92 y/o F reported strokee

[DwayneEMTP]

Called to a nursing home at 0200 for a 92 y/o female that CNA reports had slurred speech and R sided facial weakness. RN on shift tells CNA to have EMS transport for evaluation.

What do you do?

Dwayne

Edited to remove double word only.

Edited July 8, 2011 by DwayneEMTP

[usmc_chris]

I don't know what I want to do without more information.

Questions to ask the CNA/RN:

-What is the patient's baseline?

-What was the last time the patient was seen at her baseline?

-Advanced directives? Any directions about when/if to treat/transport the patient in the transfer packet? (I ask because we have a kind of "super" DNR form called a MOLST around here, which allows the patient/HCP to specify that the patient is not to be transported unless permission is specifically given by the patient and/or family and MD if the patient isn't competent, by checking all the "comfort care" options. Not quite hospice care, but it allows people the option when terminally ill to stay where they are rather than being forced to the hospital).

-Medical history, especially any h/o diabetes or previous CVA. If previous CVA, what are the residual deficits, if any?

Patient assessment:

-Is the patient alert and oriented? If not, are they at their baseline if they have dementia?

-Full Stroke Scale, including facial droop, speech, and grips/pronator drift test.

-Vitals, including BG?

That should get us started.

[DwayneEMTP]

...

-What is the patient's baseline?

AAOx4 no noticeable mental deficits, only slight arthritic deficits.

...-What was the last time the patient was seen at her baseline?

"about a half hour ago." Per CNA

...-Advanced directives? Any directions about when/if to treat/transport the patient in the transfer packet? (I ask because we have a kind of "super" DNR form called a MOLST around here, which allows the patient/HCP to specify that the patient is not to be transported unless permission is specifically given by the patient and/or family and MD if the patient isn't competent, by checking all the "comfort care" options. Not quite hospice care, but it allows people the option when terminally ill to stay where they are rather than being forced to the hospital).

No heroic measures. Comfort care only.

...-Medical history, especially any h/o diabetes or previous CVA. If previous CVA, what are the residual deficits, if any?

No significant history. (Honest to God)

...Patient assessment:

-Is the patient alert and oriented?

Yes

...-Full Stroke Scale, including facial droop, speech, and grips/pronator drift test.

Negative facial droop, negative hand drift, grips equal, PERRL, speech clear/appropriate/diction unremarkable, extremity movement purposeful/coordinated bilat, gait slow but even and confident.

...-Vitals, including BG?

B/p 138/86, 78/reg, RR 14/clear all fields, BGL 88, physical exam shows some minor bruising of arms and legs not unexpected for a patient of this age having minor bump and bruises.

RN insists, per CNA, that patient be transported for evaluation.

Dwayne

[Bieber]

Could be a TIA.

-Does the patient have any complaints?

-What does the patient say about what happened? Who witnessed the episode? CNA or RN? Anyone else? What do they say happened? If it's the RN, I'd like to speak to her, please. =)

And, most important of all:

-What does the PATIENT want to do?

[DwayneEMTP]

Could be a TIA.

-Does the patient have any complaints?

-What does the patient say about what happened? Who witnessed the episode? CNA or RN? Anyone else? What do they say happened? If it's the RN, I'd like to speak to her, please. =)

And, most important of all:

-What does the PATIENT want to do?

Pt states that she was awakened by the "need to pee' and that the CNA seemed irritated at her being up and began questioning her as to why she didn't pee before bed or wait until morning.

She has no complaints other than being treated "rudely" in her opinion by staff and being kept awake when she would like to go back to sleep.

Only the CNA was present for the 'episode', it seemed to have resolved before the RN arrived. The on call Dr didn't answer his phone.

CNA states that pt had slurred speech, is pretty sure that the right side of her mouth seemed 'weird', and that she answered questions slowly. CNA helped her to pee and then returned her to bed, calling the RN after. By the time the RN arrived the symptoms had seemed to be resolved. She ordered her taken to the ER for eval.

RN is called, refused to return to the EMS/pt, per CNA. CNA reports that RN states that EMS is required to do what they're told. CNA asks that you please take the patient to the ER so that there won't be trouble.

Pt only wishes to go to bed and tells you to "Please just let me go back to sleep..."

Dwayne

[chbare]

Track the RN down and insist that a complete, bedside report occurs. Partner can stay at bedside while I personally find the nurse. Transfer of care and continuity of care cannot occur via the agency of a CNA, a non-licensed provider that is ultimately not responsible for the the patient's care. Also, involve the patient during this bedside report. If need be, involve medical control; however, at this point I cannot force a person who is alert and oriented and presumably (we need to verify that the patient is in fact making her own decisions) able to refuse care to go to the hospital.

Take care,

chbare.

[DwayneEMTP]

Track the RN down and insist that a complete, bedside report occurs. Partner can stay at bedside while I personally find the nurse. Transfer of care and continuity of care cannot occur via the agency of a CNA, a non-licensed provider that is ultimately not responsible for the the patient's care. Also, involve the patient during this bedside report. If need be, involve medical control; however, at this point I cannot force a person who is alert and oriented and presumably (we need to verify that the patient is in fact making her own decisions) able to refuse care to go to the hospital.

Take care,

chbare.

I send the CNA for the RN, informing her that the patient is not going anywhere until I speak with her. I also inform her that I need to see the nursing home's POA. Pt informs me that her daughter is her medical POA. While I wait for the RN I call the daughter who claims that her mother has always been 'sharp as a tack' and asks that we make no decisions until she arrives, approx 15 minute ETA, and can be walked through our assessment.

RN arrives and angrily claims that she has the ultimate authority on the patients transport and insists that she be transported immediately! She refuses to participate in further assessment. ER doc is contacted but is unable to consult secondary to other responsibilities. ER RN states that he has confidence in medics judgement.

Pt continues to claim that she is 'fine... Just tired' and additional assessment fails to confirm previously CNA statement of stroke like symptoms.

Dwayne

[chbare]

Tell the RN that is okay and I would like to speak to the charge nurse about the situation. Possibly involve the DON if needed. Also remind staff of the patient's bill of rights and the fact that the patient's POA will be in shortly to review the assessment findings with all providers involved. If needed, we may consider involving the independent patient ombudsman at some point.

Take care,

chbare.

[Bieber]

Tell that CNA that I'm pretty stupid and I don't know what "weird" means. She's gonna have to be a lot more specific. Was it a droop she saw? If so, how pronounced? Did she assess it further? Does the patient recall having any symptoms at the time of the episode?

At this point, the patient is alert and oriented and--at least around here--can make their own decisions. DPOA doesn't take effect until the patient is no longer competent to make those decisions on their own. I want to make sure that the patient understands the risks involved in not going with us (could have been a TIA, could have been any number of things I can't assess for or diagnose in the field), but ultimately, if she doesn't want to go I can't make her.

Let's hang around while the DPOA shows up and see if anything changes, maybe check another set of vitals and do another stroke screen.

Edited July 9, 2011 by Bieber

[DartmouthDave]

Could be a TIA.

-Does the patient have any complaints?

-What does the patient say about what happened? Who witnessed the episode? CNA or RN? Anyone else? What do they say happened? If it's the RN, I'd like to speak to her, please. =)

And, most important of all:

-What does the PATIENT want to do? <----I like this.

Edited July 9, 2011 by DartmouthDave