Called 911 Based on Bystander's Symptoms

[AlanShore]

Here's a story for you all,

So i'm starting my probationary class next week for the station i'm joining, i've been tearing apart the emergency care book and reading it and this happened at 9:30 this morning.

I went to a breakfast place and the lady behind the counter didn't look right. When I watched her taking care of customers and I saw her drooping her face and slurring her words. At first I thought she was abused but i'd never seen her that way after about a year of getting breakfast there.

I started talking to her to confirm she was having a stroke and when I saw she could barley talk to me I came the conclusion she was having a stroke, I didn't want to alarm her so I asked her for a pamphlet so I could call in, and saw there was a address on the back.

I called EMS and they started asking me the normal questions and when I went back inside I told her that I called EMS and they were going to check her out. She was almost shocked that I did that but stroke is one of those things you don't mess around with. While they were on their way I asked her what her name was, she looked down and back at me with a blank face for about 10 seconds and then finally said her name. Paramedics came and agreed she was having a stroke, the last time I saw her she was refusing to go but calling her husband, she started agreeing to go after some time but the crazy part is she said this is been happening since sunday her face looking like that. She said "Her doctor" told her her face would go back to normal in 2 weeks.

Here's the crazier part, I was going to show my local govt my TB skin test for the pre-placement physical and i'm not usually in the area until 30 minutes later, and I haven't been there in about 2 months.

Anyway, before a EMT or even started I had the honor of saving a life. =]

 

[JPINFV]

Paramedics came and agreed she was having a stroke, the last time I saw her she was refusing to go but calling her husband, she started agreeing to go after some time but the crazy part is she said this is been happening since sunday her face looking like that. She said "Her doctor" told her her face would go back to normal in 2 weeks.

1. So you called 911 without even talking to the woman?

2. Look up Bell's Palsy.

 

[AlanShore]

1. So you called 911 without even talking to the woman?

2. Look up Bell's Palsy.

No, I did have some conversation with her before I called 911, she was very sluggish and slow with responding, Not like usual.

The Paramedics agreed when she arrived that she was probably having a stroke. Could be Bells Palsy though! After I called and started having some more one on one with her she had a hard time telling me her name she just couldn't remember until about 10 seconds had passed. I didn't see any tripping or issues with her walking through which is one of the things I was looking for.

So how do you tell the difference between BP and A stroke @JPINFV?

 

[mycrofft]

You can have a CVA and Bell's Palsy. (Not granting permission, mind you).

Good attention to details, ask questions before forging ahead.

 

[mycrofft]

Edit timed out as I typed

Bell's Palsy: strictly motor and sensory effect, pain is not unusual. Stroke will not have facial pain as a rule. Bells's will not affect gait, seat or stance, but pain meds can make you sluggish.

Go google Bell's and figure out why the two are different, it is an educational event (hint: cranial nerves versus intracranial vascularity).

 

[JPINFV]

No, I did have some conversation with her before I called 911, she was very sluggish and slow with responding, Not like usual.

Yet you called 911 without telling her. Also, did you do any sort of neuro exam besides looking for facial droop, slurred speech, and asking her name?

The Paramedics agreed when she arrived that she was probably having a stroke.

I didn't realize that ambulances carried CT scanners and MRI machines now. Suspecting a stroke is one thing. Using that expectation to confirm your suspicion, however, is a completely different thing.

Could be Bells Palsy though! After I called and started having some more one on one with her she had a hard time telling me her name she just couldn't remember until about 10 seconds had passed. I didn't see any tripping or issues with her walking through which is one of the things I was looking for.

Anything else? Strength differences, reflexes, cerebellar signs, changes/loss of sensation, other cranial nerve findings, confusion, etc?

So how do you tell the difference between BP and A stroke @JPINFV?

