Bad Headache

[benanzo]

"It is a reality check for all those people out there who think that training is more important than education, and that only skills separate basics from medics."

But there were no ALS treatments that would have been necessary for that guy. I immediately suspected intracranial bleed...not surprising. fast trans to surg was what that guy needed, not a medic. That is why cva with normal LOC and VS is BLS run.

[Dustdevil]

But there were no ALS treatments that would have been necessary for that guy.

Hmmm... you're still not grasping this very simple concept. Let me try one more time.

IT IS NOT ABOUT TREATMENT. IT IS ABOUT ASSESSMENT!!! ](*,)

It's about a normally trained basic probably not knowing the difference between a common headache and a subdural hemorrhage, and subsequently choosing an inappropriate destination and intervention. But since you are so myopically focused on skills, consider the basics inability to deal with a rapid deterioration in the status of this patient, were it to occur. Did it happen this time? Nope. But if it had (a very real possibility), a basic would have been caught by complete surprise and unable to effectively manage it.

I don't know where so many basics get the dangerously mistaken idea that it is perfectly okay to not know what is really wrong with your patient, so long as he doesn't end up needing ALS skills, but it is quite possibly the single most damaging idea in our profession. And it is the reason you find so many medics who bash basics.

SPELL CHECKED: No errors found. 8)

[Dsmittty911]

First of all I am a Basic. Even with the presentation as I read it I would have advised on rapid transport and I'll say why then you medics can agree or pick apart my statements. ( i'm far from a know it all but I want to give my read on it anyway). You said baseline vitals were wnl, pupils perrl, did you check for ability to track there's wonderful term call HGN or the eyes ability to track on a horizontal plane. It's indicative of ETOH or to a certain degree anything impairing motor function. You also stated an 80% loss of function. Even with positive results of cva exam it's obvious something is either full blown happening or coming quickly. I can sum up my reasoning in 2 simple words. Gut instinct. The signs and symptoms may not exactly fit the case but it's obvious something is bad wrong here. NO AMOUNT OF EDUCATION CAN GIVE YOU GUT REACTIONS. That only comes from experience. Gut instinct is the thing that tells you that normal level of consciousness and VS mean nothings wrong but that gut check tells you it's an ALS transport....... ALWAYS ALWAYS ALWAYS err on the side of the pt.

[benanzo]

medics don't have the monopoly on doing a good pe and knowing how to interpret the results.

I am merely saying that there aren't effective prehospital ALS rx that will serve to reduce the long term effects of a CVA. A fast bls tx is what is needed. I will grant that cva can quickly become very complicated by the onset of cardiac dysfunction, seizures etc, which would require als intervention, but in an urban environment with mult hosps in close proximity, a fast BLS tx does the job. I am not saying that ALS should be ignored even if the pt presents with those complications early on, far from it. Those are clear ALS indications which require medic rx. But if normal loc/vs are presented, a bls crew should begin fast tx.

[medic001918]

medics don't have the monopoly on doing a good pe and knowing how to interpret the results.

I am merely saying that there aren't effective prehospital ALS rx that will serve to reduce the long term effects of a CVA. A fast bls tx is what is needed. I will grant that cva can quickly become very complicated by the onset of cardiac dysfunction, seizures etc, which would require als intervention, but in an urban environment with mult hosps in close proximity, a fast BLS tx does the job. I am not saying that ALS should be ignored even if the pt presents with those complications early on, far from it. Those are clear ALS indications which require medic rx. But if normal loc/vs are presented, a bls crew should begin fast tx.

Paramedics don't have the monopoly on doing a thorough physical assessment. You're correct on that statement. However, from an education standpoint based on certification alone a paramedic is going to have a more in depth assessment. Medics have spent the time in school studying A&P, as well as being trained more specifically on disease processes. There are EMT's out there that can do an assessment as well (if not better) than some medics. Those however tend to be the exception rather than the rule and those are people who have made a goal out of seeking out more education. As the programs stand when compared side by side (EMT vs. Paramedic), a paramedic is going to be able to pull more out of an assessment.

