Didn't call a stroke alert. Ended up being a stroke

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chickj0434

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So we were dispatched for a weak woman on side of street. Got there. She was 79 and altered. Didn't know her address couldn't really answer any questions. Obtained vitals and bgl. Couldn't obtain BP because everytime cuff would inflate she would move arm and start crying. Tried to obtain it 3 times without an accurate reading. Perform stroke scale. Equal grip strength no droopage or slurred speech no arm drift. Transport was only 5 min away. Called for als but they could not intercept. Got to the hospital and told nurse I couldn't get a bp and that we performed the stroke test but didn't find anything besides the confusion. Apprently they got a bp reading of 220/110 and brought her to cat and she was having a stroke. So now the nurse is very upset. I'm also upset with my self as well.
 
chickj0434 said:
Def would of gone with the stroke alert with it being that
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You would have called a stroke alert for something that, based on your information, doesn’t meet any stroke assessment criteria? There are a lot of different reasons someone can be altered.

You say you would have called it a stroke alert if you got a pressure of 220/110 but what if this patients pressure was 130/90? Could an altered patient be having a intracranial bleed with a low or normal BP?
 
Plenty of ways to have a stroke with a completely normal or even low blood pressure. BP shouldn't even come into it if the patient endorses no neuro symptoms. The nurse would hopefully (but apparently not actually) be aware that an evolving stroke and hypertension, though simultaneously present, may or may not have a relationship. In fact, the presence of hypertension may be more therapeutic than not in some circumstances.
 
There’s also about 1000 other reasons that patient could have been altered that would have had nothing to do with a stroke. Altered mental status by itself is not reason to call the stroke alert. You had no history, no last known well and nothing to correlate any of your findings with. With the hospital five minutes away, I think the best thing is bring them to a place where they can get diagnostics performed. I think you did just fine.
 
Let's break it down piece by piece.

"So we were dispatched for a weak woman on side of street. Got there. She was 79 and altered. Didn't know her address couldn't really answer any questions. Obtained vitals and bgl. Couldn't obtain BP because everytime cuff would inflate she would move arm and start crying. Tried to obtain it 3 times without an accurate reading."

All sounds right - you ruled out any trauma, went down the AMS pathway, ruled out hypo/hyperglycemia

"Perform stroke scale. Equal grip strength no droopage or slurred speech no arm drift."

To the best of your ability, identified no immediate indication of a CVA using CPSS (not that specific of a scale, but if you combine with age and BGL, it's not so far off from LAPSS, which is much higher specificity).

"Transport was only 5 min away. Called for als but they could not intercept."

If a stroke, not much ALS could do.

"Got to the hospital and told nurse I couldn't get a bp and that we performed the stroke test but didn't find anything besides the confusion. Apprently they got a bp reading of 220/110 and brought her to cat and she was having a stroke. So now the nurse is very upset. I'm also upset with my self as well."

Transport is the only BLS intervention indicated, as far as I can tell here. You can't get a BP - that happens! Did you try to palp one at least?

Don't be upset because the nurse is upset - she doesn't have the context of what you can/cannot do outside of the hospital. And you don't have CT - not like you could know! (If you get a follow-up on the patient, it might be interesting to see what kind of stroke it was. If a posterior stroke, my understanding is that traditional prehospital stroke scales aren't great at catching these.)

Also, as mentioned by others -- the BP alone in the setting of AMS is *not* solely indicative of a stroke, and shouldn't change your management in this case.
 
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I would say that, on the whole, you did the right thing for that patient. You found that the patient was having some kind of acute problem, knew you were about 5 minutes away from a hospital, determined that ALS wasn't available so transport was the appropriate thing to do, and you got it done.

As to getting a blood pressure, something I've noticed is that most of the crews I interact with now use NIBP and aren't as good at doing manual BP measurement as perhaps they should be. In hospital, I have found that also to be the case. We rely heavily on NIBP machines. Why? It's easy. Literally. It's EASY. You apply the cuff, press a button, and wait for the machine to give you a number.