The easiest way is to look at the forehead. The upper motor neurons for the forehead are shared by the left and right side of the brain. So if the lesion is in the brain, you would still normally have some motor tone on the forehead (granted, if the lesion is large enough it can take out both sides of the brain, but then you're going to have a whole lot more than just unilateral facial droop). However a Bell's Palsy affects the lower motor neuron (cranial nerve 7), which is after the signals switch sides.

 

[JPINFV]

You can have a CVA and Bell's Palsy. (Not granting permission, mind you).

If you had to listen to "some doctor" tell you that you have Bell's Palsy or "some paramedic" tell you 2 days later that you're stroking out, who are you going to believe?

 

[AlanShore]

Yet you called 911 without telling her. Also, did you do any sort of neuro exam besides looking for facial droop, slurred speech, and asking her name?


I didn't realize that ambulances carried CT scanners and MRI machines now. Suspecting a stroke is one thing. Using that expectation to confirm your suspicion, however, is a completely different thing.


Anything else? Strength differences, reflexes, cerebellar signs, changes/loss of sensation, other cranial nerve findings, confusion, etc?




The easiest way is to look at the forehead. The upper motor neurons for the forehead are shared by the left and right side of the brain. So if the lesion is in the brain, you would still normally have some motor tone on the forehead (granted, if the lesion is large enough it can take out both sides of the brain, but then you're going to have a whole lot more than just unilateral facial droop). However a Bell's Palsy affects the lower motor neuron (cranial nerve 7), which is after the signals switch sides.

Man, I know absolutely nothing.

Time to go learn =)

 

[johnrsemt]

Sorry; for someone who hasn't even started his EMS training yet, he did a good job.

Why does he have to ask patients permission to call 911? I have called for accidents that I have seen happen, without being able to talk to the patient first.
Yes he could have talked to her more, and asked her permission to call. What if the lady had said no don't call; and died later of a massive stroke? It wouldn't have been Alan's fault put wouldn't have helped him feel better.

 

[AlanShore]

Sorry; for someone who hasn't even started his EMS training yet, he did a good job.

Why does he have to ask patients permission to call 911? I have called for accidents that I have seen happen, without being able to talk to the patient first.
Yes he could have talked to her more, and asked her permission to call. What if the lady had said no don't call; and died later of a massive stroke? It wouldn't have been Alan's fault put wouldn't have helped him feel better.

I agree,

My intuition kicked in by going outside and calling, because based on the way she is and my dealings with her she would of tried to stop me. The only thing I saw wrong with going outside is leaving the patient for a short period of time.

For example, about 3 months ago I tried to pay for someone elses breakfast, she almost denied my ability to do so. She just said, I'm not going to allow you to pay for this mans breakfast, he has to pay when it's my money. She finally allowed it but it took some fighting. Same for trying to get her to go to the hospital.

I grew up in a gas station for 19 years where it was just us and if we weren't there we didn't get fed and people didn't get their gas. I'm sure she felt the same way

Plus, while I agree I am untrained, I did it to the best of my ability. I didn't leave until the paramedics got there and said I could go as I am the caller and should stay there until.

@JPINFV.

Please forgive my choice of words while I speak about paramedics as I don't understand your sarcasm or way of speaking.

The only benefit i've seen to your responses to our conversation is when you stated looking at the paitents forehead, that was very informative and exciting.

What's a neuro exam?

I'm asking that question not because I can't get on google but because I will state that i'm untrained and for the time being I will not apologize for seeing something that has a suspicion of being life threatening before entering into training and choosing to act rather than saying "NOPE! I am not trained, i'm just going to walk away", then go get my breakfast the next day and hear from her husband she's dead.

I'd rather live with the Good Samaritans law than a guilty conscious.

 

[mycrofft]

If you had to listen to "some doctor" tell you that you have Bell's Palsy or "some paramedic" tell you 2 days later that you're stroking out, who are you going to believe?

Uh…...Alan?:blink:

 

[mycrofft]

Yet you called 911 without telling her. Also, did you do any sort of neuro exam besides looking for facial droop, slurred speech, and asking her name?


