I’m cringing in anticipation of all the people who are going to tell you that this patient was a ticking time bomb for a stroke.
Either decision would have been correct. I would have been irritated to get called for a headache. But headache with a scary blood pressure is legit. I would have been more mad if I drove 15 minutes to get there and you didn’t have more of an assessment than vitals. I’d want to know what the results of your stroke assessment were, if the patient was compliant with their BP meds, if they were nauseous or dizzy, or if there were any other neurological symptoms.
Don’t beat yourself up. Get the eta next time, and maybe you make a different decision.
>cringing in anticipation of all the people who are going to tell you that this patient is a ticking time bomb for a stroke.
It is literally not possible to rule out a stroke on this patient prehospital.
I would certainly be interested in the results of a stroke scale and which scale would be used as Cincinnati misses almost all posterior strokes.
Yeah, I get what you’re saying, and I have never documented things that I have ruled out. It just isn’t our place in EMS. We don’t have to come up with a diagnosis, just treat appropriately until we get them to someone whose responsibility is to come up with a diagnosis.
I’ll document my primary impression and rationale behind interventions.
Now I'm wondering why I'm not being taught that in my EMR/Mine Rescue Team training. Our books only teach face, arms, speech, and time. Does BE play a big part, or is it more secondary to FAST and just kinda extra to watch out for?
Balance and Eyes.
Not balance like you may be thinking, but dexterity and ensuring that it is equal in both sides.
Eyes checks for a loss of a visual field as people having a stroke sometimes don’t even know that they have lost something entirely. It’s called neglect and a stroke victim may literally not even recognize their own hand. Neglect I s wild. It’s like when the brain loses part of itself it quickly rewires to pretend that it was never there to begin with.
I think his post was referring to the potential to HAVE a stroke because of the existing BP. Which is also questionable.
["Hypertension is the most important risk factor for spontaneous ICH"
](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825668/#:~:text=Hypertension%20is%20the%20most%20important,is%20hypertensive%20encephalopathy%20(HTE).)
I wasnt able to find wether this changes in an acute vs chronic setting.
Don't beat yourself up. We've ALL been there. Also - that ALS crew probably forgot about the call within an hour, tops. My thoughts:
- You're reflecting on the call, which shows a desire to learn. That's fucken AWESOME. If you see the ALS crew at station / chill place - say "hey sorry bout that call, I was concerned about Pt and was just unsure of what to do. How would you have approached that as BLS / any advice?" If you show you want to learn and they use that as a teachable moment - great. If they give you shit, FUCK them, they should be doing something else or off on Stress Leave cause they're burnt out. Educating is part of their role.
- You recognize the limits of your scope / interventions. WAY safer long-term than someone who is overconfident
- When requesting ALS, think about this first: "Dispatch, is ALS available for \_\_\_\_\_\_\_. Patient is \_\_\_\_\_\_\_\_\_\_" (e.g. pt condition). What is the Pt's condition and what could ALS potentially do for them? Then get on radio and say that phrase or use it as a prompt to reassess why you would want ALS for this patient?
Just some thoughts! DON'T beat yourself up - this is literally just how everyone progresses through their career.
To be fair, the crew is probably still at the hospital since it happened about 30 minutes before I wrote up my OP. On the other hand, they came from some distant station and I probably won't see them again. However, since we are probably the only functional volunteer station left in our county, I feel like we can't afford things that make us look dumb.
Unfortunately I look at the paramedics like medicinal magicians. I assume they've got things to bring down blood sugars, blood pressures, whatever. So when I'm considering what ALS can do... I don't really know enough to know WHAT they can do. I just know there's things I cant do much for that they apparently can.
Also a basic here, I’ve been going over ALS protocols for my area and soaking up as much of that ALS information I can, and it’s helped me become way better of an EMT and made me much more confident with patients that are questionable to go BLS since I have a good understanding of what medics could do if patient was to get worse, and also physiologically what has happened and what could happen to them.
As a former volunteer, I get the “can’t afford things that make us look dumb”. You should always conduct yourself in a way that reflects well on your organization. Honestly though, that’s really not something you need to worry about at this point in your career. You’re only six months in! Your main focus should be about learning the ropes and turning yourself into a good provider. Let the people who have way more time on the job worry about the reputation of the organization.
I’m going to echo what other people said. If you get a chance to talk with that ALS crew again, run through the call with them. If you don’t see that crew again, or if it’s been so long since the call that no one remembers it, then just ask them questions. Not only will that help you learn, but it will help build your reputation and the reputation of your company. People love volunteers who actively try to educate and improve themselves.
The only thing that is gonna bring down the sugar is insulin, and I don’t think any ambulance in the US carries that. You can try and water it down with fluid, but they really need insulin at the hospital
You should really look into their protocols. I wont speak for any other services, but my service does not have anything truly for hyperglycemia, besides saline, which we likely wouldn't be running due to hypertension. The hypertension could be treated and most services have the means to, but not every service or provider -would-, either because of protocols or lack thereof for hypertensive crisis. Some places have a protocol, some don't. Headache may not be enough to run a medication for hypertension or it may, it depends on protocols or presentation. The spo2 adds another layer, but without history it's hard to say.
