Stay-play / Load-go/ Upgrade?

[JPINFV]

Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.

When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.

On the other hand, imagine the outrage when that drunk actually is hypoglycemic? Provided appropriate education, I see nothing wrong with a finger stick as a part of a normal workup for any ALOC, even if the etiology seems clear. However, as with any other lab value, the context of the results needs to be understood. If a paramedic or the ED is going to get a BGL for a patient, an EMT who has been approved to use a glucometer should be getting one as well.

 

[Too Old To Work]

On the other hand, imagine the outrage when that drunk actually is hypoglycemic? Provided appropriate education, I see nothing wrong with a finger stick as a part of a normal workup for any ALOC, even if the etiology seems clear. However, as with any other lab value, the context of the results needs to be understood. If a paramedic or the ED is going to get a BGL for a patient, an EMT who has been approved to use a glucometer should be getting one as well.

I didn't say that they were unresponsive, I said they were drunk. As in sitting on the sidewalk requesting transport to a shelter.

 

[JPINFV]

To be fair, I didn't say unresponsive (you can be altered and not be unresponsive), you did use the term "passed out," and you didn't say that they were just asking for a ride to a shelter.

 

[reaper]

So what is wrong with checking a BGL on them?

 

[Veneficus]

On the other hand, imagine the outrage when that drunk actually is hypoglycemic? Provided appropriate education, I see nothing wrong with a finger stick as a part of a normal workup for any ALOC, even if the etiology seems clear. However, as with any other lab value, the context of the results needs to be understood. If a paramedic or the ED is going to get a BGL for a patient, an EMT who has been approved to use a glucometer should be getting one as well.

To just take this a bit farther, i am partial to checking a glucose on any patient as part of the normal vital sign workup.

Abnormal glucose can cause some vague symptomology prior aloc. It can detect early changes in both young and old (though not usually in middle age) and in the event of a normal finding correlated to last intake can clue in other metabolic or endocrine syndromes that admitidly may be of more use to the hospital staff than EMS, but also becomes a pertinent negative as well.

from the financial point, if a BLS unit does a glucose check, it does not increase the BLS billing, but if the hospital does one, it does increase the patient cost. In patients it is not specifically "indicated" for in EMS, it can be basically a free screening.

 

[JPINFV]

it can be basically a free screening.

tanstaafl

 

[Veneficus]

tanstaafl

? you are going to have to help me out with that one.

 

[JPINFV]

There Ain't No Such Thing As A Free Lunch. Not saying it isn't valuable. Not saying that it isn't good patient care and community service for the ambulance service to donate a lancet and test strip, just that it's isn't truly free.

 

[Veneficus]

There Ain't No Such Thing As A Free Lunch. Not saying it isn't valuable. Not saying that it isn't good patient care and community service for the ambulance service to donate a lancet and test strip, just that it's isn't truly free.

I meant it doesn't cost the patient anymore. Not that it was totally free. Besides, with what is being paid for a BLS emergency ambulance ride, whoever is collecting could lose a few bucks and still make out quite well.

It is not like the horizontal tax ride with some o2 and a set of vitals is worth $300

 

[Fox800]

Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.

When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.

You should be checking a BGL on these patients.

 

[DrParasite]

No IV, no 12 Lead. Point the BLS crew in the direction of the appropriate facility and wave good bye.

Speaking as a BLS provider, that's pretty much what I would expect.

BLS (and often ALS) providers often forget the goal is to get the patient to definitive care, not ALS care. Take them to the hospital, no need to wait for a paramedic to arrive, start an IV, take a 12 lead, and we all stare at the patient enroute to the hospital. Rapid transport to definitive care is often the best medicine, esp in a stroke situations.

Apparently on arrival to the ED, just before they whisked him off to CT, his Bp was 258/152.

yeah, and? The guy is having a stroke, what can you do in the field to help? The patient needs a hospital/stroke center to fix the underlying cause of the HTN, not a paramedic that can only treat the symptoms.