I didn't realize that ambulances carried CT scanners and MRI machines now. Suspecting a stroke is one thing. Using that expectation to confirm your suspicion, however, is a completely different thing.


Anything else? Strength differences, reflexes, cerebellar signs, changes/loss of sensation, other cranial nerve findings, confusion, etc?



The easiest way is to look at the forehead. The upper motor neurons for the forehead are shared by the left and right side of the brain. So if the lesion is in the brain, you would still normally have some motor tone on the forehead (granted, if the lesion is large enough it can take out both sides of the brain, but then you're going to have a whole lot more than just unilateral facial droop). However a Bell's Palsy affects the lower motor neuron (cranial nerve 7), which is after the signals switch sides.

Actual, pragmatic excellent assessment tips, the "virtual PET scan which is JPINFV".

 

[mycrofft]

I agree,

My intuition kicked in by going outside and calling, because based on the way she is and my dealings with her she would of tried to stop me. The only thing I saw wrong with going outside is leaving the patient for a short period of time.

For example, about 3 months ago I tried to pay for someone elses breakfast, she almost denied my ability to do so. She just said, I'm not going to allow you to pay for this mans breakfast, he has to pay when it's my money. She finally allowed it but it took some fighting. Same for trying to get her to go to the hospital.

I grew up in a gas station for 19 years where it was just us and if we weren't there we didn't get fed and people didn't get their gas. I'm sure she felt the same way

Plus, while I agree I am untrained, I did it to the best of my ability. I didn't leave until the paramedics got there and said I could go as I am the caller and should stay there until.

@JPINFV.

Please forgive my choice of words while I speak about paramedics as I don't understand your sarcasm or way of speaking.

The only benefit i've seen to your responses to our conversation is when you stated looking at the paitents forehead, that was very informative and exciting.

What's a neuro exam?

I'm asking that question not because I can't get on google but because I will state that i'm untrained and for the time being I will not apologize for seeing something that has a suspicion of being life threatening before entering into training and choosing to act rather than saying "NOPE! I am not trained, i'm just going to walk away", then go get my breakfast the next day and hear from her husband she's dead.

I'd rather live with the Good Samaritans law than a guilty conscious.

You didn't hurt anyone, you didn't act past your level of training, and the responders concurred, whether right or not. Not too shabby. Remember how different is can be when you know what's happening versus guessing, and the difference is learning. Keep on training!

 

[JPINFV]

Why does he have to ask patients permission to call 911? I have called for accidents that I have seen happen, without being able to talk to the patient first.
Yes he could have talked to her more, and asked her permission to call. What if the lady had said no don't call; and died later of a massive stroke?

Oh, your breathing hard? Let me call 911, after all I don't know that you just got done running a mile.

Sorry, but it starts to become a dangerous game when you call 911 just because you see something that might be bad. Further, accidents are a completely different issue. Even if no one is hurt, that accident on a freeway that is still in traffic lanes is a threat to public safety until it's cleared. The highway patrol and the local tow companies are still going to have to respond in order to clear it.

 

[8jimi8]

may i have that 4 minutes back please.

 

[unleashedfury]

Well I'm not gonna bash you for what you did. but in the same way you should've talked to the patient before making any interventions including Citizen Activation of the 911 system.

I roll onto scene a lot of times and people say to me "Oh Jesus" look what they did instead of letting me be they called you guys. And from there it goes either way some people can do just fine at home follow up with their PCP. and others we talk into going to the ED.

as far as a NEURO exam the easiest things to remember is FAST

Facial drooping, Arm Weakness, Speech Difficulties, Time

There will be more in depth ones you will learn over time, But I don't want to jump you to far ahead of your schedule.

Facial Droop - Ask the person to smile or show you their teeth.
Arm Weakness - Pt. cannot squeeze your hands equally, or have them hold their arms out like frankenstien and close their eyes. If having a stroke they may tend to favor one direction lefot or right
Speech difficulties - They cannot speak fluently, cannot speak or stumble on simple well known phrases like You can't teach an old dog new tricks, or The sky is blue in Pennsylvania

Time - Time to activation to the 911 system upon onset or recognition of stroke symptoms, you have limited time where interventions can be placed in to prevent residual effects of the stroke.

