Acceptable Risk

Following up on our previous post where we discussed patient refusals, it behooves us to say a few things about risk.

The culture of “everyone goes to the ED” is not writ in stone, and in some places, efforts are underway to expand it into a more sophisticated system. For instance, some patients might be transported directly to detox programs, homeless shelters, urgent care facilities, or psych treatment. Some, of course, don’t need to be transported at all, and can stay home, perhaps with instructions to follow up with their PCP. A few areas are experimenting with, or at least moving towards, the concept of an “Advanced Practice Paramedic” or “Advanced Paramedic Practitioner” who could sensibly and intelligently perform this assessment and triage, determining whether patients need immediate definitive care, or (in essence) “clearing” them of acute high-risk pathologies. Ideas like this may prove central to solving the many problems of healthcare in general and EMS in particular, such as ED overcrowding and the inefficient use of available resources.

However, just like the issue of patient refusals, to even discuss the possibility of such a system requires a fundamental shift in our thinking. At the moment, the approach is, “Try to recognize and treat Sick People — but if you don’t, that’s okay, because they’ll recognize them at the hospital.” Obviously, this practice is based firmly on the presumption that most or all of our patients do end up being evaluated in a full-fledged emergency department. Even the very notion that a patient can refuse to be transported ends up as a grudging allowance — we reluctantly acknowledge that we can’t actually kidnap people, but we still make them jump through hoops to make it entirely clear that we wanted them to go all along.

What if we started to accept that some of these patients don’t need an emergency room? Realistically, and retrospectively, it’s obvious that many of them don’t. Other destinations are more appropriate, and in some cases, no transport at all is necessary. But in order to make decisions like that, we need to be able to accept the assessment, clinical decision-making, and risk stratification of our field providers.

It goes without saying that instituting such a practice would require additional training, and providers (such as this mythical APP) practicing at a higher level than our current EMTs and medics. But it’s bigger than that. We have to be willing to let go of the safety net of everyone filtering through the ED. We have to be willing to accept the field workup as final — or at least, good enough that no further evaluation is immediately needed.

Closely wedded with the prehospital culture that treats patient refusals as bogeymen is the in-hospital culture that says every patient needs a comprehensive workup to rule out every possible killer. It doesn’t matter if the odds are 1,000,000 to 1 that the problem is benign rather than a massive MI or hidden PE; that 1/1,000,000 chance of missing the Badness is still unacceptable, so the patient gets the works.

We have the mindset that any miss is one miss too many.

This costs a lot of money. It puts patients through a lot of hell. But most of all, if we’re going to imagine a world where not every patient ends up even going to the emergency department, we have to accept a world where the ones who don’t will not receive that exhaustive workup.

Certainly, this triage process be handled sensibly, and conservatively, because we’re here to help people, not let them die at reasonable rates. So where do we draw the line? Is one miss in a thousand acceptable? One in a million? One in a billion?

We can draw the line wherever we want, but no matter where, there’s going to be a qualitative difference between a reasonable risk and “we did everything.” Because eventually, we’re going to miss one. A well-trained and conscientious clinician is going to assess a patient in their home, and appropriately conclude that their complaint is not dangerous, and that patient is going to die.

Because it happens — because flukes are inevitable. If we throw the kitchen sink at them, and we still lose, then at least we can hold ourselves blameless. But if we take a more reasonable approach, then we have to accept in advance that occasionally, the chips will fall against us. And that has to be okay.

The prevailing belief today is that anytime something goes wrong, something was done wrong. Adverse outcomes are an indicator of error, either an individual error or a flaw in policy or protocol. If I follow our procedures to the letter, and a patient slips through the cracks, it means we need to change the procedure.

Can we get to the point where we understand that if a situation is correctly evaluated, and the risks are correctly balanced, and we simply happen to get unlucky, that the decision was still right? Where we can stop spending ever-increasing amounts of time and money in the pursuit of ever-more-infinitesimal risk?

I don’t know. But if we can’t, then we’re never going to be able to solve some of these problems. Because perfection doesn’t exist, and chasing it is a good way to get very tired.

Treat the Patient?

We’re taking a short break from our series on transfers to discuss a recent post on the EMT-Medical Student blog. One of the issues he brought up is the old saw, “Treat the patient, not the machine.” Rogue Medic struck on this as well.

What do people mean when they say this? They mean that if you attach a diagnostic tool like a pulse oximeter, and it gives you a result that is at odds with the rest of your assessment, then it is probably wrong, and you should not base your decisions on it. It can be broadened to the BLS level, including findings like vital signs, by saying: “Treat the patient, not the number.”

And it’s essentially true. In fact, something I frequently harp on is that diagnosis must always be based on a broad constellation of consistent findings, not on any one red flag. We like red flags, we want red flags, because they’re easy, but it never works that way. The body is an interdependent system, and if a pathology is present, then it almost always has multiple effects detectable in multiple places.

This idea can be looked at differently by asking another question: is it possible to be severely, acutely sick without showing it? I don’t mean long-term problems like cancer; you can’t look at someone and detect that. But if someone’s dying in front of you, of a proximate cause like hypoxia, is it always obvious based on their presentation?

Generally the answer is yes. That’s why it’s wrongheaded to look at a healthy patient with pink skin, normal respiratory rate, calmly denying shortness of breath, but with a low oxygen saturation, and say, “Oh no — he’s hypoxic!” If your oximeter says 72%, what’s more likely — that the number is wrong, or that the patient is somehow hypoxic without any other evidence of it?

Call this the phenomenon of the Hidden Killer. Is it common? Is it real?

It is not common. But it is real. And that’s what’s not recognized when people say, “Treat the patient…”

Why do we take 12-lead ECGs on chest pain patients? Because a clinical assessment alone cannot reliably detect ST elevation, which (simplifying the issue!) is diagnostic for a heart attack.

Why do we take CT scans of blunt head injury patients? Because a clinical assessment alone cannot reliably detect intracranial hemorrhage.

Why do we perform abdominal ultrasounds in multi-system trauma patients? Because a clinical assessment alone cannot reliably detect abdominal bleeding.

Now, some critics will say that all of these will indeed present with obvious, frank clinical findings. The major STEMI patient will eventually enter cardiogenic shock. The head bleed will become comatose and present with Cushing’s Triad and herniation. The abdominal hemorrhage will have guarding, distension, and eventually outright shock.

All true enough. But we’d like to find them earlier than that. It’s true that severe and late pathologies are usually obvious, but our job is to find them when they can still be treated, not after their effects are permanent or lethal. Heck, we could also just provide no medical care and wait until everyone died to make a diagnosis, which would extremely easy to assess, but a little pointless. It is rare that big problems do not have a big assessment footprint, but “small” problems can still be a big deal.

