Really bummed in myself for messing up on a call. Stroke

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chickj0434

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So we were dispatched to a 74 year old female for back pain. Get there pt is sitting on chair conscious and alert. Daughter called because she hurt her hip but also wasn't making sense. She presented with left hip pain stating she fell mechanically. Denies loc or head strike. She was alert to time place president even corrected me on her age. There was something off about her but wasn't sure. Performed stroke test with negative findings at the time.

So I get vitals and bgl of 128. No stroke hx. We get rolling to hospital. I drop patch in for fall hip pain . About a minute from the hospital she starts slurring her words. By the time we got her in the bed at the hospital I noticed some droopage in her face that wasn't there prior and she then couldn't answer the basic questions.

Really upset with myself with this call. What could I have done differently.
 
If she wasn't presenting like a stroke patient when you were with here there is nothing you could have done.
 
If your evaluation doesn’t suggest something, and you covered all the bases, you did nothing wrong. If you missed something, lesson learned.
 
If you have never had a patient completely change their symptoms intentionally or unintentionally between your arrival to them and their arrival at the ER, then you have not been doing EMS long enough. :)

This even happens inside the ER. As a RN, I get one story from a patient, the Provider walks in and gets completely different story. Or how they were presenting is now completely different. People lie. Conditions change rapidly. All you can do is assess what you see in the moment and treat or not treat accordingly.
 
you should have driven faster to the hospital; that way, she would have started showing her stroke symptoms on the ER. see, not your concern.

all kidding aside (I was only joking, driving faster is rarely the solution), she had a stroke. these things happen, sometimes without warning. update the hospital, activate the stroke team before you arrive, and as long as her sugar is good (and you said it was 128), you did all you can do. don't stress it.
 
the more you're in this business, the more you'll realize you don't have the influence and control you think you have now...and that's a good realization...
 
We had a similar call. One evening we got a lift assist call. A unit responded, AOx4, GCS-15, answers all the questions. Pt refused. Next morning, get a call to the same residence, for a lift assist. Guy is AOx4. answers all the questions, does not want to go to the hospital. BP, BGL, etc. all good Something is off, and wife is insisting he go to the hospital. Wife and Pt both in their 80's and she's too frail to lift him. He doesn't want to go. We explain the rules to her several times.

Get him off the floor, from the corner he was in, get him to his wheel chair and the wife wants him in the kitchen for breakfast. Fine, we get him to the table, and he insists that he wants to sit in "his" chair, which happens to be in a very tight corner. Ok, finally get him set at "his" place and the wife serves him. Wife still wants him to go, we call the medical director and the hospital ER and explain to them the situation. Both are on speaker so the wife can hear that we cannot force him.

So, while he is eating, he starts spilling food out of his mouth, slurring words, can't hold his arms out, ask all the questions again, answers all of them correctly. Ask wife if she has anyone she can call to come take him to the ER. She ticks off a list of people who can't come and finally says she can drive him.

We stay with the Pt, who still refuses, while she gets the car out of the garage, and wheel him out to the car, because we are going to follow her to the ER. Wife wants to lock up the house, comes back after 5 minutes or so, semi-frazzled because she can't find the keys. Well no problema, we advise her the keys are in the ignition. Get it locked and she heads for the ER with us behind her.

Call the ER on the phone and advise them we have folks coming to the ER with a possible stroke. Get to the ER, wheel him in with ER staff help, get him in a bed, and he's still answering all the questions, but by this time there is no doubt in anyone's military mind, this guy has a problem.

So, long story short, yep, he had a stroke, but had the answers to all the questions memorized. Never had a single repercussion from that and no complaints from higher about the delayed "scene" time.
 
Sounds like he started showing symptoms upon arrival to ER. That’s not something you can predict/assume to happen.
 
akflightmedic said:
This even happens inside the ER.
Click to expand...
During my hospital clinical this happened. They brought a guy in after narcaning a guy. As soon as EMS left, guy had a flash pulmonary edema due to the narcan. Had no idea that narcan could case a flash pulmonary edema.
 
Nothing you did wrong, patient "worsened" en route. Reminds me of a call we had in April:
Dispatched to urgent care to transfer a pt to the ER across the street (waste of time) for a person presenting with asthma exacerbation. Pt is satting fine, on 2L NC and has no wheezing. Ask nurse what their temp was, 98.7 and asked pt if they had any coughing, fever or travel out of the country. All negative. We get across the street and the patient starts coughing in triage. The nurse asks them the same questions we did and guess what? Pt said they had a cough for 4 days, a fever yesterday and returned from New York the week prior. I thought I missed something until the nurse checked the notes and urgent care had exactly what she told us at first.
 
Fezman92 said:
During my hospital clinical this happened. They brought a guy in after narcaning a guy. As soon as EMS left, guy had a flash pulmonary edema due to the narcan. Had no idea that narcan could case a flash pulmonary edema.
Click to expand...
Narcan doesn't...it's the acute severe hypertention/cardiac ischemia and systolic/diastolic failure that causes acute pulmonary edema.
 
So it’s not the Narcan per say?
 
Fezman92 said:
So it’s not the Narcan per say?
Click to expand...
If someone has the cardiac reserves to withstand all of the severe hyperdynamic effects of acute opiate reversal, this type of event doesn't occur. If the patient sufferers from cardiovascular deconditioning, all the things on the posted list conspire to cause these problems.

So, strictly speaking, the narcan just antagonizes the opiate....it is the patient's particular response that determines how he tolerates it.

Running a marathon shouldn't be thought of as causing pulmonary edema either. Get the point?
 
The patient was taken to the hospital fortunately, so overall things worked out ok. Think about how often ground level falls are refused and now consider if you didn't perform well on that call. Not saying that everyone should go to the hospital if they call 911, but things do get missed and bad refusals do happen...at real detriment to the patient.
 
What stroke assessment tool were you using? Unfortunately many used in EMS are not very thorough and do miss a decent number of strokes. Even the NIHSS which is typically considered to be the gold standard is not very good at detecting posterior strokes.

Clarly something was wrong, you identified that something didn’t seem right. Likely her ischemic penumbra was enlarging during your transport making her symptoms more pronounced.
 
E tank said:
If someone has the cardiac reserves to withstand all of the severe hyperdynamic effects of acute opiate reversal, this type of event doesn't occur. If the patient sufferers from cardiovascular deconditioning, all the things on the posted list conspire to cause these problems.

So, strictly speaking, the narcan just antagonizes the opiate....it is the patient's particular response that determines how he tolerates it.

Running a marathon shouldn't be thought of as causing pulmonary edema either. Get the point?
Click to expand...
Ok now I get it. Just like how a bee sting doesn’t cause an allergic reaction, it’s how the body responds to it.
 
Just remember the cardinal rule of EMS: There are 5 stories to every patient.
1: The story the patient/caller tells the dispatcher.
2: The story the patient tells the EMS crew
3: The story the patient tells the Nurse at the hospital.
4: The story the patient tells the resident.
5: The story the patient tells the Attending.

and then the story the patient tells the family to explain why they are being ignored at the hospital to cause problems when 3, 4, and 5 talk to each other and realize the patient is lying about what is actually wrong.
 
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