Be careful with the speech one though, I had a EMT once decide a patient needed a level one trauma center because he was slow to respond to questions or did not respond to questions.. Seemed to forget the most important one that was appropriate for the patient - "hablas englas". Si? No?

 

[JPINFV]

@JPINFV.

Please forgive my choice of words while I speak about paramedics as I don't understand your sarcasm or way of speaking.

Here's my point of contention. What did you put "her doctor" in quotes? Generally, when I write something like that, it's because I'm calling to question the ability of the person to act in that capacity (and yes, there are plenty of "doctors" out there that are doctors in name only).

The only benefit i've seen to your responses to our conversation is when you stated looking at the paitents forehead, that was very informative and exciting.

What's a neuro exam?

Neurological examination. An exam specifically to check out the neurological condition of the patient. Granted, the following is going to include more than what EMTs are trained to look for, but scope of practice doesn't limit the physical exam, just the tools used.

The following is also in no particular order. It looks like a lot, but with expereince it only takes a couple of minutes. Heck, I don't do the same order necessarilly every time. Additionally, if you're looking for stroke patients specifically (instead of a general neuro exam), look up the National Institute of Health (NIH) Stroke Scale.

Muscle strength:
Strength is rated on a scale of 0/5.
5= Full strength
4= Weak, but able to move agaisnt gravity plus some force.
3= Not able to push against force, but able to move against gravity.
2= Able to move, but not agaisnt gravity.
1= Able to twich only.
0= No movement.
UE: Test the patient's grips, then have them push you and then pull you. You can, if you want to, also isolate individual muslces to find out which muscle is weak specifically.
LE: If they're sitting, have them push their leg out (one at a time) agaisnt your hand and pull back agaisnt your hand. Have their foot down against your hand ("like pushing on a pedal") and then pull up.

Sensation:
Light touch, pain/sharp touch, and proprioception (able to tell where your limbs are relative to the body). Pain/sharp touch is generally not tested prehospitally.

Light touch: Touch multple places along the upper and lower limb on both sides. Ask if they feel the same. If you an go by dermatome, then do so (I'm posting at the hospital, I'll post a link to a dermatome guide when I get home tomorrow).

Proprioception: Take the person's shoes/socks off. Have them close their eyes. Grip the big toe by the sides and then extend it up or flex it down and ask them whether it's pointing up or down. Repeat until you're satisfied. Pronator drift test: Have them extend their arms out, palms up. Close their eyes. Watch for 30 seconds to a minute. If the patient can't keep their arms out, palms up, then it's positive.

Cerebellar:

Watch gait if appropriate (it's not always best to walk every patient).

Finger to nose test: Have them touch their nose with one finger and then touch your finger that's at about arms length. Move your finger around so they're reaching to the left and right. Repeat with other hand. It should be smooth

Rapid alteranting movement test: Have them put their hands on their knees and the have them flip from palms down to palms up as fast as they can.

Cranial nerve (CN) tests:
Check pupils, ask about blurry vision. Test peripheral vision. ("confrontation", easier to see then explain).

Check eye movement using the "H" test. Have the patient follow your finger with their eyes as you trace the shape of an H on it's side. Move your fingers to one side, and then up and down, then to the other side and up and down (6 muscles control the eye, 4 are controlled by CN3, 1 by CN 4, and 1 by CN 6. This isolates each muscle).

Check sensation at the forehead, cheeks, and under the chin on both sides (CN5 has 3 different branches, hence why you check 3 areas). Another thing is you can feel their cheeks as they clench their teath to feel muscle tone (CN5 also controls the muslces for chewing, the rest of the facial muscles is CN7).

Have the patient smile and then frown. (CN 7).