Now, on to the transport decision. You're correct that this patient does require a rapid transport to the hospital. And that could very well be your closest ALS provider. But would I want to risk simply transporting this patient BLS without asking if a medic was available? Not at all. If something were to happen and you hadn't requested a medic I could see a lawyer having fun in court with this case. If you don't request a medic and the patient does seize or end up with a respiratory compromise (both very real possibilities), you might get picked apart for not knowing where the closest medic is. It would be in your best legal interest, and the patients best health interests to call for a paramedic and at least attempt an intercept. If you miss the intercept and are at the hospital by the time you could make the connection then you've done yourself and the patient a great service. You have gotten them a higher level of care as quickly as possible. At least that way you are covered by having recognized the problem and attempting to request the proper resources. If those resources are unavailable it is not your fault and you transported expeditiously. Transporting BLS on a call you admit to be an ALS call without making the request just strikes me as not being in anyone's best interests.

Part of being a paramedic is being ready for what "could happen." In a case like this, we might not have to make any major interventions. But the fact remains that if the patient should deteriorate (which can happen quickly), as an EMT you are limited as to what you can do to control the situation. As a paramedic, we can control the airway more effectively or control a seizure. And as a side note, I would rather put an IV in this patient when they're not having a major compromise so that should they need the intervention I'm not fighting for a point of IV access...it's already there. It's the same reason why seizure patients get IV's while they're postictal. It's safer for them to have the access and easier for me to do then as opposed to when they're seizing. Thinking ahead and anticipation is part of critical thinking.

Shane

NREMT-P

[benanzo]

I actually feel like I'm arguing with myself on this issue.

This scenario is perfect for the examples that I've given in other posts as to what is fundamentally wrong with my EMS system (Seattle.) We were called to transport a 50ish lady to the hospital for sudden onset CVA symptoms (droop, unilateral deficit, a&ox3, stable vitals.) This is a BLS call here. I have taken many of these patients to all ERs in the area with no second thoughts even though I have always known the POTENTIAL for serious complications which could arise at the drop of a hat. There was a medic pulling some OT on the engine that day (so she was operating as BLS) and said: "yeah, she's good to go BLS." But even if she hadn't been a medic none of us would have thought differently because it's protocol. Anyway...the lady had a seizure half way to the ER (which was only 10 mins away total.) She never lost her airway/pulse, stable vits the whole time....we wheeled her in and transferred care....end of story. I understand that if a medic would have taken the call from the beginning, she would have had a line/monitor/advanced airway capabilities right away. But the argument I keep hearing is that those things are always imperative on all calls...which simply isn't true. I agree that King County protocol needs to reevealuate whether BLS should keep transporting people with clear CVA signs...but that doesn't change the fact that a stable CVA fares just as well for the 10 min trip in a BLS rig to the ER as they would in an ALS rig and if complications arise we simply treat what we see and wait a few minutes for the medics. Complications which require immediate ALS intervention are rare when the pt presents as stable cva. However, it must be known that deep down I believe medics should do all transports for all patients so as to minimize those risks.

[Dustdevil]

Part of being a paramedic is being ready for what "could happen." In a case like this, we might not have to make any major interventions. But the fact remains that if the patient should deteriorate (which can happen quickly), as an EMT you are limited as to what you can do to control the situation.

Exactly, Shane. We wear body armour because we can be shot, not because we have been shot. The same thing applies in patient care. We provide advanced practitioners to our patients because they might need them this time, not because they needed them last time.

SPELL CHECKED: One error corrected. :?

[medic001918]

I actually feel like I'm arguing with myself on this issue.