Where I work, I'm quite often found doing triage. I like at least having a manual cuff option close-by. Conservatively speaking, I've probably done more than 20,000 manual BP measurements over my career. My ears are very well attuned to doing this task, even though it's been YEARS since I've regularly done it. Do I use NIBP? Absolutely. All the darned time! However I do keep a manual sphyg adapter for our BP cuffs handy so I can quickly switch to manual if I need to. With patients that move a LOT, getting a manual BP can be MUCH faster and gentler on your patient than the NIBP machine is. Worst case scenario is that I get a palpated BP and run with that. You can't easily do that with the machine when it keeps trying to cycle...

Were I in your shoes, would I have done anything differently than you have? Aside from manual BP, no. Getting a manual BP wouldn't have changed my management in the field. I would have still transported to the local hospital for an initial workup. Given the altered mentation, if there was someone that could have provided a recent history, I would have wanted to know time of onset/last seen normal and if the onset was very rapid or if it was more gradual (if known/witnessed).
 
Inexperienced folks need to learn that because something bad happens, doesn't have to mean that someone has done something wrong. Common sense, but it's one of the cudgels that people who should know better (ie, the nurse in the scenario) use to bully their 'lessors' in order to cover for their own short comings IME.
 
EpiEMS said:
Let's break it down piece by piece.

"So we were dispatched for a weak woman on side of street. Got there. She was 79 and altered. Didn't know her address couldn't really answer any questions. Obtained vitals and bgl. Couldn't obtain BP because everytime cuff would inflate she would move arm and start crying. Tried to obtain it 3 times without an accurate reading."

All sounds right - you ruled out any trauma, went down the AMS pathway, ruled out hypo/hyperglycemia

"Perform stroke scale. Equal grip strength no droopage or slurred speech no arm drift."

To the best of your ability, identified no immediate indication of a CVA using CPSS (not that specific of a scale, but if you combine with age and BGL, it's not so far off from LAPSS, which is much higher specificity).

"Transport was only 5 min away. Called for als but they could not intercept."

If a stroke, not much ALS could do.

"Got to the hospital and told nurse I couldn't get a bp and that we performed the stroke test but didn't find anything besides the confusion. Apprently they got a bp reading of 220/110 and brought her to cat and she was having a stroke. So now the nurse is very upset. I'm also upset with my self as well."

Transport is the only BLS intervention indicated, as far as I can tell here. You can't get a BP - that happens! Did you try to palp one at least?

Don't be upset because the nurse is upset - she doesn't have the context of what you can/cannot do outside of the hospital. And you don't have CT - not like you could know! (If you get a follow-up on the patient, it might be interesting to see what kind of stroke it was. If a posterior stroke, my understanding is that traditional prehospital stroke scales aren't great at catching these.)

Also, as mentioned by others -- the BP alone in the setting of AMS is *not* solely indicative of a stroke, and shouldn't change your management in this case.
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Perfect analysis. It does not appear as though anyone did anything wrong here. Other than, perhaps, the triage nurse being a PITA.
 
E tank said:
Inexperienced folks need to learn that because something bad happens, doesn't have to mean that someone has done something wrong. Common sense, but it's one of the cudgels that people who should know better (ie, the nurse in the scenario) use to bully their 'lessors' in order to cover for their own short comings IME.
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This is a critically important point that unfortunately, most of us only learn through experience. And I personally think that this issue is one of the biggest factors contributing to the very high rates of job dissatisfaction and burnout in both EMS and nursing.

EMS training essentially teaches folks that if they do everything right, then the outcomes will usually be positive and if the outcome isn't good, then it is probably the fault of the EMS provider. When in reality, nothing could be further from the truth. In actuality, it is very often (certainly not always, but quite often) true that the outcome of any type of acute illness or trauma has been decided before anyone even dials 911.

Surly, burned-out triage nurses bullying his/her "lessors" just muddies all that and reinforces the original, flawed message of EMS training.
 