Consider the much-maligned pulse ox. Surely it does not replace a full assessment. But when used appropriately and its role understood, it provides valuable information. A drop from 99% to 94% saturation may not be clinically obvious, but it is potentially significant and surely worth knowing about. What about the patient who is non-verbal at his baseline? Is he going to complain if he drops from 95% to 87%? Will it be frankly obvious from his skin and breathing? Maybe, maybe not. (How about if he’s on a mechanical ventilator at a fixed rate?) If not obvious, does that mean it’s no big deal?

Is the pulse ox always correct? No. But like all things except magic, it’s wrong in predictable ways, ways that can be accounted for, and when it is wrong, that can tell you something too. It requires adequate peripheral circulation, and poor perfusion will make it read low. How is the patient’s distal perfusion? Pink and warm? Good capillary refill? Then you’re probably okay. Carbon monoxide poisoning will make the sat read high. Has the patient been in enclosed spaces with heaters or open flames? Working around engines? Is there any potential source of CO in their history? If not, you’re probably okay. Alternately, does their sat read unusually high compared to their clinical presentation? You might then consider carbon monoxide — something you might not have otherwise have known without the oximeter. It didn’t give you a correct number, but by knowing how and when it fails, it gave us a useful answer.

Here’s a recent example. I picked up a patient with a blood pressure of 54/4. That is a ridiculous blood pressure; arguably, nobody should have it, on the theory that a pressure that low should be pretty close to unobtainable. But, there it was. We diverted to the nearest hospital and I was subsequently chewed out by the receiving nurse.

Do I think that patient truly had a central arterial pressure of 54/4? Nah. Although she wasn’t doing well, her skin was better than that, and although she was altered and combative, she wasn’t comatose. However, her pressure was undoubtedly low, and just how low? If I don’t go with this number, then I’ve got no guidance. The clinical picture was clouded. I couldn’t ask if she knew what day it was; I couldn’t ask what her complaints were; she was non-verbal. She was tachycardic and hypoxic and diaphoretic; she was certainly sick. So, treat the patient, or treat the number? The number may not have been right, but it was concerning enough that it couldn’t be ignored without an assessment that otherwise screamed “no problems here!”, which was not what we had.

Treat the patient? We always treat the patient. A hands-on physical and history is a vital, vital tool for assessment, but other tools are also useful. Some people lament the downfall of the traditional clinical assessment, from the days when doctors with fingers like pianists made diagnoses from findings like Ewart’s sign, and it is shame, but the reason that the high-tech tools like imaging and labs have become de rigueur is that they work well — they diagnose many problems with a speed, sensitivity, and reliability that is not otherwise possible. Nobody would ever say, “Treat the patient, not the unstable cervical spine fracture,” because we recognize that’s the sort of thing you may not otherwise notice until it’s too late. That’s why we spend big bucks on CT scanners.

It all matters. It’s all useful. We should neither cast aside our individual numbers nor ignore the bigger picture. Data is something that, like money and sex, you can never have too much of.

The Art of the Transfer (part 2)

Continued from part 1…

One of the best types of transfer for educating yourself is a discharge from a hospital, or in some cases from a nursing home or rehab.

It doesn’t matter where they’re going; what matters is where they’re coming from. Because your patient’s leaving a prolonged stay in skilled medical care, they should come with a whole bevy of paperwork and documentation chronicling their course of care. And you get to read it!

He presented to the ED with X symptoms. Was worked up with Y tests, and awarded Z diagnosis. Was admitted for A, B, and C treatments, and is now being discharged in Q condition.

Now if you ever get a patient with X symptoms, you have a great idea of what’s going to happen to them at the ED; you’ll know the leading diagnostic possibilities in their differential; and you can guess the types of treatment they’re going to receive. Did you learn this stuff in EMT class? I sure didn’t; for many of us, once the patient hits the door of the hospital, they’re no longer of interest. But that’s not how it works — you’re part of a sequence of care, not a one-act play, and if you don’t understand what happens later, you can’t make effective decisions now. Even something as simple as explaining to the patient what’s going to happen once they arrive at the ED is impossible if you don’t have a clue yourself. “We walk in the door… and then magic happens!”

Moreover, once you enter that patient’s room, you get to assess and communicate with that very same patient you just read about in the chart. You can say, “Ah, so this is what that disease process looks like”; you get to feel the pulse fixed at 60 by a pacemaker, listen to the lungs filled with fluid in the CHFer, and examine the scar made by a recent craniectomy. This is like getting the answer to a quiz, then learning the question. In the future, if you hear those crackling breath sounds, you’ll know what they mean, because you’ve heard the same thing in patients whose diagnosis you already knew. Remember, in the field we often never learn the answers; we make best-guesses and presumptive diagnoses, but unless we’re able to follow up later on their eventual diagnosis, we may never know if we were right. The discharge is your chance to get in at the other end of the process and put it all together.

You also get to organize your mental categories of disease. Coming out of class, you’ve learned a litany of human ailment that runs from A to Z; and whatever order you learned it in is probably the order you remember it in, except for some important, life-threatening illnesses that received special attention. But in real life, facing a real patient, the diagnosis probably isn’t the first one in the textbook, and it’s probably not the most deadly zebra; it’s probably the most common disease, because that’s what common means. Transporting a hundred patients helps you understand what’s common. You do need to remember that shortness of breath can be caused by a pulmonary embolism, but you’re coming from the wrong direction if it’s the first thing on your mind when you meet a gasping patient, because it’s just not as likely as other possibilities. Discharging a few dozen people with COPD will help rearrange this for you.

How about meds? People come out of the hospital on lots of them. Diligently reading those charts will help you learn which ones are used for which diseases, and if you make an effort, you can start to memorize their names and connect generic with trade names. And you’ll read Coumadin and then meet the elderly lady with bruises all over, complaining about how she gets cold so easily. Connecting the dots, connecting the dots.

If you’re enterprising, you can practice analyzing EKGs, interpreting labs, and reading imaging reports. It’s all in there, and it’s all part of the patient’s medical care. And no matter how distant something might be from your own scope of practice, as long is it involves the same human beings you’re treating and transporting for the same problems, then more knowledge will make you a better EMT.

The Art of the Transfer (part 1)

One of the problems with EMS today is that it involves a bait-and-switch.

From the outside, it’s not widely understood what the work involves. There’s a vague idea about flashing lights and saving lives, but that’s about all the public knows. So, enterprising young men and women take the class, get the training, find a job, and quickly discover that EMS from day to day isn’t quite what they had in mind.