The only thing that could have helped would be for the BLS to call the ER and advise them of the patient's condition, so they could have a bed waiting for them when they walked into the ER. other than that, it's an asymptomatic HTN episode, which is a BLS call

 

[reaper]

Speaking as a BLS provider, that's pretty much what I would expect.

BLS (and often ALS) providers often forget the goal is to get the patient to definitive care, not ALS care. Take them to the hospital, no need to wait for a paramedic to arrive, start an IV, take a 12 lead, and we all stare at the patient enroute to the hospital. Rapid transport to definitive care is often the best medicine, esp in a stroke situations.
yeah, and? The guy is having a stroke, what can you do in the field to help? The patient needs a hospital/stroke center to fix the underlying cause of the HTN, not a paramedic that can only treat the symptoms.

The only thing that could have helped would be for the BLS to call the ER and advise them of the patient's condition, so they could have a bed waiting for them when they walked into the ER. other than that, it's an asymptomatic HTN episode, which is a BLS call

Where are you getting that this pt was having a stroke? There is not any indication of this in the assessment. This pt is having a hypertensive crisis. How can you say it is a stroke and then say it is an asymptomatic HTN episode? This pt had plenty of symptoms, to go along with his HTN.

Based on being so close. I would have told to the BLS crew to transport him to ED. Any distance out, purely depends on protocols. Some systems can treat this on scene and treatment can be started right away.

 

[clibb]

So as you all know, one of the BEST parts of being a brand new medic is always doubting yourself... and tonights has to do with Staying, loading, or upgrading.



It's common consensus that on a BLS truck, if the hospital is closer than the ALS intercept, just transport... but what if ALS intercept is there, but it takes less time to get to the hospital than to do ALS treatment?




Tonight we were dropping a patient off at a psych hospital. As we were calling on, dispatch said "We have a BLS truck at that location with a hypertension call, would you mind sending your medic (me) to go check them out and see if they need help?"


So I go to where the BLS truck crew was, an Intermediate and a Basic. The Basic is just about to finish his paperwork. Quick rundown of the patient--- 40's male, BP of 198/118 hr of 58, headache, nausea (but no vomitting), seems a slight bit lethargic (but unable to tell if that's baseline, it being 2am, medications, or the BP) no CP, no SOB, pupils are fine, lungs clear, no other medical history aside from psych. Nurse states his BP's been elevated since Friday. (Keep in mind this is a generally good psych hospital). They've given Norvasc with little change in BP.



Now comes the question. This psych hospital shares a parking lot with a major hospital. The transport from A to B takes less time than it would take me to set up a 12-lead.




So, considering his condition has been "stable" for atleast 24 hours, and you're literally THAT close to the hospital, what would your decision have been? Stay and treat the BP, let the BLS crew transport, or start some ALS and ride in their rig and go?

A question I would ask is if the patient has fallen. With that kind of a bp, hr, and nausea I would suspect Cushing's Triad or other head injury. What is his usual AAOx4?

Our BLS crews have glucometers for that reason. Of course now they use them for everything, which is stupid. Every drunk passed on out on the sidewalk gets his BG checked. Drives me nuts.

When the only tool you have is a hammer, everything tends to look like a nail. When the only tool you have is a glucometer, everyone tends to look like a hypoglycemic.

Of course you would check gluco on a DRUNK PASSED OUT patient. You want to eliminate and trouble shoot, it's a part of medicine. Here in our protocols we are required to get a gluco check on any patient who appears intoxicated, hyper/hypo - glycemic, AMS, falls, and any other incident that would scream diabetic emergency at you. It's pretty simple to rule out if the patient just needs d-25/50 or a full/limited - trauma team activated.

I didn't say that they were unresponsive, I said they were drunk. As in sitting on the sidewalk requesting transport to a shelter.

I've never heard a drunk person asking or requesting transport to a shelter. Maybe to the hospital due to a "medical emergency" so they could sleep at the hospital since the shelters won't take them in since they are intoxicated. But, we don't pick patients off the street and transport them back to their shelters.
Also, if you would read above it will tell you that you DID say " Every drunk passed on out on the sidewalk gets his BG checked" and not " they were drunk. As in sitting on the sidewalk requesting transport to a shelter."

