Inspire Confidence in the Patient... how about myself?

[CritiqueMyCalls]

tl;dr - Royally screwed up a stroke call. Don't trust my skills for medium / high priority calls, should I still run as a charge EMT?

Been an EMT-B for a year, run calls with the ambulance for at least two. I've just got my charge status, and I'm running calls now. Just me and a driver. I'm slowly getting better at the process, but I don't feel confident in my skills as a BLS provider. As a horrifying example...

We had a BLS stroke call a while back, and I had to check with the driver which hospitals take stroke patients en route. Got to the patient, and was ransacking my mind for questions to ask the patient. Squeeze my fingers. Smile. (Can't teach an old dog new tricks? Nope. Arm drift? Nope. Didn't do them for some odd reason...) I had a bit of a hard time seeing facial droop, but there was decreased grip strength on her right hand.

Patient advised numbness on the right side of her face, and got a confusing history of previous "TIAs". I had to Google that when I got back to figure out what it meant. En route to the hospital, I scrambled for the little protocol book I keep in my pocket, and found a series of questions to ask the patient. (On any blood thinners? Recent surgeries? Head trauma?) I could swear they never taught us to ask those in class. Oh yeah, and oxygen 2 LPM via NC. How did I forget this? Can't remember what she said for meds / allergies, but I had them noted down. She recanted a story of her medical history, but for the life of me I couldn't follow her--this might be her, it might be me. I remember being confused, but I didn't press the matter.

Got to the ER. My pre-notification made it through, and they already had a room for me, which was great. Doctor asked me what he had. Low and behold, I'd left my note paper in the back of the ambulance. I sat there and stared numbly at him while the patient gave him all the relevant information. He looked a little miffed, but I felt a little "He's volunteer BLS, useless anyways" attitude (which was well deserved at this point.)

To crown the matter, when I got back in the ambulance, I realized that I hadn't asked her if she had nitroglycerin to take. My driver stared at me with a dumbfounded expression, and reminded me that nitro was for chest pain / MI, not strokes. I wanted to curl up in a corner and die.

Later, I ran a patient from a car wreck... That seemed to run a lot smoother. At least, I didn't re-make previous mistakes (like holding C-Spine, and then remembering I didn't have my radio, extrication kit, backboard, or cot near by...)

Either way, my point is this. Every now and then, I run a call and royally screw things up. Fortunately, it's never caused the patient harm -- at least, to the best of my knowledge. I fear it happening some day. I still have trouble relaying the story to ER docs, and sometimes dash for my protocol book behind the patient's back (not that it will do me any good in situations where I can't spend more than 30 seconds away from the patient...)

The only reason I keep doing this, is the majority of my station's calls are low priority transports... but I know I'll get a high priority call sooner or later. I don't know. What advice do you guys have? Should I run as an aide to the charge until I've seen more high priority calls?

Edit: BP was 150 / 80 in R arm, didn't get left. Pulse Ox was 99% @ ~80 bpm. Only vitals I can remember... don't think I took many more.

Edit 2: Oh, and I forgot the pulse-ox at the hospital. When I came back with the wreck patient, I got to talk with the stroke patient. She was glad to see me again, was resting comfortably, and said she was being held overnight. We swapped stories on a mutual vacation spot for a few minutes, before I ducked out to put the ambo back in service.

Edit 3: Symptoms had started 30 minutes prior to 911. Transit to nearest stroke center was ~15 minutes... More pertinent details I'm forgetting to list...

 

[Handsome Robb]

I'm not sure what to tell you...

Get back to the basics? Focus on the task at hand? Like you said it hasn't cause a problem yet but it very well could in the near future. Sounds like you need some more time assisting rather than attending as you said.

 

[systemet]

First, congratulations for being mature / intelligent enough to recognise that this is an issue that needs addressing. Thanks for caring -- because we have too many people in EMS who don't.