Nowhere is this more apparent than for the EMT-B. For him, in many areas, most or all of the available work involves not emergency 911 response, but non-emergent patient transfers. Patients travel from home to hemodialysis centers, from nursing homes to doctor’s offices, or from hospitals to rehab facilities. Sometimes these are patients who need oxygen therapy or airway management; sometimes they are medically unstable and need close monitoring (although these patients often travel by ALS); but most often, they’re simply people who can’t easily stand or walk. If due to age or disability you’re unable to climb into a car or shuttle, and can’t safely transfer yourself to and from a wheelchair or sit in it, then you need to travel from place to place in a bed — and ambulances are the only traveling “bedmobiles” out there. Well, ambulances and hearses.

Routine transfers can get old. Real old. Maybe you’re looking for excitement. Maybe you’re looking to make a difference. Maybe you just want to use your skills or activate some neurons. Whatever the case, it’s easy to feel like bringing an endless parade of old people to their eye appointments is neither “emergency” nor “medical” even if it is a service.

Nevertheless, for many of us it’s an unavoidable part of our day. So it’s worth making the most of it.

A Classroom in the Ambulance

Transfers might be boring. But boring’s a good way to start out. There’s no better way to learn how to be an EMT.

My first job in this business was in a system doing 911 coverage almost exclusively. This seemed like a great opportunity, especially in an area (Northern California) where EMTs in the private sector were rarely able to work emergencies.

In retrospect, though, it was the wrong way to start. I walked in the door with absolutely no idea of how to do this job, and was immediately thrown into the field with no learning curve. I was expected to assist the medic, drive the ambulance, check the equipment, manage communications, and of course handle any BLS care. This was fresh out of EMT class, where I had no idea how to do any of that, and most of what I did know is not what was needed. And guess what? Every call was an emergency. Admittedly most “emergencies” are not exactly world-ending, but there were still stakes involved, which meant that being useless was bad for the patient, bad for my medic, and bad for me — because with the pressure on, it was difficult to relax and make the necessary “learning mistakes.”

My next job was in a service where almost 100% of our work was routine transfers. Although this could be mind-numbing, I quickly realized how much of a better learning environment it was. Because in nearly every case, the patient in front of me was not having any acute problem, my assessment could be a total blind-man’s fumble and there wouldn’t be any adverse results. That’s not to say that you’ll never be in a position to take action — but it’s rare.

On a 911 response, you’re the patient’s initial point of entry for the health care system. Before today, there was no problem, at least not from this particular episode. Now there’s something new that needs to be addressed, and you’re deciding how that will happen. The answer might be easy, but it’s still being made.

On a transfer, the patient’s course of care has already been planned and initiated. Their problems are diagnosed, their treatments are underway. Your responsibility isn’t to set anything into motion, but merely to ensure that there’s no deviation from the intended path. This requires learning the patient’s current baseline — which may be very sick — so you can note any new changes, and learning what their current plan is (perhaps a discharge back to their home, which will require a stair-chair carry to get inside), so you can facilitate it as best you can.

Take some vitals. Check pupils, feel skin, listen to breath sounds. Listen to their story. You’re doing these things as a matter of course, because you’re supposed to, in the midst of friendly chit-chat — but you’re also practicing all of your foundational skills. In the off chance of anything unusual, you’ll hopefully find it. But in the mean time, you’re turning yourself into a good EMT, so in the future when you do start running emergencies, you’ll be ready. Do more than you need to, because the time to figure out the tricks of taking a thigh blood pressure is when it doesn’t matter, not when it does.

To quote the biblical if crass House of God,

Look, Roy, these gomers have a terrific talent: they teach us medicine. You and I are going down there and, with my help, Anna O. is going to teach you more useful medical procedures in one hour than you could learn from a fragile young patient in a week. . . . You learn on the gomers, so that when some young person comes into the House of God dying . . . you know what to do, you do good, and you save them. (76)

Tune in next time for more on the fine, fine art of squeezing juicy goodness out of each transfer you get.

Some Things to Say

We’re not idiots. Everyone knows how to communicate. You just flap your jaws and blow.

In this business, though, we often find that it’s not enough to communicate; we have to do it efficiently. Likewise, it’s not enough to ask the right questions eventually. We need to do it promptly, because we’re not going to be here all day.

Heck, never mind efficiency. Sometimes there’s just a right thing to say, and everything else is wrong things. As Mark Twain put it, it’s the difference between the lightning-bug and the lightning.

So when you find a good bunch of words, you hold onto it, because like a master key, it’ll come in handy again. Here are two little phrases that everyone should have in their toolbox.

Has anything been bothering you lately?

I borrow this from Thom Dick, who suggested instead “Have you been upset about anything lately?” This is good, but to my ear leans more toward psychological troubles — very legitimate, but perhaps not what you’re after.

The patient has chest pain. Okay. Abdominal pain. Difficulty breathing. Clicky elbow. Can’t pee. So you assess their complaint from every angle, real and metaphoric, and you see what there is to see about it. But what’s the context? Is this the final stage of a grab-bag of other problems? Before it was abdominal pain, was there nausea and discomfort? Have the past few days produced a gradually increasing malaise? Is that onset truly sudden, or were there precursors?

Forget all that. Did your cat just get run over? Is your insurance refusing your reimbursements? Did your medication run out last week and you haven’t been able to afford to refill it? Are you living on ramen noodles and water?

Has anything else been bothering you? We can’t list every malady, but this question encompasses them all, and it can reveal entire storylines you wouldn’t have learned without an open-ended query. Patients have a habit of not mentioning anything that doesn’t seem directly related to their chief complaint, but those blips can make or break a clinical picture. I never call a history complete without asking it once.

How can I help?

Patients have a lot of complaints. Sometimes it’s the very reason they called you. Sometimes it’s just a complaint. They’re sick. Stuff hurts. Feels bad. Has problems.

They may share these complaints with you. And you may be able to help. Chest pain, you say? Why, I have just the morphine for that!

The trouble is, sometimes we’re not sure if we can help. Or it doesn’t seem like we can. Chest pain’s one thing. But what can you do when they complain of feeling “awful”? What about an uncomfortable stretcher — sure, let me just grab the plush memory foam? Heck, on my BLS truck, we don’t even have the morphine. We’re not magicians here.

But if you’re drawing a blank, try the wild card: ask!

Hey, sorry you’re having problems. How can I help? Often they have a solution. They’ve dealt with their problems for longer than you have. Next time, maybe you’ll have that answer on tap. But you don’t have to know all the answers; you just have to be able to ask. Funny thing, too; even when you really can’t do anything, they’re glad you cared enough to try. Sure is better than just sitting there trying to ignore their whining.

How can I help? Hey — isn’t that our whole business? They give us textbooks on how we can help. But sometimes helping’s easier than a CPAP or a trauma alert. Sometimes we can cheat, because the answer’s up for grabs. You just gotta ask.