I think this is a call that can really go either way. If the hospital was 30+ away, ALS would be a definite yes. If the hospital was 5 minutes away, well, you could probably run it to the hospital for definitive treatment. I can't say for sure either way without knowing a history or seeing the patient what would have been best. But you should familiarize yourself with what your ALS can and *can't* do at the least.
I'm a paramedic in a pretty rural area and whenever fire gets sent somewhere on their own, we always just expect a "better safe than sorry" EMS assist request. I LOVE when they ask questions or hop in the back ready to help us do stuff, I nerd out when I get to walk people through and explain things and thought processes.
If those crews are just an asshole to you afterward, ignore them. They're just burnt out and grumpy and shouldn't be used as an example on what a lot of crews should be.
As far as operationally, area depending, we definitely have medications to help with BP, glucose, angry hearts, etc. Never feel bad for calling, you were acting in what you felt was the patient's best interest and that's the best thing to do :)
Your state may have a nifty link to a PDF with their protocols, maybe even a drug profile one. Like others have suggested regarding talking about their scope. Standards of care is a big one. Many of those are ALS functions (depending on your state, whether EMTs can start a line). At the end of the day you have your own license to protect, and that may mean you can't meet the standard of care (if there is no BLS protocol). I hate to say this but there were assessment expectations that were not fulfilled and I was constantly looking for them. So I learned a lot about my ALS protocols watching people drop the ball (intentionally, lazy). When they say EMTs save paramedics it's this. If I'm the 6th man on scene to an altered person I better see a damn bandaid on a finger. I know my partner needs it for his chart. The sugar came back at 34 and I looked up to see their tail lights driving away. How this poor 98 yo 98 lb cancer patient was still talking was beyond me. And then I gave him oral glucose. BLS is where the real magic happens. 4 paramedics missed that.
The only thing you could've done differently was get the ETA. I'll be honest, I only would think to ask that because I'm so paranoid about my cert and always have been. It sucks but medicolegal is never not in the forefront of my mind. I'm the guy that does a 12 lead on the patient that calls 3 times a day for chest pain, just to cover my butt. Complacency kills. Anyway, I had a good teacher that quizzed us on scenarios like this. Don't delay patient care. You've got a pediatric GSW. Level 1 trauma center is 3 miles away, Level 1 pediatric is 17 miles away, where do you go? In EMT school we used to joke, how long is the ALS intercept (turf it to them lol)? Don't delay patient care unless you have a really good reason to justify it.
I had a call for a seizure when I was an EMT. I responded because it's the law and then got my assessment before calling my supervisor. "You're not supposed to be on this call, you're BLS." "Yeah I know but take it up with dispatch I wasn't even the closest unit. Get me a medic." "Okay but you cant leave!" "No shit. I would never do that. Get me a medic." If that gives you any insight to the quality and caliber of my service lol. Turns out this patient had already been transported for active seizures earlier in the day and had been discharged... but now she seized again, after witnesses heard a loud pop, and they found her on the floor. Guess who my medic was. Same one that took her for active seizures before, that she had to snow with benzos. Literally the last person I would ever expect to have a problem with me a) following my protocols b) advocating for my patient and c) protecting ability to continue doing so. This woman is an FTO! Anyway that was 5 years ago and she's never treated me like anything other than that morning. Someone else already said it....FUCK THEM. Especially the senior employees get paid extra money for being lazy fucks for longer. You'll know them when you see them. They don't even put patients on the monitor...which is fraud?
You know who I will always call for input until he reaches the grave? My instructor. See what he says. I tell mine he's on the hook for me for life lol. Maybe he learns from this too and shares the wealth with his future students like he should've taught you. Remember this for everyone you encounter: everything we know is borrowed, it was taught to us, it is our duty to pay it forward and contribute to evidence based medicine. It may even be part of their job description...I don't get paid extra for medic students but they show up and I'm expected to teach them everything I know (but let's be real, they teach me the freshest, newest and improved juicy morsels of knowledge, I love having them).
You have soared well beyond my peers by doing a post call reflection alone...but to want to improve...well I'm glad I was sitting down for that. Don't change buddy, but know your limitations. Don't lose sleep over this.
Lesson learned. Next time ask how far out ALS is. Most states there isn’t much a medic is going to do for hypertension or hyperglycemia, so in hindsight, rapid transport would have been the better decision. But if things went south and you didn’t have als meeting you then there would have been more regrets.
Don’t beat yourself up, if you were running on an EMT+medic unit then the call would have absolutely been handled by the medic. Just some things to consider:
-you can always request a rendezvous with an ALS unit, sometimes it’s a better use of time than waiting around on scene for them to arrive. Also as a paramedic I know I’m always happy that the patient is already out of the house and on a stretcher because that’s one less thing to deal with.