A few opinions:

* You don't seem to understand pathophysiology very well. This may not be your fault. It may not have been taught well in your program. But you need to fix this. You should know what a TIA is without having to google it. This needs to be fixed.

* It seems like you are looking for a list of history questions to ask, instead of trying to understand the disease process, examine the patient, and use your knowledge and pertinent findings to guide the history. This is a skill that takes time to develop, and is not typically well taught in BLS (or even ALS) programs.

* If you're allowed to give meds / do med assist, you have to be absolutely dialed in as to when they're indicated and contraindicated. You can't make mistakes here.

My suggestions, if you like:

* Go through and re-read your textbook, systematically. Take notes. Set an amount of time each night, or each week, and re-teach yourself basic physiology and pathophysiology.

* Keep posting here, and ask questions as you identify problems.

* Try and adapt a structured approach to examining the patient and obtaining vital signs, so that you don't find yourself "missing" vitals, etc. Note that unless your transport time is extremely short, you want to have at least 2 sets of vitals, because without this you don't have a trend, and you don't know if the patient is responded to any treatment you've given.

* First thing: get cue cards, burn any pharmacology you are responsible for into the back of your eyeballs. You cannot make mistakes here.

* Try and understand why you're are doing things, not just that "we check this in a potential CVA", but why. For example, in your neuro exam, you're concerned that the patient may have an obstruction of hemorrhage that's affecting a region of the brain on one side. You're trying to see if the grip strengths are normal to see if there's regional dysfunction in the motor cortex, or descending tracts. You're looking for facial droop, to evaluation cranial nerve function etc. When you do the Cincinnatti, you're doing this because the battery of tests has been shown to be fairly sensitive/specific for identifying stroke patients.


With reports to the ER, remember that they care about what's relevant to the patient's presentation. If the vital signs are normal, it's probably enough to say "the vital signs are normal", rather than spending a minute with "the radial pulse is strong and regular at 84 beats per minute at the radius, respirations are 16 non-laboured, without accessory muscle use... etc.". What they want to know is what's different, what sticks out, and anything that's pertinent. For example, I have an 84 year old women with new-onset facial droop, and arm drift, since 0800, no recent trauma, her glucose is normal." might be a better way to start.

Good luck.

 

[Handsome Robb]

listen to sytstemet, he/she's a lot smarter than me.

 

[Aprz]

Everything I say isn't the gold standard; review and follow your protocols. I agree with systemet, but I'll contribute a little bit. These are just my thoughts, take them with a grain of salt.

It would be awesome if you could rely less on your notes; listen and retain what your patient says. If you don't know what something is, don't be afraid to ask the patient/others about it. "What's a TIA?" Steve Whitehead from theemtspot.com wrote a nice thing about him asking a patient "What's speedball?" during his paramedic internship.

Unless the patient is hypoxemic, you shouldn't give a suspected stroke patient oxygen. Oxygen is a vasoconstrictor, and metabolized oxygen will create free radicals that'll cause further damage. For most people, 21% (room air) oxygen is sufficient enough.

An acronym they taught me in EMT school was FAST.

Facial droop
Arm drift
Speech
Time/Transport

So assess for facial droop, check for pronator drift "raise your arms and have your palms facing up like this (demonstrate it to them), close your eyes, and hold it there for ten seconds". Afterwards, tell them to repeat a phrase like "The sky is blue in Cincinnati", or "You can't teach an old dog new tricks" like you mentioned. Time is important to find out for whether they can receive certain treatments for it or not. Determine when was the last time they were seen behaving normally, and definitely relay this information to the receiving ER.

I recommend checking out the LA Prehospital Stroke Scale. A big criteria from that is their blood glucose level (BGL); diabetic emergencies/hypoglycemia can mimic a stroke. If the patient is a diabetic, have they checked their BGL? When was the last time they had their insulin? Has their dosage recently increased? When was the last time they ate? If I recall correctly, usually the BGL increases so if it's on the low side, I'd be suspicious of hypoglycemia.

