Assumed Wrong on a TIA

[bstone]

She probably got both within 10 minutes of the doors being shut, given the lack of transport time in NYC.

I do agree with the principle of a medic on every ambulance. Perhaps it would mean the end of the role of EMT-B in anything other than the driver / bag monkey role.

10 minutes on the ground, 10 minutes to the hospital, 10 more minutes until she is assessed and treated= 30 minutes

vs

10 minutes on the ground, 5 minutes until a line with fluids and meds administered=15 minutes

If you fx your hip would you really want to be moved and driven on bumpy streets and then moved again and wait until you got the beginnings of treatment?

 

[bstone]

you were in NY and didn't call? The shame!

NYC is weird but she was probably in the hospital in 5 minutes. It isn't a defense but....

Hah! Sorry! I was in town for my cousin's engagement party. Had a blast!

 

[AJ Hidell]

I do agree with the principle of a medic on every ambulance. Perhaps it would mean the end of the role of EMT-B in anything other than the driver / bag monkey role.

Nah. The majority of all EMTs in this country are either first responders, IFT techs, or unemployed anyhow. Removing them from EMS ambulances would not significantly change that. They should be on their way to paramedic school anyhow.

 

[MSDeltaFlt]

i don't think they did anything horribly wrong. I just think it is an ALS call.

It may have been in your eyes. It may have been in my eyes as well. This whole thread is Monday morning armchair quarterbacking. The OP said that the pt's face drooped, then did it again in the ER. That tells me it wasn't doing it in their presence. So there were no signs of CVA on their assessment; which is why they cancelled ALS.

If they followed their protocols, then no foul.

 

[Scott33]

10 minutes on the ground, 10 minutes to the hospital, 10 more minutes until she is assessed and treated= 30 minutes

vs

10 minutes on the ground, 5 minutes until a line with fluids and meds administered=15 minutes

If you fx your hip would you really want to be moved and driven on bumpy streets and then moved again and wait until you got the beginnings of treatment?

Not disagreeing with you. I don't think we take pain management remotely seriously enough at any level in EMS. Even at the BLS level, N2O should be standard prior to stabilizing.

Tell me, did they neglect to use the scoop, in favor of rolling her onto a longboard?

 

[Sasha]

The Pre-hospital Acute Stroke Triage (PAST) protocol is based on four elements: the presence of hemiparesis, impaired speech, and normal glucose levels, and a time from symptom onset of less than 2 hours.

If ambulance personnel find a patient meets these criteria, is older than 18 years old, and is normally ambulant, then they activate the Stroke Intervention Protocol. This involves taking the patient directly to a hospital providing specialist stroke services, and pre-notifying hospital staff of the patient’s arrival.

Perhaps I'm seriously misguided, but what part of this, bar the glucose check in places that do not allow for a basic to preform a BGL check, cannot be preformed by a Basic?

Sounds like a good history, and a "Squeeze my fingers, push on my hands, say such and such phrase" would take care of that.

 

[alphatrauma]

Bells Palsy

Assumed Wrong on a TIA

Sounds to me like Bells Palsy, which is commonly mistaken for a TIA by the untrained/unfamiliar. While it is unlikely the EMTs suspected Bells Palsy, this patient was STABLE, and ultimately their decision to forego ALS was appropriate. There is nothing a Medic, thrombolytics, monitoring, or ER treatment can do for this patient. Outpatient Neuro followup is what's needed.


A Bells Palsy patient will NOT have any involvement of the extremities on the affected side. They will also have no memory deficit or behavioral changes, and gait will be normal. I think the EMTs got this one right... and when the heck did glucose come into this :sad:

 

[triemal04]

Sounds to me like Bells Palsy, which is commonly mistaken for a TIA by the untrained/unfamiliar. While it is unlikely the EMTs suspected Bells Palsy, this patient was STABLE, and ultimately their decision to forego ALS was appropriate. There is nothing a Medic, thrombolytics, monitoring, or ER treatment can do for this patient. Outpatient Neuro followup is what's needed.


A Bells Palsy patient will NOT have any involvement of the extremities on the affected side. They will also have no memory deficit or behavioral changes, and gait will be normal. I think the EMTs got this one right... and when the heck did glucose come into this :sad:

This is where having only a little education can be dangerous. Is it possible that was Bell's Palsy? Yes. Is it possible that was a TIA? Yes. And that the second occurence was also a TIA or the beginning of a full blown CVA? Yes.