I would love to see that narrative. "Patient was drunk on the side walk and asked for transport to shelter. I decided that the patient was drunk, so I didn't need to check his gluco level (Even though I learned that in the first week of EMT-B class that a patient who "appears" intoxicated can be cause by many different medical reasons, such as diabetes)." I'm sure that goes well with you supervisor.

No IV, no 12 Lead. Point the BLS crew in the direction of the appropriate facility and wave good bye.

Would had done the same.

Telling dispatch to go ahead and take them is fine and probably what I would have done, but once you as a medic are on scene with the patient, it is your patient, especially if your standing orders list hypertension as an ALS ride. If he had told dispatch to have the BLS crew transport before arriving on scene that is different.

Everyone has different protocols. After a simple blood sugar test we could see if this would be a BLS or ALS call for my area. If a Paramedic leaves the scene of an ALS call without having a refusal sign (On an ALS call you most likely wouldn't have a refusal signed to begin with) or leaving the patient in the hands of a person who has less medical training than the Paramedic, it's neglect.

Linuss, you were the Paramedic at this scene and you have experience under your belt, so you made the best judgment. We can all argue for or against you, but you made the best judgment since it's your call.
It's all about the patient's well-being. Treat them like you would want your family members to be treated. Would you had wanted an BLS or ALS unit on this call if this was your son or father?

 

[DrParasite]

Where are you getting that this pt was having a stroke? There is not any indication of this in the assessment. This pt is having a hypertensive crisis. How can you say it is a stroke and then say it is an asymptomatic HTN episode? This pt had plenty of symptoms, to go along with his HTN.

Your right, I made an assumption that due to the fact that his BP was skyrocketing, especially from the time they found him to the time he made it to the ER despite the facility giving norvasc. Plus the whole headache thing makes me think it's some type of issue with his brain (bleed, etc) that is causing his pressure to increase at an uncontrolled rate. But there are no chest pain or diff breathing, so I doubt it would even be worked by ALS, since it's not really symptomatic (our ALS rarely treat hypertension without associated chest pain).

Your right, it is a hypertensive crisis, and left unmanaged, a stroke would probably result, but I did jump the gun based on the limited information presented. I wonder if the CT did reveal anything.

 

[Veneficus]

the complications of simplicity

So I go to where the BLS truck crew was, an Intermediate and a Basic. The Basic is just about to finish his paperwork. Quick rundown of the patient--- 40's male, BP of 198/118 hr of 58, headache, nausea (but no vomitting), seems a slight bit lethargic (but unable to tell if that's baseline, it being 2am, medications, or the BP) no CP, no SOB, pupils are fine, lungs clear, no other medical history aside from psych. Nurse states his BP's been elevated since Friday. (Keep in mind this is a generally good psych hospital). They've given Norvasc with little change in BP.

As I follow the thread I see a lot of honing in on Cushing's triad and the potential for CVA. I would just like to kindly add a few words on this.

I would like to fist define what cushing's traid is:
1. irregular respirations
2. widening pulse pressures
3. bradycardia

Cushing's triad is seen in head injuries ( late stages), it does not mean there is a head injury.

It is also manifests in When chemoreceptors in the brain and baroreceptors are receiving mixed inputs.

In hypertension patients the heart must overcome the resistance of the reverse flow in order to adequetely eject blood and achieve perfusion pressure.

In the findings posted by Linuss. There was no evidence of intracranial shift. Pupils were normal, a bit of lethargy (possibly baseline at 2 am) and no irregular breathing pattern.

These findings (or lack of findings) rule out cushing's triad. As only 2 of the 3 criteria are met. The fact the pt is still conscious at any level also plays a strong role in this finding. There is also only one set of vitals so there is no way to tell if the pulse pressure is widening.

Now when we add a drug into the mix the dynamic completely changes.