Signs you want to check for are if the pupils are equal and reactive to light and check for equal grip strength. Start to ask questions that can rule in or out a stroke e.g. "I noticed your grip was weaker in this arm. Did you hurt it?", find out if they've bumped their head, been complaining of headaches, etc.

You can expect a blown pupil on the ipsilateral (same sided) side of the stroke, and contralateral (opposite sided) hemiplegia (half sided paralysis; think hemi like hemisphere)to the stroke. I've read that commonly aphasia (slurred speech; if you're really fancy, you can distinguish between different types of aphasias e.g. Broca's and Wernicke's aphasia, which could help narrow down where the stroke is occuring) is associated with left brain ischemia (like congresswoman Giffords who was shot on the left side), and right side has to do with vision (I'm unsure if it has to do with their ability to see things, or their ability to interpret their vision, The Man Who Mistook His Wife and 9 other clinical tales confused me on this subject a little bit). If they are having a hemarrhagic stroke, they are more likely to throw-up, and if at the pons, have miosis (pinpoint pupils). Lookout for irregular respirations. You can expect the same for head trauma. Like in head trauma, I expect to see an increase in blood pressure/wide pulse pressure.

When gathering a history, be suspicious of a stroke if they have a history of it, atrial fibrillation (afib), any clotting problems like MIs and pulmonary embolism, deep vein thrombosis (DVT), recent surgeries, fractures, hospitalization, high blood pressure (HTN), road trips, etc. If the patient was telling you if they have a history of TIAs, did you ask if this experience was similar to their experience of a TIA? Since a stroke is an altered mental status thing, don't be afraid to use outside sources too like family members, friends, bystanders. The patient may not be a reliable source.

For treatment, I think some EMS providers forget about position. I believe it was preferable to have the patient be semi-recumbent to fully-recumbent on the side of the stroke/opposite side of the hemiplegic limbs, but either side works. Left lateral recumbent for most ambulances is gonna be easier to monitor and manage. Don't forget to use pillows to prevent joint strain.

 

[systemet]

listen to sytstemet, he/she's a lot smarter than me.

Probably not! (Oh, I'm a "he", last time I checked).

Thanks for the kind words though. I've been lucky enough / willing to sacrifice enough to spend some time in university, and I've read a few books. But I've made more than my share of mistakes as well!

[If I was really smart, I probably would have gone to med school a few years back! Oh well, no regrets! ]

Aprz's post is awesome.

 

[FourLoko]

I finished my EMT course in December 2010 and still remember what TIA stands for. Still want to get my textbook back (let a friends brother borrow it) so I can refresh though. Recall the "sky is blue" thing but not the rest of the scale.

After you read the good advice up there remember that it's not your job to make a diagnosis. Find out what isn't normal and be able to report it.

 

[Sasha]

One thing about making mistakes and wanting to curl up and die is you are not likely to make them again. You learn from them.

Take a chill pill, you seem to be making mistakes because youre wired and uppity. Slow down a little and think. Contrary to what they tell you taking a few minutes longer wont kill anyone.

Sent from LuLu using Tapatalk

 

[Sasha]

I finished my EMT course in December 2010 and still remember what TIA stands for. Still want to get my textbook back (let a friends brother borrow it) so I can refresh though. Recall the "sky is blue" thing but not the rest of the scale.

After you read the good advice up there remember that it's not your job to make a diagnosis. Find out what isn't normal and be able to report it.

BS. How do you form a treatment plan without a working diagnosis?

Sent from LuLu using Tapatalk

 

[tssemt2010]

take a step back and assess your breathing and heart rate before continuing your assessment with the patient, ive learned that alot of medics get too wound up, all they need to do is relax

 

[FourLoko]

BS. How do you form a treatment plan without a working diagnosis?

Sent from LuLu using Tapatalk

you like to argue everything so I won't toy with you too much

How much can an EMT-B do to treat? DRIVE! or call ALS.

 

[18G]

tl;dr - Royally screwed up a stroke call. Don't trust my skills for medium / high priority calls, should I still run as a charge EMT?