Some good references:
http://emedicine.medscape.com/article/791311-overview
http://www.emedicinehealth.com/transient_ischemic_attack_mini-stroke/article_em.htm
http://emedicine.medscape.com/article/794281-overview

And this is a good example of why having a proper, paramedic level assessment done is appropriate. While this could be something like Bell's, it also could be more. And it will be, given the situation, impossible to determine which with complete accuracy in the field. So, while nothing will be done prehospital, the pt will still need to be taken to a hospital capable of treating CVA's in a rapid manner. It would not be appropriate to assume that it's nothing, blow it off, and take them to a local hospital, or worse, tell them to ignore it and follow up with their PCP in a couple of days.

It's also worth remembering, or maybe learning for the first time, that not all TIA's (hell, not all CVA's either) will present with the classic signs of facial droop, slurred speech, and one-sided weakness. Some may have slurred speech only, or facial droop, or only be complaining of a headache, or severe nausea. But all are having the same problem. Once again, recognition is the most important thing paramedic's do that EMT's don't.

And you may want to look up how thrombolytics are used in the treatement of CVA's. And how hypoglycemia can present; might clue you in on why a cbg is neccasary.

Edit: This is on CVA's in particular. http://emedicine.medscape.com/article/793904-overview You'll notice that under the differntial dx's that need to be ruled out, Bell's Palsy is one of them.

 

[medic417]

This is where having only a little education can be dangerous. Is it possible that was Bell's Palsy? Yes. Is it possible that was a TIA? Yes. And that the second occurence was also a TIA or the beginning of a full blown CVA? Yes.

Some good references:
http://emedicine.medscape.com/article/791311-overview
http://www.emedicinehealth.com/transient_ischemic_attack_mini-stroke/article_em.htm
http://emedicine.medscape.com/article/794281-overview

And this is a good example of why having a proper, paramedic level assessment done is appropriate. While this could be something like Bell's, it also could be more. And it will be, given the situation, impossible to determine which with complete accuracy in the field. So, while nothing will be done prehospital, the pt will still need to be taken to a hospital capable of treating CVA's in a rapid manner. It would not be appropriate to assume that it's nothing, blow it off, and take them to a local hospital, or worse, tell them to ignore it and follow up with their PCP in a couple of days.

It's also worth remembering, or maybe learning for the first time, that not all TIA's (hell, not all CVA's either) will present with the classic signs of facial droop, slurred speech, and one-sided weakness. Some may have slurred speech only, or facial droop, or only be complaining of a headache, or severe nausea. But all are having the same problem. Once again, recognition is the most important thing paramedic's do that EMT's don't.

And you may want to look up how thrombolytics are used in the treatement of CVA's. And how hypoglycemia can present; might clue you in on why a cbg is neccasary.

Edit: This is on CVA's in particular. http://emedicine.medscape.com/article/793904-overview You'll notice that under the differntial dx's that need to be ruled out, Bell's Palsy is one of them.

Very good response. I am going to try to work on how I answer in the forums. My methods seem to be leaving to many lost and confused.

 

[Sasha]

Very good response. I am going to try to work on how I answer in the forums. My methods seem to be leaving to many lost and confused.

Because you don't explain things! You can't sit there and tell everyone that you're right with out explaining why you're right. Yes, you have more education than me, but that doesn't mean you're above being wrong and I'm going to blindly agree with you.

Guess what? I agree with you now, but in order to agree with you I had to ask Veneficious to explain to me how a BLS assessment for a stroke would be different from an ALS assessment and he explained it to me in detail. He also explained how one would differentiate possibly from a bleed and a clot. You didn't do that! Even when asked!

Instead of just preaching about education why don't you try doing a little educating? You may be received better.

 

[medic417]

Because you don't explain things! You can't sit there and tell everyone that you're right with out explaining why you're right. Yes, you have more education than me, but that doesn't mean you're above being wrong and I'm going to blindly agree with you.

Guess what? I agree with you now, but in order to agree with you I had to ask Veneficious to explain to me how a BLS assessment for a stroke would differ in depth from an ALS assessment and he explained it to me in detail. He also explained how one would differentiate possibly from a bleed and a clot. You didn't do that! Even when asked!

Instead of just preaching about education why don't you try doing a little educating? You may be received better.

Well thank you grasshopper even an educator can learn how to use the intenet to educate.

 

[alphatrauma]

This is where having only a little education can be dangerous.

...or having too much

Is it possible that was Bell's Palsy? Yes. Is it possible that was a TIA? Yes. And that the second occurence was also a TIA or the beginning of a full blown CVA? Yes.

Agreed, but it doesn't take a medic to perform a competent assessment and safe/rapid transport.

And this is a good example of why having a proper, paramedic level assessment done is appropriate. While this could be something like Bell's, it also could be more.