Carlos Danger said:
EMS training essentially teaches folks that if they do everything right, then the outcomes will usually be positive and if the outcome isn't good, then it is probably the fault of the EMS provider. When in reality, nothing could be further from the truth. In actuality, it is very often (certainly not always, but quite often) true that the outcome of any type of acute illness or trauma has been decided before anyone even dials 911.
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As much as it is an initial education problem, I wonder if it is also age/life-experience related. I'd posit that younger entrants into the field are more likely to fall prey to the error of attribution more so than others with more life experience.
 
I'd like to add some perspective to the non-clinical portion of the run here. Sometimes the closest ALS is the hospital and a pre-hospital ALS intercept will do nothing but delay definitive care. I had a surprise transport like that (was supposed to be non-emergent BLS dialysis transport, found patient unresponsive, SNF was on the doorstep of the hospital, a 0.1 mile transport). My report to the triage nurse explained all this clearly and I still got a "but why no ALS?"
 
Kevinf said:
Sometimes the closest ALS is the hospital and a pre-hospital ALS intercept will do nothing but delay definitive care.
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This is something more people should remember... especially in places where the norm is for only ALS crews to bring patients to the ED.
 
Kevinf said:
I'd like to add some perspective to the non-clinical portion of the run here. Sometimes the closest ALS is the hospital and a pre-hospital ALS intercept will do nothing but delay definitive care. I had a surprise transport like that (was supposed to be non-emergent BLS dialysis transport, found patient unresponsive, SNF was on the doorstep of the hospital, a 0.1 mile transport). My report to the triage nurse explained all this clearly and I still got a "but why no ALS?"
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I swear that is the reason I sometimes wanted to drag nurses out the door or to a window, point at the building next door, and go yeah we came from right over there.
 
As everyone else said, this is an AMS with no known onset, no clear baseline, and no stroke signs... even if I had known the BP was 210/110, I wouldn't be calling a stroke alert. And as long as you ruled out hypoglycemia, there is no need for ALS, as there are no ALS interventions that are going to undo the stroke (assuming no airways issues, or other issues). And the nearest ALS provider was the ER. The only thing I would have suggested is make sure you give the ER a heads up on this patient, that you are bringing in an ALS patient with no ALS available

Now, have I activated a stroke team on a patient that wasn't clearly a stroke? yes, and she ended up having a hemorrhagic stroke. but even one of the paramedics wasn't convinced. But in the case you describe, I wouldn't have called a stroke alert.

Let the nurse be upset; if she's really upset, she can follow the normal process and file a complaint with your supervisor, but if that happens, I doubt anyone would agree with her. After all, we don't have a cat scan in the truck to scan the patient on the sidewalk.

Good Job
 
E tank said:
Inexperienced folks need to learn that because something bad happens, doesn't have to mean that someone has done something wrong. Common sense, but it's one of the cudgels that people who should know better (ie, the nurse in the scenario) use to bully their 'lessors' in order to cover for their own short comings IME.
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Very much, this.

A few months ago my partner and I were dispatched for a panic attack. Presented very much like a panic attack. Patient described it as a panic attack, and even said that the symptoms she experienced were like some of her other bad episodes. Patient had experienced a death in the family and that, with the resulting bills sure lined up as anxiety. Didn't even do a Cincinnati.

Hospital found a stroke.

We talked a lot about it, and tried to find anything that we would be done differently, other than a Cincinnati, which... I think the patient would have passed anyway. Heck, she may have only started - and maybe that was what increased her anxiety.
 
Don't kick yourself; learn from what happened, think next time about doing a manual BP, in this case cause it is easier to hold the arm still when you are literally holding it to take the BP. Still won't change anything that you did, except tell the hospital BP is high. Stroke check was still negative, and if they did it in the ED, it would have been negative too.

Another thing to learn is that ED nurses get mad a lot about patients we bring in. We didn't do a CT in the field to find out the patient was having a stroke. We don't do blood tests to find out what drugs the patient is on before we get to the hospital. We don't know why the patient is unconscious. They get upset about things that we have no control over. The floor or ICU nurses get upset at the ED nurses, so the ED nurses only have us to get upset at. It flows backwards.
I have had my job threatened by a lot of ED nurses; nothing has ever happened, except that I have laughed at a couple of them and they get more upset about that.
 
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