Interesting call...

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SoCal

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We got called ALS to a transport from a :censored::censored::censored::censored:ty ER to another :censored::censored::censored::censored:ty hospital last night, and the other medic and I were just cracking our skulls at this one, so I thought I'd ask on here.

Ok, well upon our arrival Pt. was laying in ER bed, gazing up and not tracking with his mouth wide open. We asked the nurse why he had been brought in and of course we got the generic, ALOC c/c.

Anyways, this pt. had a "dead look" to him and I had to go up and check the pulse because he looked that bad.

Pt. had history of CVA w/ left sided deficit, Diabetes, HTN.
NKDA
List of meds.

V/S: B/P: 138/78
Pulse: 80
Skins: Normal
Resp: 14 nonlabored
BGL: 132

The first abnormal finding was that the Pt. was not tracking with his eyes, however he could answer appropriately to his daughter, just without moving his mandible.

The second was that he had Pinpoint pupils like 1mm. These were more than I have ever seen before, even on our opiate addicts. Pt. family denied ANY opiate/ painkiller and there was a list of meds but again no opiates.

The only thing I could think of was a dystonic reaction to some medication/ or an accidental OD, however I couldn't think of what would cause the mandible to not close. I was also thinking possible 2nd CVA, however CT was negative.

Any help? We are racking our brains...
 
You gave us very few and poorly defined details of a neuro so it is impossible to even begin with the many differential diagnoses.

A CT Scan is not definitive for many neurological disorders and may not give any initial results. A followup may be necessary and it may best performed at a hospital with neuro care rather than hanging around a hospital without these services for 24 hours. You also did not mention whether it was done with contrast.

Did you happen to look at the lab results? Electrolytes? Tox screen?

Now, without the profanity, can you tell us exactly what type of hospitals you were transporting from and to? Was one a neuro or stroke center? Was it a direct admit to a floor or ICU? Or just ER to ER? What type of doctor was the rec'g? What was the reason for the transfer?
 
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For 1.... my partner was the attending, so I didn't have all the details on the CT, however, I did hear all of the labs/tox/electrolytes came back WNL. And these hospitals were both Neuro/ Stroke centers. however when you think of a "good" ER, these hospitals do not pop into my mind.

And what do u want to know about Neuro...

He could answer Yes and No also he could tell us where he was, however he didn't know his age/ birthdate, however that was his normal per his wife and daughter.

It was ER to ER for "insurance reasons" haha... why else...
 
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Ya my partner did one, along with the daughter's help, cuz the pt. didn't want to respond to anyone except her.... What do u wanna know?

And in LA there is no other reason that a pt. is transferred except Insurance....
 
SoCal said:
Ya my partner did one, along with the daughter's help, cuz the pt. didn't want to respond to anyone except her.
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So, what were the results? Strength, tone, reflexes, cranial nerves assessment?


SoCal said:
And in LA there is no other reason that a pt. is transferred except Insurance....
Click to expand...

If all hospitals in LA are the same what is the big deal about STEMI alerts, cath labs and Stroke centers?

What do u wanna know?
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It this just another scenario guessing game that you placed in the ALS discussion thread?
 
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SoCal said:
Ya my partner did one, along with the daughter's help, cuz the pt. didn't want to respond to anyone except her.... What do u wanna know?

And in LA there is no other reason that a pt. is transferred except Insurance....
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Dual medics for an IFT? Thats pretty cool.

Care to share the hospital names?
 
VentMedic said:
So, what were the results? Strength, tone, reflexes, cranial nerves assessment?
Click to expand...

Strength was equal bilateral all extrem., muscle tone was strong/ intact in all extrem. reflexes were present in all except the left arm, and cranial nerve responses were all normal.




VentMedic said:
If all hospitals in LA are the same what is the big deal about STEMI alerts, cath labs and Stroke centers?
Click to expand...

I know there are differences, I was just exaggerating my above post^

But both were Stroke centers yes...
 
VentMedic said:
So, what were the results? Strength, tone, reflexes, cranial nerves assessment?




If all hospitals in LA are the same what is the big deal about STEMI alerts, cath labs and Stroke centers?



It this just another scenario guessing game that you placed in the ALS discussion thread?
Click to expand...

She wants to know if you or the attending/doc did any type of neuro exam. You know, the full one, not the LOC and pupil tests most medics just do. I have heard of neurologists who can pinpoint the lesion/infarct based on a good physical exam.
 
SoCal said:
Strength was equal bilateral all extrem., muscle tone was strong/ intact in all extrem. reflexes were present in all except the left arm, and cranial nerve responses were all normal.


I know there are differences, I was just exaggerating my above post^

But both were Stroke centers yes...
Click to expand...
But you said no movement in the face, so I am assuming facial innervation and tongue movement and orbital movement was not tested?
 
daedalus said:
Dual medics for an IFT? Thats pretty cool.

Care to share the hospital names?
Click to expand...

daedalus

Does your area do just ALS with a Paramedic if a CCT is not warranted?

I've seen them in the northern part of the state if just a cardiac monitor is warranted or an IV that is within the ALS scope.
 
daedalus said:
But you said no movement in the face, so I am assuming facial innervation and tongue movement and orbital movement was not tested?
Click to expand...

It wasn't the facial nerve, regions on both the left and right side of the face moved, however just the mandible didn't move. It was weird, it felt like it was riggored open. It was so stiff. Tounge and orbital movement was intact. However the Pt. did not track us
 
SoCal said:
cranial nerve responses were all normal.
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You tested all of them or read the physician's report?

Since the patient has had a previous CVA and some memory deficits are present, did he also have long term accessories such as a peg or was he wearing a diapher?
 
VentMedic said:
daedalus

Does your area do just ALS with a Paramedic if a CCT is not warranted?

I've seen them in the northern part of the state if just a cardiac monitor is warranted or an IV that is within the ALS scope.
Click to expand...

Ay.

Our ALS in Los Angeles is like IV TKO, and EKG. That is the extent of their scope. Our CCT RNs and RTs handle the vents, drips, IABPs, etc. I work on a CCT unit most of the time.

It is embarrassing. However, I live in Ventura. In Ventura, we can do heparin and nitro drips (and Integrin/other anti platlet aggregates I think) for emergent STEMI transports! Thats cool!
 
We tested it before we even loaded the pt. on our gurney...
 
SoCal said:
He had a Foley... and he lived in a SNF...
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Why was he at a SNF and not a nursing home? Was he still in need of convalescence or IV therapy that required a higher level of care?

All skin intact, that's impressive. No decubitus?

Fever?

This could be anything from a UTI to another CVA and anything inbetween.
 
SoCal said:
Strength was equal bilateral all extrem., muscle tone was strong/ intact in all extrem. reflexes were present in all except the left arm, and cranial nerve responses were all normal.






I know there are differences, I was just exaggerating my above post^

But both were Stroke centers yes...
Click to expand...

But what type of stroke centers were they. Was the first one a "drip and ship" and the second one a primary stroke center?
 
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