Was I wrong?

[Imagine89]

We are dispatched to a residence for an 80 year old male presenting with AMS. Arrive to find pt seated on bed, slightly disoriented. We get a brief history from his wife, stating that he had failed to turn off his alarm clock at the proper time, and he awoke in an awkward position, seeming confused. Last seen at baseline the previous night, seemed to sleep normally. History of CVD, nothing else, according to wife. We consider stroke, so we do some stroke tests, which find strong and equal hand grasp, equal smile, negative facial droop, negative slurred speech, and negative arm drift. Assessment of vitals finds bp of 130/84...pulse 68, skin warm dry and unremarkable, 12 resp/min, rales in lower left lung, SP02 93 on RA...NC on 4LPM based on o2 sats. Pupils PERL. These s/s were constant throughout transport. We didn't call ALS or transport to a stroke center due to the fact that he was requesting transport to his PCP's hospital., as he just seemed confused. He was unable to remember the year or who the president was, hwoever did answer personal questions well. Negative headache, neg chest pain, no SOB no discomfort/pain.

Would you have called ALS? Would you have transported to a stroke center?

I ask because I was told after the call by a senior EMT (i'm 17) that we made the wrong call, and I was wondering what you all thought?

[Imagine89]

We are dispatched to a residence for an 80 year old male presenting with AMS. Arrive to find pt seated on bed, slightly disoriented. We get a brief history from his wife, stating that he had failed to turn off his alarm clock at the proper time, and he awoke in an awkward position, seeming confused. Last seen at baseline last night...seemed to sleep normally. History of CVD, nothing else, according to wife. We consider stroke, so we do some stroke tests, which find strong and equal hand grasp, equal smile, negative facial droop, negative slurred speech, and negative arm drift. Assessment of vitals finds bp of 130/84...pulse 68, skin warm dry and unremarkable, 12 resp/min, rales in lower left lung, SP02 93 on RA...NC on 4LPM based on o2 sats. Pupils PERL. These s/s were constant throughout transport. We didn't call ALS or transport to a stroke center due to the fact that he was requesting transport to his PCP's hospital., as he just seemed confused. He was unable to remember the year or who the president was, hwoever did answer personal questions well. Negative headache, neg chest pain, no SOB no discomfort/pain.

Would you have called ALS? Would you have transported to a stroke center?

I ask because I was told after the call by a senior EMT (i'm 17) that we made the wrong call, and I was wondering what you all thought?

[JakeEMTP]

I think I would have to disagree with the " Senior EMT ". From the excellent information you provided, the pt. doesn't seem to be in any life threatening distress. In fact, other than being a little disoriented, he doesn't sound to bad at all. I don't think I would have called for ALS intercept either. IMHO, you made the right decision.

I can't really blame the Gentleman for forgetting who the president is. :wink:

[BEorP]

We are dispatched to a residence for an 80 year old male presenting with AMS. Arrive to find pt seated on bed, slightly disoriented. We get a brief history from his wife, stating that he had failed to turn off his alarm clock at the proper time, and he awoke in an awkward position, seeming confused. Last seen at baseline the previous night, seemed to sleep normally. History of CVD, nothing else, according to wife. We consider stroke, so we do some stroke tests, which find strong and equal hand grasp, equal smile, negative facial droop, negative slurred speech, and negative arm drift. Assessment of vitals finds bp of 130/84...pulse 68, skin warm dry and unremarkable, 12 resp/min, rales in lower left lung, SP02 93 on RA...NC on 4LPM based on o2 sats. Pupils PERL. These s/s were constant throughout transport. We didn't call ALS or transport to a stroke center due to the fact that he was requesting transport to his PCP's hospital., as he just seemed confused. He was unable to remember the year or who the president was, hwoever did answer personal questions well. Negative headache, neg chest pain, no SOB no discomfort/pain.

Would you have called ALS? Would you have transported to a stroke center?

I ask because I was told after the call by a senior EMT (i'm 17) that we made the wrong call, and I was wondering what you all thought?