More at Some Things to Say (part 2)

The Rapid Initial Assessment: Look, Talk, Feel

The initial assessment (known to old-timers as the “primary survey,” but it’s all the same idea) is the first phase of patient contact. It’s the initial period where you aim your eyeballs at the human being you’re going to be caring for and uncover the most basic facts about them.

Nowadays it’s taught as a discrete series of steps, usually something like this:

General impression
Assess responsiveness: AVPU
Assess life threats: ABCs
1. Assess and manage airway
2. Assess and support breathing
3. Assess and support circulation
Determine patient priority

All good stuff, and there’s a reason it’s taught this way. All of these steps are important, and in order to teach (and test) them, they have to be broken down and explicitly described.

But this can be a shame, because in reality, the initial assessment isn’t like a recipe for a cake — mix this, then add that, then stir, then bake. It’s a brief burst of information, compacted into a dense flash of simultaneous sight, sound, and touch, and it can always be completed within a few seconds. In many cases it will be near instantaneous. In some it might take up to ten seconds. But it should never take as long as you’d need to actually verbalize all the steps.

The initial assessment should be a tight, elegant performance, and it’s one of the EMT’s most important skills. In the field, patients don’t come with charts or reports; all we know is what we’re dispatched with, which is usually wrong. But 90% of what you need to know about the patient can be learned promptly in the initial assessment. This is how you orient yourself to the situation and discover immediate life threats; more information and a more detailed assessment will follow, and it may reveal important findings, but our most critical job is to discover and treat what’s killing them, and that happens in the initial assessment. If you never got past this step you’d still be doing all of the most important things for the sickest people.

Here’s the process I recommend. It condenses everything you need to know into three simple steps.

Step 1: Look

You walk up and encounter your patient. What do you see?

Is he standing? Then he’s certainly conscious and alert. Is he moving purposefully or talking? Same business. Is he lying on the ground unconscious? We’ll learn more in a moment.

If he’s talking, his airway is intact and likely secure. You can roughly assess his breathing in about two seconds. Is he gasping for breath? Is he apneic? Is he speaking in full sentences?

Look at his skin. Is it pink? Is it pale and sweaty? Is it cyanotic? Is there obvious major trauma, such as significant bleeding anywhere or a puncture wound to the chest?

Step 2: Talk

Greet the patient and introduce yourself. “Hi, I’m Brandon.”

On a 911 response, you then ask for the patient’s name. How does he respond? Does he fail to recognize your presence at all? Does he look at you, but say nothing? Does he respond with a moan? Does he respond with, “George,” but his wife shakes her head and tells you otherwise? Does he promptly tell you his name?

To hear your words and verbalize an appropriate response requires alertness, engagement, memory, eye movement, vocal activity, and more. It requires the use of his airway and respiratory system, and thus reveals much about their status. Is he gurgling as he breathes? Gasping? You’ve learned a great deal already.

If you’re transferring a patient from a facility, you will already know the patient’s name, and pretending otherwise may make them wonder if you’ve got the wrong room. Better to skip their name and ask instead how they’re feeling. This leads you right into their chief complaint and subjective wellness, which is another huge slice of information. Are they in pain? Nauseous? Dizzy?

Step 3: Touch

As you talk, grasp the patient’s arm. You might politely interject, “May I grab you?” as appropriate.

Feel his skin. Is it dry, moist, or wet? Is it warm, hot, cool, or cold?

Feel his radial pulse. Is it present or absent? Is it weak, strong, or bounding? Is it slow or rapid, regular or irregular? There’s no need to count; that can wait for a full, proper set of vitals, which will come after our initial assessment. We’re just looking for a quick snapshot here.

This single touch tells you all sorts of things about his circulatory status. A patient with warm skin and a strong, regular radial pulse almost certainly has adequate volume and no immediate systemic crises. And anyway, taking someone by the hand is comforting in a primal way.

Let’s watch a few examples of this process at work.

Dispatched: MVA

Upon your arrival, you see a sedan in the middle of the road, with minor damage to the front bumper and right quarter panel. Beside it, you see an adult male walking around, slightly obese but appearing generally well.

He is ambulating easily and has no obvious bleeding or deformities. He therefore has a patent airway, largely adequate breathing and circulation, and his general impression is good. You could stop here, but we won’t.

You approach him, saying with a smile, “Hi, I’m Brandon. What’s your name?” He replies, “Greg Rogers — some idiot tried to pull out in front of me.” His breathing appears unlabored. As you talk, you take him by the wrist, feeling warm, dry skin and a strong, regular, slightly rapid radial pulse.

He appears neurologically intact, with good memory and appropriate responses. His breathing is normal and his circulation appears fine, although he is obviously a little excited.

[Initial asessment complete. Total time: 1 second to learn everything important; 5 seconds from soup to nuts. He has no life threats and is a low transport priority.]

Dispatched: Welfare check

You walk in the room to find an elderly woman supine on the bed, curled in an awkward position and motionless.

You are already highly suspicious of a depressed level of consciousness. It is possible she is merely sleeping, but most people would not sleep in such a position.

Approaching, you lean over and call, “Ma’am! Can you hear me?!” You gently shake her shoulder while you do. There is no response.

She is not alert. This is the “are you napping?” test; if she were easily roused in the same way you’d wake up your roommate, we would call her alert, not “responsive to voice”. You don’t lose points just for being asleep.

You lean into her ear and call again, this time in a loud shout. There is no response.

She is unresponsive to verbal stimuli. A loud, intrusive sound elicited no reaction.

Rolling her over, you note the sound of snoring respirations. Her chest is rising and falling with good depth, but not very quickly. Her skin is slightly ashen. You give her brachial plexus a tight pinch, to which she flinches and withdraws slightly.

She is responsive to painful stimuli, but does not open her eyes. (If you later wanted to calculate her GCS, she would earn a 5.) Her airway needs managing, and an OPA would probably be appropriate. She should receive supplemental oxygen as well, and may require assistance with the BVM. Since she’s breathing, she presumably has a pulse.

With one hand, you palpate her carotid pulse, while you palpate her radial pulse with the other. Her pulses are regular and slightly slow. Her radial is strong, and her skin is warm and dry both at the neck and at the wrist.

She has adequate circulation, perhaps with a slight bradycardia due to hypoxia. Her volume is adequate.

[Initial assessment complete. Total time: 6 seconds. She will need airway and breathing support, then a rapid assessment and transport due to her diminished level of consciousness.

Dispatched: Discharge to skilled nursing

You walk into the hospital room to find your patient in bed, semi-Fowler’s. Her eyes are open and staring at the ceiling, but she makes no acknowledgement of your presence. She is breathing adequately and without labor. Her skin appears dry and slightly pale.

She appears conscious, has an airway, and is breathing. She presumably has a pulse. She appears unremarkable for an ill but stable elderly patient, perhaps with a baseline dementia.