Based on what you posted... definitely not.

You should only be running as a third person. It sounds like you do not understand the most basic medical terms, pathophysiology, how to transfer patient care at the hospital, or how to systematically approach your patient. And you thought a CVA patient should receive nitro.

It's great to remember the "right" questions to ask, but knowing why your asking those questions and how to interrupt the answers is more important.

You asked so I am answering honestly and not meaning to sound rude. If you have any questions I am more than willing to answer and help ya out. And as already mentioned, it does take a lot to admit when you messed up or feel a problem may exist so I do commend you for that.

 

[Aprz]

you like to argue everything so I won't toy with you too much

Ooo... be nice to Sasha. She's a valued member here, and you can learn a lot from her. When I first started working IFT, I went straight to her for advice. You also only have 14 posts since September 2011 which makes me think you haven't gotten a chance to make a fair assessment on a lot of the members here.

How much can an EMT-B do to treat? DRIVE! or call ALS.

I somewhat agree with you. I think the unfortunately thing is even with the skills EMTs have, they still do not perform it appropriately. We inappropriately administer oxygen, one of the few drugs an EMT can administer, all the time, and we don't even really know much about it thinking it's some sort of wonderdrug. As I've mentioned before, our treatment plan is pretty much slap on oxygen, roll the patient onto their side, and treat with diesel.

One thing an EMT can definitely do is a thorough assessment, you don't need all the diagnostic tools, and look how much you can figure out without an MRI, CT, EKG, etc. You can relay your positive/negative pertinent findings to a higher level of care, and with your limited treatment plan, put the patient in the right position, and give the appropriate amount of oxygen if any. Sure, they will do their own assessment, but they can also use your information to guide their assessment.

JPINFV wrote a wonderful piece on diagnosing. http://emtmedicalstudent.wordpress.com/2010/11/09/ems-and-diagnosis/

 

[mikie]

Take a more wholesum look to EMS...

Did you get the patient to the hospital without causing them further harm/injury? If so, it sounds like you did your job.

If it was really a stroke and you're a BLS provider, just what treatment did you have in mind? (other than O2 and maybe some glucometry)

addendum: don't be so critical on yourself. If you truly 'messed' up/wrecked a call, someone would def. let you know; if they haven't, then carry on!

 

[Steam Engine]

Although you stated you've been active as an EMT for a year, you're also a volunteer, which I imagine means you aren't actually spending very much time on an ambulance at all. I had a similar issue when I started out, working part time for a paid service alongside people with many years of experience or even people who, while technically working a shorter period of time than me, had double or even triple the actual amount of "experience" as I did. Therefore, it took me a lot longer to get comfortable with my role, and made the transition quite a bit more stressful.

While sometimes we falsely doubt whether or not we're ready for a responsibility, I think in this case you really aren't ready. This isn't a bad thing...quite the opposite, actually. You've demonstrated the ability to critically and effectively critique your own performance and ability, and have come to the conclusion that it needs some improvement. Think about it...would you rather have someone who is not ready for the job, but thinks they are anyway and blindly goes at it, or someone who is not ready but has the foresight and introspection to realize it and then take the necessary actions to improve? I know my answer.

So, the solution...I would talk to your supervisor. Tell them that you would like to continue, but don't feel comfortable being the lead EMT, and would like more time riding third. Then, hit the books again and really try to learn your material. Perhaps it was never taught to you properly, or perhaps your study skills are not working for you and you need to find something different...in any case, you need to find out what will work to help you retain the information, and then do it. A lot. Review your calls with people you trust, and ask for their input. Practice mock-assessments and treatments, and practice giving reports and handing off patients. Familiarize yourself with your equipment during down time, and familiarize yourself with your local hospitals...make yourself a list if it helps and keep it with you (i.e., Hospital A 1 Main Street, Stroke Center and Trauma Level 1.) Go through this for a while, and see how it goes. I bet you'll be ready sooner than you think.