If all your assessments were done correctly I don't see the need for a stroke centre. What signs and symptoms of stroke did the senoir EMT think warranted a stroke centre? Also if the pt was last seen normal the previous night is there even any potential for thrombolytics to be used?

[Imagine89]

I think I would have to disagree with the " Senior EMT ". From the excellent information you provided, the pt. doesn't seem to be in any life threatening distress. In fact, other than being a little disoriented, he doesn't sound to bad at all. I don't think I would have called for ALS intercept either. IMHO, you made the right decision.

I can't really blame the Gentleman for forgetting who the president is. :wink:

Yeah I've not gotten a straight response on the president question yet.

I think as BLS we overuse ALS, and I dont think that theres any reason pts like this should take an ALS unit out of service...as emts we have the skills to continually assess and monitor patients, and if this guy went south, the resources are still there.

[Imagine89]

If all your assessments were done correctly I don't see the need for a stroke centre. What signs and symptoms of stroke did the senoir EMT think warranted a stroke centre? Also if the pt was last seen normal the previous night is there even any potential for thrombolytics to be used?

He was saying that since we can't diagnose, that confusion was reason enough...

He was last seen at baseline the previous night due to the fact that they were both asleep until the time of call. THe stroke could have had an onset (if it was a stroke) while he was asleep, which would indicate use of thrombolytics.

FYI, i completely disagreed with the EMT in question, I was just making sure.

We asked the patient if he'd ever had a stroke, and after a few minutes he said yes 5 years ago, however we asked the wife and she said no.

[BEorP]

He was saying that since we can't diagnose, that confusion was reason enough...

He was last seen at baseline the previous night due to the fact that they were both asleep until the time of call. THe stroke could have had an onset (if it was a stroke) while he was asleep, which would indicate use of thrombolytics.

FYI, i completely disagreed with the EMT in question, I was just making sure.

We asked the patient if he'd ever had a stroke, and after a few minutes he said yes 5 years ago, however we asked the wife and she said no.

Do you not have a directive in place for who goes to a stroke centre that maybe you could show this other EMT? If it's anything like ours then the other EMT should take a read of it before giving you a talking to.

The provincial directive in Ontario requires that to go to the stroke centre the pt have new onset of (at least one of) unilateral arm or leg weakness or drift, slurred or inappropriate words or mute, or facial droop AND can be transported to the stroke centre within two hours of "a clearly determined time of symptom onset or the time the pt was 'last seen in a usual state of health.'"

Based on our directive, even if the person was having a stroke (which it doesn't look like they were, but let's humour the other EMT) they would not be transported to the stroke centre since the onset may have been too long ago.

[Imagine89]

Do you not have a directive in place for who goes to a stroke centre that maybe you could show this other EMT? If it's anything like ours then the other EMT should take a read of it before giving you a talking to.

The provincial directive in Ontario requires that to go to the stroke centre the pt have new onset of (at least one of) unilateral arm or leg weakness or drift, slurred or inappropriate words or mute, or facial droop AND can be transported to the stroke centre within two hours of "a clearly determined time of symptom onset or the time the pt was 'last seen in a usual state of health.'"

Based on our directive, even if the person was having a stroke (which it doesn't look like they were, but let's humour the other EMT) they would not be transported to the stroke centre since the onset may have been too long ago.

We can not determine whether or not the onset was too long ago in this situation, adn if he was presenting with stroke symptoms it would be negligent according to our protocols to transport to a facility without CT scans and other stroke equipment. I did explain myself to him, but hes very stubborn. WE'll see. Monthly meeting tomorrow night.

[Michael]

that confusion was reason enough...

Was the call to 1600 Pennsylvania Avenue?

[BEorP]

We can not determine whether or not the onset was too long ago in this situation, adn if he was presenting with stroke symptoms it would be negligent according to our protocols to transport to a facility without CT scans and other stroke equipment. I did explain myself to him, but hes very stubborn. WE'll see. Monthly meeting tomorrow night.

Ah so your protcol is very different than ours... in that case you'll need to just politely need to explain to this EMT that they are a tool and then also that not every pt who is confused with a hx of CVD is having a stroke.