Rub your fingers by each ear to test hearing (CN 8)

Have them stick their tongue out and it should be midline (CN 9). Have them wag it left and right (CN 12... it's out already and there's no reason to go in strict order).

Look at the back of the throat with a light and have them say "ahh". The uvula (that dangly thing) should move straight up (CN 10).

Have them shrug their shoulders against force or touch their ear to their shoulder against force (CN 11).

Frontal lobes:
Speech, mentation, etc. Note any issues.

I'm asking that question not because I can't get on google but because I will state that i'm untrained and for the time being I will not apologize for seeing something that has a suspicion of being life threatening before entering into training and choosing to act rather than saying "NOPE! I am not trained, i'm just going to walk away", then go get my breakfast the next day and hear from her husband she's dead.

I'm not saying to walk away. I'm saying to investigate a little before calling 911. Would you call 911 because you saw smoke coming from a backyard on a summer's day, or would you make sure it wasn't someone burning their hotdogs and hamburgers on a grill first?

 

[18G]

I have to say I disagree with the OP in calling. I know the intentions were well intended but to "call 911 on someone" is kinda crazy. If she was that bad I can't believe her boss or co-workers overlooked it. I was thinking Bells Palsy too as soon as you started in with the details. Especially when the lady said she was seen by her doctor for the problem and gave her a prognosis of improvement in two weeks.

It also seemed like you were being a bit of what some call "Ricky Rescue", "wacker", etc. As in you were excited about your new endeavor and wanted to become engaged by calling 911.

As for the neuro exam... I have been doing this job for about 20yrs, 911 and critical care transport. It may be nice to learn the cranial nerve exam and all that but honestly, speaking for myself, I would use it so infrequently that I would never remember it. I also question the necessity of it for stroke assessment in the field. I am all for the highest of standards in assessment but reality speaking if you don't use it, you lose it. The Cincinnati Pre-hospital Stroke Assessment is catches about 70% of strokes and is deemed to be a pretty good assessment tool for the field.

 

[mycrofft]

I have to say I disagree with the OP in calling. I know the intentions were well intended but to "call 911 on someone" is kinda crazy. If she was that bad I can't believe her boss or co-workers overlooked it. I was thinking Bells Palsy too as soon as you started in with the details. Especially when the lady said she was seen by her doctor for the problem and gave her a prognosis of improvement in two weeks.

It also seemed like you were being a bit of what some call "Ricky Rescue", "wacker", etc. As in you were excited about your new endeavor and wanted to become engaged by calling 911.

As for the neuro exam... I have been doing this job for about 20yrs, 911 and critical care transport. It may be nice to learn the cranial nerve exam and all that but honestly, speaking for myself, I would use it so infrequently that I would never remember it. I also question the necessity of it for stroke assessment in the field. I am all for the highest of standards in assessment but reality speaking if you don't use it, you lose it. The Cincinnati Pre-hospital Stroke Assessment is catches about 70% of strokes and is deemed to be a pretty good assessment tool for the field.

Last paragraph: righto, overkill. But don't NOT learn it if you get a chance, it can lead to more insidious things like a better paying job with maybe a license.

Para 2: OP, just save this for a few months from now when you're trained and seasoned and getting too secure!

Para 1: I'd have asked more questions around, but new folks are inculcated with getting that 911 call out FAST (pun intended). And if it went bad, I'd feel silly saying "But her co-workers didn't look concerned…". Good thing to note, but make the final call on your own responsibility.

In my sorry old opinion, the call was probably not necessary, but the process to making it was ok for the OP's level of experience and training.

 

[mycrofft]

FAST note: I teach my students to have the subject extend their arms then push the rescuer's hands up. The ARC video has the subject extend their arms and wait for one to droop or wander or do the hokey-pokey.

The resisted raise maneuver helps you assess if they can understand you, and rapidly determine which side is weaker (and yes, most people will be a little stronger on the right. But serial re-exams while waiting for the ambulance will yield data on whether it is getting better or worse, as well as reassuring the subject/pt that someone is doing something).