You approach her, saying, “Ms. Smith!” She turns her head and makes eye contact. “I’m Brandon. How are you feeling?” She replies, “Hi…” After another couple attempts, the best response she gives is to call you “Aaron” and ask about the elephants.

She is alert and engaged with her surroundings, but poorly oriented and disconnected with reality.

While you talk, you ask if you can see her arm; she pulls it slightly out from the sheets. You take her wrist with one hand. Her skin is pale, dry, and slightly cool peripherally, with poor turgor. Her radial pulse is very weak and irregularly irregular.

She is able to follow commands, but physically weak. Her peripheral circulation is poor, likely secondary to both poor cardiac output (her irregular pulse is consistent with atrial fibrillation) and peripheral vascular disease.

[Initial assessment complete. Total time: 8 seconds. Her presentation is consistent with her documented history and she is likely ready for transport.]

You may notice in all this that we haven’t performed any interventions — not even a lowly nasal cannula. The initial assessment is usually taught in a “treat as you assess” fashion; if you check the airway and find it compromised, you should address it before moving on. But look how fast we moved through all this! Wouldn’t you rather bang out your initial assessment in a few seconds, then move on to your treatments having a full knowledge of the situation? If we check the airway, and go to the trouble of sizing and inserting an OPA, by the time we’re done we still have no idea about breathing or circulatory status — something that would have taken another second or two to assess at most.

Initial assessments are like a flash of lightning: you start with nothing, and with a sudden burst of light, you end up with a great deal. That flash won’t tell you the whole story, and you’ll always need to keep looking and keep digging. But with a smart and efficient initial assessment, you’ll set the stage and choose the course for everything else to come. All in under ten seconds.

What it Looks Like: Seizure

See also what Agonal Respirations, Jugular Venous Distention, and Cardiac Arrest and CPR look like

A seizure is an episode of chaotic, disorderly electrical activity involving part or all of the brain. It is most often seen in epilepsy, but seizure can also occur acutely due to hypoglycemia, eclampsia, stroke, head trauma, alcohol withdrawal, and other causes.

Seizures are typically divided into two major types, partial seizures which involve only a portion of the brain, and generalized seizures which involve the entire brain.

Partial seizures are further divided into simple partial and complex partial seizures. In a simple partial seizure, consciousness is maintained, but unusual sensory, motor, or emotional sensations are observed — muscular tics, visual disturbances, strange feelings, and more are all possible depending on the area of the brain affected. Most often, this will then proceed into a larger seizure, in which case these early effects are called an aura, and used as a warning sign. Complex partial seizures are similar, but involve both hemispheres of the brain, and are distinguished by a loss of awareness or memory — the individual’s consciousness is impaired during the episode. This is the most common form of seizure.

The best known generalized seizures are tonic-clonic seizures, known historically (and still called by many laymen) “grand mal” seizures. They are characterized by two phases: a tonic phase, where the body becomes rigid and immobile, followed by a clonic phase, where full-body involuntary muscular jerking occurs. This is usually followed by a post-ictal period, where the patient may be unresponsive, or behave unusually, appearing combative, stuporous, or otherwise impaired. Either the tonic or clonic phase may be minimal or absent.

Absence seizures, historically “petit mal,” are characterized by a loss of awareness with a lack of outward activity. The individual may simply stare without moving or speaking, and after cessation of the seizure resume where he left off with no memory of the episode. Absence seizures may also present with some outward seizure activity, in which case the distinction between types becomes blurred.

Febrile seizures are seizures caused by elevated temperature (usually >100 degrees), most often seen in infants and young children. They are typically tonic-clonic in nature and almost always have benign outcomes; they rarely go on to develop into adult epilepsy.

Status epilepticus describes a prolonged seizure state, customarily defined as a seizure lasting over 30 minutes or multiple seizures without a full recovery in between. Some authorities draw the line at any seizure over 10 minutes, and there is evidence that even seizures longer than 5 minutes are unlikely to end without medical intervention. Status epilepticus is a true life-threatening emergency with high mortality; the continued chaotic activity of the brain can lead to permanent brain damage or death. Definitive treatment is the use of anti-convulsants, which attenuate the neuronal activity; in the field these are typically benzodiazepines like lorazepam (Ativan), diazepam (Valium), or midazolam (Versed). Since the duration from 911 call to EMS arrival on scene is often greater than 5-10 minutes, a seizure that is still ongoing upon your arrival should raise immediate suspicion of status epilepticus; a careful history should be obtained from bystanders when possible, including time since onset and any intervening recovery.

In some cases, seizures will be followed by a persistent, unilateral focal weakness in muscles that were active during the seizure. This is called Todd’s paresis, and since it can closely mimic the signs of stroke (even impairing eyesight or speech), it is wise to ask about recent seizure activity in patients with a history of a seizure disorder who present with signs of stroke.

Field care for seizure generally involves preventing secondary injury, such as blunt trauma caused by hitting or landing on nearby objects. During the tonic phase, respirations may be minimal, resulting in cyanosis; this is usually brief enough not to cause harm. The greatest concern is to maintain an open airway and prevent aspiration; when possible the patient should be placed in the lateral recovery position to help prevent soft tissue obstruction and allow fluids to drain away. Suction may be valuable, and an NPA may be considered in prolonged episodes. Supplemental oxygen is always appropriate, although a non-rebreather mask may not be tolerated in the post-ictal period. If respiration appears inadequate in prolonged seizures, positive pressure ventilation (by BVM or invasive airway) may be attempted.

This video from Dr. Robert S. Fisher is an excellent summary of the basic types of seizure. (Here is another on partial seizures; these are unusually good educational videos for a free resource.)

Here is an example of a simple partial seizure in a child, in this case manifesting as a repetitive facial tic. Note that the child retains consciousness throughout.

Here is an example of a complex partial seizure, also in a child. Note the repetitive, aimless movements of the arm and head, which are known as automatisms and are wholly involuntary; if spoken to, she would not respond.

Another complex partial seizure, in a young adult. Note the automatisms of the mouth and the wandering posturing of the arm.

An absence seizure in a child. Note the lack of any outward signs, except a total lack of responsiveness.

An excellent video of a tonic-clonic seizure in an adult. Note the labored breathing and obvious altered level of consciousness post-ictally.

Another good tonic-clonic in an adult. You see his awareness of its onset due to an aura, followed by gradual tonicity and then clonic jerks. Also note the snoring respirations; better positioning (and the suction catheter that the nurse couldn’t find) would have helped here.

Tonic-clonic in an infant, this one of febrile etiology.

Tonic-clonic in a sleeping adult; skip to 1:00 if you see better with lights.