This scenario is perfect for the examples that I've given in other posts as to what is fundamentally wrong with my EMS system (Seattle.) We were called to transport a 50ish lady to the hospital for sudden onset CVA symptoms (droop, unilateral deficit, a&ox3, stable vitals.) This is a BLS call here. I have taken many of these patients to all ERs in the area with no second thoughts even though I have always known the POTENTIAL for serious complications which could arise at the drop of a hat. There was a medic pulling some OT on the engine that day (so she was operating as BLS) and said: "yeah, she's good to go BLS." But even if she hadn't been a medic none of us would have thought differently because it's protocol. Anyway...the lady had a seizure half way to the ER (which was only 10 mins away total.) She never lost her airway/pulse, stable vits the whole time....we wheeled her in and transferred care....end of story. I understand that if a medic would have taken the call from the beginning, she would have had a line/monitor/advanced airway capabilities right away. But the argument I keep hearing is that those things are always imperative on all calls...which simply isn't true. I agree that King County protocol needs to reevealuate whether BLS should keep transporting people with clear CVA signs...but that doesn't change the fact that a stable CVA fares just as well for the 10 min trip in a BLS rig to the ER as they would in an ALS rig and if complications arise we simply treat what we see and wait a few minutes for the medics. Complications which require immediate ALS intervention are rare when the pt presents as stable cva. However, it must be known that deep down I believe medics should do all transports for all patients so as to minimize those risks.

You are 100% correct that your protocol needs to be reevaluated. As a paramedic here if I were ever to downgrade a call like that I would be pulled into my medical directors office to have a chat about why I felt that was a BLS call and possibly undergoing further review or possibly having my medical control suspended. Interesting how protocols vary from area to area, but I would find those to be unacceptable and there's no way that I would allow myself to downgrade a call with a presentation like that.

On to another part of your post. You say that she "never lost her airway." I don't know what you have been taught, but I have always been taught to assume a patient having a seizure to be hypoxic and to be without an airway. Maybe it's another case of preparing for the worst but I don't think so. Consider the pathophysiology of a grand mal seizure. You have the underlying increase in intracranial pressure and/or ischemia due to the event itself. This can cause lethal dysrythmia as well as respiratory changes. Now throw a seizure on top of this and you lose the ability to control your muscles. Being that we use muscles to assist with our respiration's by causing changes in intrathoracic pressures a seizing patient may not be able to ventilate (remember that ventilation and respiration are two different things) effectively. Now we get into where ALS comes into practice. While this patient may not need an advanced airway such as an ET tube, the patient needs to have their seizure controlled rapidly in order restore their respiratory status back to where it needs to be. So going on the premise that a seizing patient is hypoxic, how can your service (not you) justify letting that call go in BLS? Your patient seizes 5 minutes into a ten minute transport and is now status epilepticus secondary to the increasing intracranial pressure; according to my math that leaves approximately five minutes of having a questionable (at best) airway until you arrive at the ED? Now, that assumes that the patient has a continuous seizure. The patient may have a series of seizures which would still leave the same question? A paramedic can't do anything for the CVA itself. A paramedic can however maintain better control of some of the side effects that can and do occur with a patient experiencing an active CVA.

Benanzo, I am not trying to give you a hard time. I'm just curious now as to how your service allows that kind of treatment to occur? It just strikes me as being care that is less than the standard. If you don't have ALS available, that's one thing. I have a hard time understanding how you can downgrade that call. And more so how a BLS provider is okay with that if they understand any part of the possibilities that can occur on this call?

Shane

NREMT-P

[benanzo]

I should have clarified that she did not continue seizing throughout the remainder of the transport. The seizure lasted about 30 seconds followed by extensive postictal state during which she was protecting her airway and vitals remained stable. But the point of my story was just to point out that it is common practice for this pt to be initially evaluated as BLS and during transport the situation changes and the initial presentation compounds by these kinds of complications. I have only ever complained to the queen bee about this once because my opinions and thoughts were severely discounted because I work for the private BLS ambulance which apparently doesn't have much insight to offer. Unfortunately it's going to take some codes that were cleared by medics in order to get anyone's attention.

[ropfirechick]

Hello! I am new hear and the topic of this thread caught my eye, I am a new EMT and very inexperienced. I have never been on a call where someone called 911 because of a headache what do you mean by "just another headache call". I frequently get severe migraine headaches, I have never called 911 because of a headache (I have someone to drive me to the ER if that becomes necessary...and would only use 911 as a last resort). A migraine can be more than just a headache ie..sensitivity to light and sound, extreme pain, vomiting, and changes in mental status. I'm sure there are people out there who call 911 when it isn't necessary, however if I ever am without other transportation and NEED to go to the ER I will call 911 and apologize for the inconvenience. As it has been pointed out several times it comes down to s/s, Hx, OPQRST, etc..