply cannot teach or learn good assessment skills -- and all the other crap they teach in EMT school these days -- in 120 hours.
ALS is an all or nothing proposition. You can't piece mail out advanced "skills" a la carte and expect it to result in competent practice. And, unlike something like defibrillation, there is not enough patient benefit realized from BGL determinations to dump it on minimally trained providers.
As to the original post, the only safe answer is the one that was already given. The patient should have had an advanced assessment in the first place. He was showing obvious neuro deficits, including altered mental status and disorientation. It may have been a stroke. It may have been one or two of a hundred other things that present similarly. Whether he needed ALS care is not clear from the information you give. Probably not, but the situation certainly may have quickly deteriorated to that point. By the time that happens, it's too late to recall ALS to help you, and you're likely to get fired for that error. On the other hand, if the patient was indeed having a stroke, then time is of the essence, so undue delays are not warranted. If the ALS truck was on it's way and was going to arrive within a minute of when you were going to depart with the patient, then you should have waited. If you were looking at sitting around and twiddling your thumbs for five minutes waiting for them, then your partner was probably right to hit the road. It is sometimes a tough call, but that is the kind of dilemma that is placed upon providers in a tiered system. That's why so many of us hate tiered systems.
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MSDeltaFlt
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It appears they followed their protocols. They did fine. No problems.
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It isn't that EMT-bs will mess up. Originally EMTs were not allowed to do anything that breaks the skin. Protocols were changed for the possibility that EMT-Bs could do this. Up to now there this no money for the glucometers and in service training required. Since we have ALS flycars with 2 medics on board that respond to most if not all calls, it is unnecessary for EMT-Bs and paramedic to check. BLS treatments would not be altered by the glucometer reading anyway.
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i don't think they did anything horribly wrong. I just think it is an ALS call.
Sasha
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I get what you are saying... to a degree. But why do they have oral glucose at all, then? If you feel an EMT will get tunnel visioned, don't you feel that's still possible with or without the glucometer? If they feel it's hypoglycemia, they are still going to administer oral glucose if not contraindicated and still may botch the assesment.
And let's not limit this to just EMTs. Paramedics get tunnel visioned too with pulse ox and glucometers. I've been in the hospital too many times when there paramedic argues with the nurse or doctor, or vice versa "But her SpO2 read 96%!! She's breathing just fine!" "Yeah, this is the broken leg patient... no she didn't have AMS but I gave her D50 because her blood glucose read 54! No.. I don't remember when the last time the glucometer was calibrated... no.. we didn't do it this morning..."
mikeN
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If it was a new onset of facial drooping I wouldn't have cancelled medics. This thread kind of went into focusing more on glucose than the actual tia, but only BLS would do such a thing. ^_^.
AJ Hidell
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For empirical, symptomatic treatment of cut and dried diabetic situations, such as the diabetic who gives a clear history of insulin administration without adequate caloric intake. Nothing wrong with that. But neither the glucose nor the glucometer should be used for a fishing expedition by someone not adequately educated to perform a more thorough assessment.
medic417
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They're BLS no way for them to do a full exam. A BLS assessment leaves out way to much information.
ALS can start process for that fancy new fangled thrombolytic drug. Some even can administer it. Also ALS can already have blood draws, IV's, 12 lead, etc saving time at the ER so patient can get to definitive care quicker.
Sasha
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A lot of the process for new fangled thrombolytic drugs require labs and a CT confirming the fact it's an ischemic stroke, not a hemorrhage. The last I checked, a CT machine was not the standard of care, prehospitally, and there is no way to tell, in the presentation of a stroke if it's a clot or a bleed.
They need to get the patient to the hospital, not wait around for ALS to arrive so they can take the patient, waste time on scene getting their 12 lead and IV, and then head to the hospital with a stroke alert.
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medic417
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I'm hurt you reverted to basic thinking.
Sasha
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I'm hurt you can't seem to think past a blanket statement.
What does this patient need? I think we can all agree this patient needs a hospital.
Whoever can get them there the quickest should go ahead and take them. Soemtimes ALS gets so wrapped up in "ALS procedure" that they delay on scene time and getting them to that hospital.
medic417
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No delay. OP even said they were not closer to hospital. IV and blood draw in route. 12 lead ads 30 seconds to scene time. wow we now call hospital with more complete details they gather stroke team. We get checklist started. Get there they complete checklist and boom. By adding 30 seconds we saved minutes if not hours depending on the ER. And again some services now administer.