This is a terrible example of why Paramedic level assessment/intervention is needed... because it wasn't. Unless medics are now equipped with a GE Lightspeed or Siemens Somatom strapped to their backs, there is no need for them on scene (unless already there) for a patient presenting like the one described.

Could it be more... sure. Just like an 19 year old male with chest discomfort could be having an MI. We could play this game with any patient/complaint.

And it will be, given the situation, impossible to determine which with complete accuracy in the field.

which can be said for just about any condition/complaint

So, while nothing will be done prehospital, the pt will still need to be taken to a hospital capable of treating CVA's in a rapid manner.

On this point we both agree... and the EMTs did just that

It would not be appropriate to assume that it's nothing, blow it off, and take them to a local hospital, or worse, tell them to ignore it and follow up with their PCP in a couple of days.

Where did I say, assume that it's nothing and tell the patient to ignore the symptoms or blow it off? The crew transported the patient to the facility, where (Physician) evaluation and diagnostic testing would ensue.

It's also worth remembering, or maybe learning for the first time, that not all TIA's (hell, not all CVA's either) will present with the classic signs of facial droop, slurred speech, and one-sided weakness. Some may have slurred speech only, or facial droop, or only be complaining of a headache, or severe nausea. But all are having the same problem. Once again, recognition is the most important thing paramedic's do that EMT's don't.

The EMTs "recognized" that the patient was STABLE, ALS was NOT NEEDED and transported appropriately. I'm quite aware of atypical presentations, but this patient (according to the OP description) was not one of those cases. I agree totally that medics are needed in many situations where basics are not qualified, but this scenario is not the litmus test for that argument.

And you may want to look up how thrombolytics are used in the treatement of CVA's. And how hypoglycemia can present; might clue you in on why a cbg is neccasary.

I'm quite familiar with the application of thrombolytics/clot busters/heparin/tpa protocols etc... but all of this is academic. The patient was clearly not having a CVA. We can theorize all day about hypothetical/atypical symptoms and presentations, but at the end of the day the correct decision was made, and there was nothing that an ALS unit could have done to improve the patients condition or eventual outcome.

Edit: This is on CVA's in particular. http://emedicine.medscape.com/article/793904-overview You'll notice that under the differntial dx's that need to be ruled out, Bell's Palsy is one of them.

Read it and extracted the pertinent info

"Central facial weakness from a stroke should be differentiated from the peripheral weakness of Bell palsy. With peripheral lesions (Bell palsy), the patient is unable to lift the eyebrows or wrinkle the forehead.

Stroke mimics commonly confound the clinical diagnosis of stroke. One study reported that 19% of patients diagnosed with acute ischemic stroke by neurologists before cranial CT scanning actually had noncerebrovascular causes for their symptoms. The most frequent stroke mimics include seizure (17%); systemic infection (17%); brain tumor (15%); toxic-metabolic cause, such as hyponatremia (13%); and positional vertigo (6%).[/b] Miscellaneous disorders mimicking stroke include syncope, trauma, subdural hematoma, herpes encephalitis, transient global amnesia, dementia, demyelinating disease, myasthenia gravis, parkinsonism, hypertensive encephalopathy, and conversion disorders. A critical masquerading metabolic derangement not to be missed by providers is hypoglycemia"


According to this particular study... Bells Palsy isn't even on the map, when considering "stroke mimics". I'd be very interested to see more studies that would point to the contrary.

 

[AJ Hidell]

Agreed, but it doesn't take a medic to perform a competent assessment and safe/rapid transport.

Nope. But it does take a lot more education than is given in any EMT-B course I have seen in the last thirty-six years. You can only do so much in 120 hours. If there are EMTs out there who can perform a competent advanced assessment, it is because they learned elsewhere. Therefore, whether it takes a paramedic or not, it still cannot be trusted to EMT-Bs. And it takes more than the simple cookbook steps of performing the assessment to understand the results well enough to interpret them.

The patient was clearly not having a CVA.

Clearly? You determined that strictly from the original post? I think you just destroyed your own theory about EMT-Bs being able to perform competent assessments.

 

[medic417]

...The EMTs "recognized" that the patient was STABLE, ALS was NOT NEEDED and transported appropriately.

This statement scares me. Any patient that presents as described is not "stable". They are in a potentially life altering or ending moment. If I were a basic I would distance myself from you immediatly because you are providing proof that basics are not educated enoughed to be doing any assessment.

They made a mistake by not choosing ALS but if you can not determine that based on the comments made by many others no need for me to waste time restating them.