Live from Prospect St: Dizzy at Hillcrest (part 3)

Continued from Part 2

My apologies for the delay on this update: there have been major computer troubles here at EMSB HQ. We’re back in action now with the final piece of our scenario.

Ultimately, this patient was rapidly packaged and transported emergently to the nearer facility for immediate imaging to rule out intracranial hemorrhage. Her final diagnosis and disposition are not known.

This case demonstrates the ambiguity we’re often faced with in the field, where we may encounter findings in our assessment that are suggestive of Badness, but not definitively so. Particularly when faced with a patient whose complaints are minor or who generally presents well, it can be difficult to make the call to upgrade these patients to a higher level of care. Nobody wants to be the Boy Who Cried Wolf. However, our job is to get people to the most appropriate care, and although we should try to minimize overtriage, within reason, safe is better than sorry. The situation can be particularly difficult when we are dispatched as a low priority to an unremarkable complaint; changing gears from a low- to a high-severity mode takes more balls than merely continuing what’s already been set in motion.

Assessment: The Pink Flags

The suggestive if not outright alarming findings (I like to call them “pink flags” — not quite red, but close) with Ms. Smith were the following:

A recent fall, reportedly with a blow to the head and loss of consciousness.
A subsequent (apparently new) complaint of dysnomia (the inability to express oneself in words, a form of aphasia), which suggests some sort of neurological or metabolic insult.
A subsequent and sudden onset of vomiting with no other apparent explanation. This could be a sign of hemorrhagic stroke, although more minor head injuries can also induce vomiting.
A history of Coumadin (warfarin) use — a “blood thinner” or anticoagulant — which is a risk factor for intracranial bleeding.
A complaint of “head pressure,” which remotely suggests headache, typical in head bleeds.
A reported positive finding on a neurological test (failed finger-to-nose), which potentially supports a neurological event.
A complaint of dizziness, which is suggestive of either a balance-type (inner ear) pathology or a neurological one.
A finding of hypertension, which may or may not be elevated above the patient’s baseline.

On the other hand, the following findings point generally away from the likelihood of a stroke or intracranial bleed:

An alert and oriented patient mentating at her cognitive baseline.
A normal Cincinatti Stroke Scale, which assesses for arm drift, facial droop, and speech slurring.
A lack of other “focal” neurological deficits (an abnormality that is localized to a single sensory or motor region, such as a droop in one half of the face, or loss of sensation in the left arm but not the right). She has equal peripheral CSM, no complaints of partial vision loss, and so forth.
A lack of any significant headache. Although there is a vague complaint of pressure, which could be explained by the actual trauma to the head, headache associated with intracranial hemorrhage is typically severe and sudden.
Equal and non-dilated pupils. (Although they do present as small, this is an unremarkable finding in the elderly, as is poor reactivity — constricted pupils can’t constrict much more.) Furthermore, the eyes track well towards all sectors; gaze paralysis is suggestive of brain damage. None of this is highly predictive, however.
A lack of rigidity of the neck, which would support a hemorrhage.

Taken together, this cloud of positive and negative findings produces our clinical picture. We are not so fortunate that any one finding is diagnostic, or highly suggestive to either rule in or rule out Badness. Rather, we have a constellation of weak findings.

Differential: Strokes and Bleeds

It can be important to make a distinction between intracranial hemorrhage and stroke. Intracranial hemorrhage (we’ll call it ICH, not to be confused with “intracerebral hemorrhage,” discussed below — both abbreviations are seen in the literature) describes bleeding anywhere inside the dome of the skull, typically from a ruptured vein or artery. Sometimes, this occurs inside the skull but outside the brain, between the various membranes that lay between brain and skull: epidural (outside the dura), subdural (inside the dura), and subarachnoid (inside the arachnoid) are the main types and locations.

Bleeding deep within the tissue of the brain itself is also possible, and is a subcategory of ICH called intracerebral hemorrhage.

A stroke is a localized injury to brain tissue resulting in permanent neurological deficits. By far, the most common cause is known confusingly as ischemic stroke, and describes an event where a clot or other obstruction blocks an artery that feeds a portion of the brain. (This is the same mechanism that damages the heart in a myocardial infarction.) The other main cause of stroke is hemorrhagic, when an artery bleeds openly into the brain, causing damage both from the loss of perfusion to downstream tissue, as well as from the pressure caused by the growing pocket of blood. This is where stroke and head bleeds intersect: when either an intracerebral or subarachnoid hemorrhage is sufficient to cause local neurological damage and permanent loss of functional brain tissue, a stroke results. Epidural and subdural bleeds do not cause stroke per se, although they can still result in acute neurological symptoms due to the increase in intracranial pressure.

Although the effects of stroke are similar with either ischemic or hemorrhagic etiologies, hemorrhagic strokes may additionally produce the telltale signs of rising intracranial pressure, such as headache, vomiting, general (non-focal) neurological deficits, and in the late stages, Cushing’s triad (bradycardia, irregular respirations, and hypertension).

Applying the Differential

Ms. Smith’s history is certainly suggestive for a bleed. Head trauma is the most common cause of ICH, and with her Coumadin use, she should probably be worked up regardless of her minimal complaints. Her additional neurological complaints make this a potential “uh oh,” advising transport to a facility that can provide immediate care. However, there are some notable negatives that tamper this enthusiasm.

For one thing, it would be unusual for a bleed of this type to present so inconspicuously. If severe, we would expect to see a profoundly altered mental status, up to and including outright coma, and probably a significant headache. If there is also the localized infarct of a stroke, we would expect focal neurological complaints — local damage should cause focal deficits. The reason that the Cincinatti Stroke Scale uses facial droop and arm drift to screen for stroke is because the majority of strokes will be revealed by unilateral deficits. Ms. Smith has none of this.

If there is indeed a stroke, the type most consistent with her presentation is probably a cerebellar stroke affecting the vestibular (balance) system. This region is responsible for coordinating motor and sensory signals, allowing synchronized behavior, such as the finger-to-nose test she failed. It’s also responsible for proprioception and balance; hence, damage could produce her complaint of dizziness. It is always important to distinguish “dizziness” (a sensation of spinning, consistent with either vestibular stroke or BPPV) with “lightheadedness” (a dimming of the vision, as seen in orthostatic hypotension). This is a notable possibility mainly because cerebellar injuries often do not produce the focal deficits characteristic of other strokes.

If you are very enterprising, Dr. Scott Weingart describes a three-test screen (introduced by Dr. David Newman-Toker and Dr. Jorge Kattah here) which can help catch vestibular stroke in borderline cases such as these. It uses two simple and easy tests, plus a third — involving a head twist — which is more difficult to assess and vaguely terrifying to perform. If you plan to use any of them, it’s the sort of thing you should be practicing beforehand. (I personally find the head twist finicky and liability-prone in most circumstances.) Like all such tests, their role in the field should only be to help determine transport destination and priority, and give you additional information on how hard to push a reluctant patient towards transport. It is not appropriate for enterprising Dr. Medics to use as ammunition to say, “oh, it’s negative, you’re clearly fine.” The weight of a thousand lawyers will descend upon you, and rightly so, the day you decide that you have the power to rule out major sickness from your ambulance.