Norvasc is a calcium chanel blocker that acts non specifically on both the heart and vascular smotth muscle. Depending on the underlying cause and patients level of compensation, norvasc is known to cause negative inotropic effect. (lack of contractility) In addition, as any CCB it can also produce negative chronotropic effects because Ca channels are part of the normal cardiac cycle. But I think the bradycardia in this case has a slightly different mechanism, more along the lines of something Dr. Cushing would be proud of.

In a well compensated patient with HTN, the body maintains perfusion to end tissues over the vascular resistence with increased inotropic or chronotropic response. (which opposes)

Decreasing the rate/pressure the heart beats at, decreases cerebral perfusion pressure. Which leads to a catecholamine response. (increased peripheral resistance to maintain central perfusion in addition to increased rate.) Having said that, the baroreceptor reflex in the carotid sinus would detect and attempt to regulate the arterial pressures by decreasing heart rate. All together central baroreceptor acting in contra to peripheral catecholamine, with chemical blockage of central catecholamine effect. Epi in particular affects cerebral arterioles.

Cushing's reflex + pharm.

Another important pharm finding is that headache is the most commonly reported side effect of norvasc. The peripheral HTN cold also produce the same effect and when adding in the nausea, it looks to me that norvasc is not the best choice here to regulate hypertension by trying to normalize numbers instead of patient condition. Norvasc is also not a first line therapy anywhere I have seen.

when you add in the nausea that is a nonspecific finding but I would think in this case it does point to a problem with cerebral perfusion and subthreshold stimulation of the vomiting reflex. Certainly a potential for CVA exists, but it seems more like an anoxic brain insult (from perfusion issues after chemically knocking out the patient's compensatory reflexes) than an ischemic or hemorrhagic insult from the limited information provided here.

But for all my musings, it doesn't change the EMS treatment... BLS ambulance to hospital where it can all be sorted out for sure.

 

[Veneficus]

just to be complete

A decrease in renal perfusion from the lower bp secondary to the norvasc could decrease GFR and then activate the RAA cycle. This would leave the explanation of the bradycardia to negative chronotropic effect of the medications.

There catelcholamine release could aslo constrict pre and post renal arteiole sphincters decreasing GFR and activation of the RAA cycle, and an attempt at baroreceptor and chemical inhibition of the heart rate.

But in any event, I am thinking the problem arose with the norvasc, not a malignant hypertension in a patient with controlled HTN.

 

[rhan101277]

Seems like a slow bleed/CVA to me. It almost fits Cushings Triad, except for him not having irregular respirations.

A embolic stroke fits perfectly though. I think you did right.

Yeah I was saying cushings triad didn't fit. As with any bleed you should have increased ICP which can lead to sluggish/dialated pupils. Which wasn't present here.

Maybe it was just a chronic HTN

 

[medicman90]

Meh, I don't know why they were sitting on scene for the length they did, and even though I didn't take over the call I hurried them up a bit.... which irked the Intermediate some. His attitude with me made me chuckle afterward.

I was using the 12-lead as an example as to how close we were, not that I had done one.

I chose NOT to treat because A) we WERE so close...I wouldn't have even gotten the supplies for an IV out by the time we would have backed in to the ER. and B ) he has been elevated for a while, so another couple minutes probably wouldn't cause more damage than has been done.



I just let the BLS truck transport, which is why I'm seeing if anyone would have done differently.

IMHO: correct

source: http://wordnetweb.princeton.edu/perl/webwn?s=ambulance

Noun

S: (n) ambulance (a vehicle that takes people to and from hospitals)

 

[Too Old To Work]

You should be checking a BGL on these patients.

Defend that statement. Tell me that there is clinical benefit to it in a non diabetic patient.

 

[Fox800]

Defend that statement. Tell me that there is clinical benefit to it in a non diabetic patient.

Tell me how you will rule out a glucose abnormality in a patient "passed out" without one and with no medical history available.

Are you seriously advocating withholding BGL checks on patients that are altered/unconscious due to an unknown cause?