 

[Sasha]

Any patient that presents as described is not "stable". They are in a potentially life altering or ending moment.

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”

It appears that at this time the patient was "stable". No neural defict, vitals normal, patient is alert and oriented. Of course, this could all go down hill, but EVERY patient could go down hill. Everyone is at a potentially life altering or ending moment.

They did this patient no harm, they got her to the hospital which is the ultimate goal of any EMS level.

I agree, this could have and should have been ALS, but you can't fault someone from following their protocols.

 

[medic417]

It appears that at this time the patient was "stable". No neural defict, vitals normal, patient is alert and oriented. Of course, this could all go down hill, but EVERY patient could go down hill. Everyone is at a potentially life altering or ending moment.

They did this patient no harm, they got her to the hospital which is the ultimate goal of any EMS level.

I agree, this could have and should have been ALS, but you can't fault someone from following their protocols.

I'm no faulting the OP for following protocol if ALS would have taken longer then fine get them to hospital. I am faulting the poster calling this "stable". There are to many unknowns when a patient has an episode as described. They may have a bleed, they may have something else happening, but regardless until a patient with theses symptoms gets a complete exam including cat scan they should be classified unstable. Honestly it is a disservice to the patient to even think stable as you let your guard down your tone in your report makes hospital go hey another patient that is not in need of immediate attention. So because a basic or medic said patient was stable patient waits and then turns out they had something serious happening.

I have had patients that were having acute MI's yet all vitals were normal were they stable? No they were dieing body just hadn't told them yet. Stable is over used in EMS.

 

[JPINFV]

It appears they followed their protocols. They did fine. No problems.

Befehl ist Befehl

 

[Veneficus]

Sounds to me like Bells Palsy, which is commonly mistaken for a TIA by the untrained/unfamiliar. While it is unlikely the EMTs suspected Bells Palsy, this patient was STABLE, and ultimately their decision to forego ALS was appropriate. There is nothing a Medic, thrombolytics, monitoring, or ER treatment can do for this patient. Outpatient Neuro followup is what's needed.


A Bells Palsy patient will NOT have any involvement of the extremities on the affected side. They will also have no memory deficit or behavioral changes, and gait will be normal. I think the EMTs got this one right... and when the heck did glucose come into this :sad:

You guys have to bait me with this stuff don't you?

I'll leave the glucose comment for everyone who has beaten into their brains to check glucose on all suspected strokes. (though I don't think it is a bad idea)

Bell's palsy isn't going to clear up in a few minutes. According to Harrison's internal medicine, Kumar's pathologic basis of disease, and my own anecdotal experience. It takes months to clear up, if it clears up at all. As a differential dx you must also rule out:

Borrelia (aka lyme disease)
Ramsay hunt syndrome
Gullian-Barre

sarcoidosis
facial neuropathy 2nd to DM
amyloidosis
Melkersson-Rosenthal synd.
local infarcts
MS
acoustic neuromas
cholesteatoma (aka a tumor)

The first 3 represent acute conditions that require emergent treatment. But my point is that the Dx of Bell's palsy prehospital without a prior hx is impossible. Even with history, it is still possible to be suffering from these conditions as well.

as for the OP since I am now commenting. In a suspected CVA, if the hospital is closer than ALS, hospital is the right choice. If ALS is closer than hospital, ALS is the right choice.

Forget TPa and all that crap. A CVA can affect respiratory as well as cardiac function, both of which can be supported by ALS until something that can better resolve the root cause can be implemented. Sure a Basic can bag as well as anyone, but i would rather some cardiac support other than CPR and an AED be available to help maintain perfusion prior to an arrest.

 

[triemal04]

No, but as has been said it takes a hell of a lot more than an EMT learns. Which has been shown allready as you've decided this was nothing more than Bell's Palsy.[/COLOR]

This is a terrible example of why Paramedic level assessment/intervention is needed... because it wasn't. Unless medics are now equipped with a GE Lightspeed or Siemens Somatom strapped to their backs, there is no need for them on scene (unless already there) for a patient presenting like the one described.
Actually, this is a good example. Where did these EMT's take the pt? Was it a community hospital, or one that was a little better equipped for someone having a CVA? What did they say in their report when they arrived; was it enough to get a bed right away, or where they stuck in triage for awhile? Did they get a good history from the pt while enroute, including risk factors for strokes, get a med list to rule out blood thinners and check inclusion/exclusion criteria for thrombolytics? Don't know, but I do know what most paramedics would do... More on that in a bit.