If an extra-cerebral hemorrhage proved to be the culprit, a subdural bleed is probably the most plausible, due to the relatively slow and insidious development of the symptoms.

Additional tests that were not performed, but might have been useful, include a visual field test (testing at minimum eyesight in both visual hemispheres), a “stick out your tongue” test (looking for deviation to either side), and a more complete test of reasoning and recall (portions of the Folstein Mini-Mental, for instance).

Many of the major components of the peripheral neurological exam we performed are taken from this excellent lecture by Dr. Gene Hern of AMR Contra Costa County (see 37:20 through 40:50), and is my favorite expansion on the typical “squeeze my hands.” Sharp sensation can be tested with the tip of a pen — or you can use Dr. Hern’s pinching method.

Two other tips: when performing the facial droop test, “show me your teeth” produces better results than “smile” — patients tend to give a larger, more symmetrical smile using more muscles. And when testing for arm drift, remember that the patient’s eyes should be shut, and the hands should be facing upward (supinated); this is a more difficult test and therefore more sensitive.

Treatment and Transport

The key points on our differential therefore come down to two: intracranial hemorrhage vs. anything else. “Anything else” could be any number of things that produce diffuse and global symptoms, including metabolic problems or even a brain tumor. Diabetic etiologies are always be a possibility, although glucometry was fortunately available to rule that out. In general, the old standby AEIOUTIPS is the sort of thing we’re looking at here. And remember, multiple concomitant pathologies are just as likely as one all-encompassing Badness, if not more so. As a starting point, we should bear in mind that around two-thirds of falls with loss of consciousness in the elderly will end in death. The risk is high.

As always, the differential only matters to the extent that it will affect our decisions. What will our field treatment be?

Certainly oxygen. Although hypoxia is unlikely to be significantly contributing to Ms. Smith’s complaints, it could be playing a role. Depending on local protocol, low-flow through a nasal cannula may be plenty.

In the case of stroke, there is some evidence that hyperoxygenation with high-flow O2 can contribute to worse outcomes. The 2010 Emergency Cardiovascular Care guidelines from the American Heart Association recommends titrating oxygen therapy to maintain an oxygen saturation of at least 94%, but not necessarily slapping on a non-rebreather at 15LPM. Depending on whether oximetry is available to you, and depending on your local policies and attitudes, this may or may not fly; it’s something to ask your boss and medical director.

What about C-spine immobilization? As always, this will be a matter of opinion and protocol. In some areas, any fall from standing height, with a blow to the head — especially for an elderly patient — must always be immobilized. However, clinically I would not consider it indicated here. Whatever criteria or standards you adhere to for selective immobilization, Ms. Smith likely meets them: she has had no peripheral neurological deficits (weakness, tingling, numbness, pain), no neck or back pain or tenderness, no factors that would impair her reporting of the above (such as distracting injuries or altered mental status), turns her head freely, and although not ambulatory on our arrival was obviously ambulatory for several hours prior. Remember that the only reason for the immobilization of blunt head trauma patients is the suspicion that any injury substantial enough to cause ICH may also be substantial enough to cause a cervical spine fracture — and while a valid reason for suspicion, this is just one factor to consider. (Conversely, if we had found focal neurological deficits, we would have likely been unable to determine whether it was secondary to the suspected ICH, or secondary to a spinal injury — immobilization would have been unavoidable.)

Close monitoring will be warranted, especially if we do suspect a bleed. Although Ms. Smith appears currently stable, there is a real possibility of her mental status deteriorating; epidural bleeds in particular are famous for a “lucid interval” following the initial trauma, after which the patient suddenly and catastrophically decompensates. Control of the airway and ventilatory support should be provided as necessary. If there are signs of herniation syndrome — an acute rise in intracranial pressure, resulting in “coning,” or the brain being forced through the openings in the skull — it may be reasonable to hyperventilate the patient slightly, at a rate of 1 breath every 3 seconds. Although the drop in systemic CO2 caused by a higher ventilatory rate results in a systemic respiratory alkalosis (high PH), which tends to reduce inflammation and hence lower intracranial pressure, it also reduces cerebral perfusion; it is therefore no longer recommended as a routine practice. Intracranial pressure is a challenging problem that produces a physiological tightrope that we need to delicately walk; hyperventilation is a last-ditch flailing that’s only advisable when things can’t get much worse.

Is an ALS intercept appropriate? Again, this may depend on your protocols. As Ms. Smith currently presents, there is no benefit to ALS care; whether or not she’s hemorrhaging, that’s a matter for the hospital, not the field. However, if should deteriorate, then ALS could prove very valuable in the management of her airway, seizures, cardiac arrhythmias, and other complications. With Ms. Smith’s currently excellent clinical picture, and the short transport to definitive care, I would not attempt to meet the paramedics unless I tripped over them in the driveway. However, the opposing argument can easily be made, and I wouldn’t call it wrong.

The most appropriate destination for this patient will likely be the nearest primary stroke center. A “primary” stroke center is required to have various resources available 24/7, the most important in our case being a CT scanner. The definitive determination of the presence or absence of our possible bleed will be via some form of CT, or possibly by MRI (if available).

Treatment may or may not involve surgical intervention, depending on location and severity. Many of these cases are managed conservatively, both because the benefits of surgery are often small and the harm (especially in deep brain bleeds) often large. As a result, my personal inclination is to steer towards the nearest facility that can provide immediate imaging; if surgical intervention beyond their capabilities is found to be indicated, transfer can be arranged. I would not advise transporting to the more distant requested facility; the only notable benefit other than the patient’s convenience and comfort (which we won’t diminish) is that her medical records and following physicians may be available there, and her history doesn’t seem complex enough for this to matter significantly.

In some areas, a few hospitals are designated as “comprehensive” stroke centers, a step above primary. These facilities are specialty centers with the most advanced stroke management capabilities, which may include diagnostic and interventional methods that would be appropriate to us. The system of comprehensive centers is still inchoate and only available in some states; check if yours is one of them.

Your local hospitals may follow a prehospital protocol that allows for a “stroke activation,” similar in principle to trauma or cath lab activations, where appropriate resources are mobilized by request of EMS and waiting upon your arrival. Depending on the local indications (for instance, your hospitals may demand a positive Cincinatti Stroke Scale), Ms. Smith might qualify.

Conclusion

In the end, I was unable to obtain patient follow-up on Ms. Smith. She received low-flow O2, was not C-spine immobilized, and was diverted to the nearer stroke center with an emergent transport and no ALS. An entry notification was made with an advisory of her status, although no formal stroke alert was given. She was stable throughout.

It’s important to note that our assessment of Ms. Smith, our analysis of her differential, and our resulting treatment and transport decisions, are not actually dependent on her eventual diagnosis. It doesn’t matter whether we ended up being “right” — hence, it doesn’t matter that we never found out the “answer,” even though I do love a good puzzle and I admit that I wanted to know. As long as we made an appropriate interpretation of our assessment findings, and made appropriate decisions based on them, then we got it right. Perhaps her complaints turned out to result from an alien egg incubating in her chest; that wouldn’t make us wrong, it would only mean that she was an aberration. Our business in the field is to play the odds in a responsible way, weighing risk-vs-benefit to provide our patient with the best chance of a good outcome.

That’s all. And that’s plenty.

Live from Prospect St: Dizzy at Hillcrest (part 2)

Continued from Part 1

While you chat, your partner helpfully places Ms. Smith on a nasal cannula running oxygen at 4 LPM.

You ask whether she lost consciousness when she fell, and she agrees that she may have briefly. When you ask why she fell, she states she simply tripped on the fringe of the rug. The fall was 3 hours ago, and she first vomited immediately afterwards. Until this morning, she was feeling normal, with nothing bothering her over the previous days. Her chief complaint seems to be her persistent inability to “find words,” although staff state that they called EMS mainly due to her dizziness.

When you pursue the “pressure” behind her eyes, she admits that it’s a pain of sorts, but it is obviously not too severe, and she refuses to quantify it with a number. She clarifies her dizziness by stating that although it may be worse when she stands or walks, it is continuous; she is experiencing it even as you speak.

Her pupils are equal, somewhat small, and react slightly to light. Her eyes track in all directions, with no appreciable nystagmus. When you ask her to show her teeth, she does so with no facial droop. When you ask her to hold her arms straight in front of her, palms up, with her eyes closed, she does so with no unilateral drift. She demonstrates good, equal grips, equal bilateral strength in finger-abduction and wrist flexion/extension, and equal bilateral strength in ankle dorsiflexion/plantarflexion. Her radial pulses are equal, as are her dorsalis pedis pulses, and she notes normal bilateral sensation when you pinch her hands and feet.

Throughout your conversation, she has demonstrated no slurring of speech, normal recall, and excellent orientation.

Consulting with the staff, you learn that her medications include Metoprolol, Simvastatin, Metformin, Lisinopril, Colace, Aspirin, and Coumadin for a recent hip surgery. She is allergic to Penicillin. They are unsure about her baseline BP, but Ms. Smith believes it is normally “in the 140s.” Staff believe her temperature has been recently normal, although they aren’t certain.

Your partner obtains her blood glucose at 149.

The nearest ALS is 15 minutes away.

At this point, what are the leading possibilities in your differential?

With that in mind, what is this patient’s priority?

What is your transport destination?

Is any treatment needed at this time?

Should you make any calls to mobilize further resources?

Live from Prospect St: Dizzy at Hillcrest (part 1)

Many moons ago, there was an enlightened discussion list run by Jeff Brosius and Valerie DeFrance called Live from Peachtree St. The format was this: Jeff would periodically present scenarios based on real-life calls, putting them out for debate on diagnosis and treatment; later he’d provide the outcomes, with a discussion of the relevant clinical issues. It was a great educational model, and I’ve always thought that scenario-based instruction was a fantastic way to learn to parse the details of a call, determine what matters, come up with a working diagnosis, and make your decisions. You can’t learn hands-on skills from scenarios, but you can exercise your noodle, and more noodle-exercise is what this business needs.

Sadly, Live from Peachtree St. closed its doors years ago, although its archives are available online and still a great read. In the same spirit, however, and with permission from the authors, I’d like to revive the tradition. With that in mind, and harkening from my own neck of the woods, I give you: Live from Prospect St!

To juggle the format a little, I’d like to break these cases up. Remember “Choose your Own Adventure” books? In a similar fashion, I’ll give you the first chunk of the call, let you analyze the facts and make some decisions, then go forward with another round of details, and finally present the outcome. Cases are either true to life (obviously edited for HIPAA) or closely based on reality with editorializing for educational purposes. Feel free to send in any cases of your own! We’re not only interested in intriguing or unusual calls, but also more run-of-the-mill cases that illustrate important fundamentals of assessment and care.

All levels are invited to play, but in keeping with our mission, we will assume a BLS scope of practice. Onward!

Dizzy at Hillcrest

You are the technician on A-8, a dual-EMT, transporting BLS ambulance. You are equipped with BLS epinephrine, aspirin, glucose, nebulized albuterol, pulse oximetry, and finger-stick glucometry. Intercepting ALS is available upon request. It is noon and the weather is fair.

The radio crackles: “Ambulance 8, respond cold to Hillcrest Manor, in the lobby, for the patient with dizziness.”

Driving non-emergently, you arrive several minutes later at an assisted living facility. In the lobby, you are met by staff, who direct you toward an elderly woman in a chair. A nurse informs you she has been feeling somewhat unwell all day, and 30 minutes ago began complaining of dizziness. She also states that she failed a finger-to-nose neurological test. They request that you transport her to Mount Doom Hospital, a high-quality community hospital several towns away (20 minute transport routinely; 13 with lights and sirens); it is a cath lab and stroke center, although not the nearest facility for either, and is not a trauma center. The nearest facility is a community hospital of similar size and capabilities (10 minutes routinely; 5 with lights and sirens).

You kneel in front of the patient, noting that she is alert and appears generally well, in no obvious distress. She introduces herself as Ms. Smith, is 68 years old and fully oriented, and tells this story:

“This morning when I was getting out of bed, I fell and bumped my head. After I got back up, I was trying to do my writing assignment for our group, but I kept finding that I just couldn’t seem to think of the words — I’d stare at a sentence for ten minutes without knowing how to finish it. I’ve been feeling a little dizzy most of the day, and a little sick — I vomited a few times. And I feel like there’s a pressure behind my eyes.”

While you talk, your partner obtains these vitals:

Skin: dry; unremarkable at the core; cool and slightly pale in the extremities
Pulse: 90 [at the radial, strong and regular]
Respirations: 14 [regular, normal depth and unlabored]
Blood pressure: 164/98
Oxygen saturation: 96%

When asked, staff report that Ms. Smith’s medical history includes coronary artery disease, diabetes, mild dementia, and hypertension.

What is your current impression of the patient’s priority?

What are the leading possibilities in your differential?

What further assessments or information would you like to better inform your decisions?

What actions or interventions, if any, would you like to take at this time?

Post responses to the comments.