Could it be more... sure. Just like an 19 year old male with chest discomfort could be having an MI. We could play this game with any patient/complaint.
Sure. But it will take more than a basic EMT to be accurate in deciding what they could be having. There's quite a few causes of chest pn in a 19 year old that a medic will come up with and rule out/in than an EMT will.

which can be said for just about any condition/complaint
Not really. You may want to check on what can actually be tested for in the field, both with the tools we are given, and with our brains. Many things can be diagnosed in the field with a high degree of certainty.

On this point we both agree... and the EMTs did just that
Did they? Allready said it once above...reread that please.


Where did I say, assume that it's nothing and tell the patient to ignore the symptoms or blow it off? The crew transported the patient to the facility, where (Physician) evaluation and diagnostic testing would ensue.
They did, but do you really think that'll happen all the time? Would they have to ability to convince a pt to go if that pt didn't want to?

The EMTs "recognized" that the patient was STABLE, ALS was NOT NEEDED and transported appropriately. I'm quite aware of atypical presentations, but this patient (according to the OP description) was not one of those cases. I agree totally that medics are needed in many situations where basics are not qualified, but this scenario is not the litmus test for that argument.

I'm quite familiar with the application of thrombolytics/clot busters/heparin/tpa protocols etc... but all of this is academic. The patient was clearly not having a CVA. We can theorize all day about hypothetical/atypical symptoms and presentations, but at the end of the day the correct decision was made, and there was nothing that an ALS unit could have done to improve the patients condition or eventual outcome.
You sure it wasn't a CVA? What if the second set of symptoms didn't resolve? Or got worse? Or the CT showed a large clot? Remember, a TIA can often be a precurser to having a CVA; just because it went away once, does not mean it will again. Again, what a pamedic could do is listed above. I'll admit though, if the appropriate hospital was closer than the paramedics, then absolutely they should go; appropriate to do that almost all the time.

Read it and extracted the pertinent info

"Central facial weakness from a stroke should be differentiated from the peripheral weakness of Bell palsy. With peripheral lesions (Bell palsy), the patient is unable to lift the eyebrows or wrinkle the forehead.
And without any current symptoms...gee...guess it could be either...

Stroke mimics commonly confound the clinical diagnosis of stroke. One study reported that 19% of patients diagnosed with acute ischemic stroke by neurologists before cranial CT scanning actually had noncerebrovascular causes for their symptoms. The most frequent stroke mimics include seizure (17%); systemic infection (17%); brain tumor (15%); toxic-metabolic cause, such as hyponatremia (13%); and positional vertigo (6%).[/b] Miscellaneous disorders mimicking stroke include syncope, trauma, subdural hematoma, herpes encephalitis, transient global amnesia, dementia, demyelinating disease, myasthenia gravis, parkinsonism, hypertensive encephalopathy, and conversion disorders. A critical masquerading metabolic derangement not to be missed by providers is hypoglycemia"
Hey, at least you know why checking a blood sugar is important now.

According to this particular study... Bells Palsy isn't even on the map, when considering "stroke mimics". I'd be very interested to see more studies that would point to the contrary.
Remember, or learn if you checked the links, Bell's doesn't normally clear up in a couple of minutes. A TIA can.

What so many people here, both EMT and paramedic alike tend to forget, or more likely never learned in the first place, is that the most important tool a paramedic has is their brain. And the most important skill we have is our assessment capability. It doesn't matter how many cool flashy things you can do if you can't figure out what is wrong with your pt and determine the need for them. People seem to forget that, or never learn in in the first place.

Anybody who was been out of the classroom for any length of time will have realized that there are huge numbers of illnesses that we come across that we will be able to do exactly nothing for in the field. None of the meds we have, none of the toys we use will help a lot of these people. But what we can do that may make the difference is use our most important tool, properly assess the pt, and RECOGNIZE what the problem is. And that is where the vast majority of EMT's will fail. Can an EMT recognize someone having a stroke with all the classic symptoms? I hope so. But what about the person with an atypical presentation? Or the cardiac pt with atypical presentation and no ecg changes? Should they go to whatever hospital they want, or maybe somewhere that is capable of treating them for what could be wrong? For the situation here, knowing the person could have had a TIA and is at risk for a CVA and taking them to a stroke-capable hospital is the most important thing to be done. For other times it'll telling the attending doc's and RN's what you've found and what you think it is...plant that idea in their heads early, don't just toss them off with a big "I dunno I'm just an EMT." Recognition is, and always will be key to what we do.

There are far to many people out there who can't do any of the above; yes, at all levels. But when the lowest, leaast taught level only get's taught things like, "high-flow O2 and rapid transport" for almost ALL problems, it makes sence to have someone who is just a little bit more competant assess the pt.