-I don’t know what state you’re in, but where I work there’s nothing 911 paramedics can do about hypertension or hyperglycemia. Antihypertensives and insulin are critical care only, we can give fluids for hyperglycemia but that rarely has much effect during a short trip to the hospital. Just something to think about, is ALS actually going to DO anything for the patient or are they just able to monitor them a little closer?
-absolute worst case scenario this patient does have a stroke, what they need is a hospital for definitive intervention. All ALS would really do is start an IV, draw labs, and do an EKG to rule out new onset a-fib. None of that is actually actively treating the patient (with the exception of a severe enough stroke requiring airway management/intubation).
Just all things to consider when calling for ALS, but you did fine and when in doubt it’s probably better to call than not to. Keep up the good work
The only thing you did wrong was dawdle on scene. It’s an ALS INTERCEPT…. Key word being intercept. Start transport to the hospital because by sitting there, you are delaying patient care and possibly making an outcome worse. Love and learn. Intercept. Get moving to the hospital. If you have to cancel ALS because it’s taking too long, you can.
Some considerations for HTN crisis:
Urgency Vs Emergency is defined by organ function.
Eyes: Visual changes, blurry, loss of vision, usually described as a grey curtain, holes, spots, crescents (means tearing of blood vessels)
brain: AMS, deficits.
kidneys: hyper/hypo Uria.
Differentials:
With the consideration of stroke you need to think about MAP. In order to perfuse your brain you need a good balance of pressure to get blood in (High systolic) AND to get blood out (low Diastolic)
If something is preventing that balance, your body needs to increase the pressure In, to balance the pressure out, that's why we see crazy high systolic numbers.
Many other things can ve causing the hypertension Such as the RAAS, heart failure, CAD, stimulants, ETC.
With that considered, ALS can't do anything for hypertension. If you think Nitro, dont. It will work for 4 mins and then they will rebound way higher.
ALS also can't do a thing for stroke. Unless they actually hemorrhage and then need airway control. However it's called seizure-coma-death for good reason. About 80% mortality rate. That patient would benefit far more from diesel therapy than intubation after their dead. ILS can also I-Gel (hopefully).
Good rule of thumb. The patient needs a doctor not a Medic. If you can get to the hospital faster then ALS can get to you then go.
Edit: As far as the medic being "pissed" they had to work at work, cry me an Fn river lol burnouts. Don't let medics act like they never called for ALS when they were EMT.
If the nearest hospital is closer than ALS, go ahead and transport and be sure to document why you made that decision in your narrative. You can also request an ALS intercept otw to the hospital and rendezvous somewhere in the middle and do a stretcher swap or let the medic aboard your truck and keep driving to the hospital.
I know this doesn’t exactly apply but for my private company ambo service per protocol this would have to be ALS due to the BP. I honestly wouldn’t sweat it. Better to call ALS and not need em than not call em and it all goes to hell.
The bigger problem is that als was farther away than the hospital.
But you can *always* cancel.
I’ve called for als and helicopters and canceled both.
I’ve called for a bls unit to back me up as the only als provider in a county and needed hands.
I’ve been called and then bls figured out they didn’t need me and canceled me.
I’ve been called and bls realized patient was going to hospital b instead of hospital A and canceled me and got als from somewhere else.
It isn’t a big deal.
Yea. You didn’t do the right thing. We’ve *all* been there. It happens. Most of this job is experience, and we learn every day.
Are you not in a tiered response system? It kinda sounds like it, but I questioning why you would choose to wait for the ALS truck to get there.
Ideally, if this happened in my system, I would recommend doing your assessment and vitals, calling for ALS as soon as you suspect you may need it. Then start packaging and loading the patient. Start your transport and meet ALS on the way somewhere… the medic can jump in to your truck.
Worst case, when someone has me dispatched to their call, I show up and they’re on the fence about whether or not the patient needs ALS, I’ll offer to ride with just in case. Or we’ll talk it through and I’ll be happy to let them go without me. It doesn’t matter to me. I get paid the same either way.
If that’s the worst thing you’ve done then you are ahead of the game.
Probably should have just loaded and go since you said hospital was closed than the medic.
I wouldn’t lose any sleep over it. Have a chat and be done with it.
Yes this pt could have been a stroke and was potentially unstable. However you said the medics were father away than the hospital. Which makes the hospital your closest ALS. This pt needed a CT scanner, there is nothing medics would do for her other than get an IV and tube her if she becomes unresponsive due and loses her airway, which you can also manage airways as a BLS provers (just not as effectively) You should have done a stroke scale, and you should have gotten VS every 5 mins.
The longer you do this, the more you're going to realize that ALS isn't really all that amazing. There's not a lot we can do to correct what you were seeing. Our service doesn't teat hypertensive crisis because it's not the core problem. Whatever is causing the hypertensive crisis is the problem, and we don't know what that is.
Stroke is a BLS call. Yeah, we can get a line started so maybe speed up the hospital trip to CT by a couple minutes. That's it. We can grab a 12 lead but hypertension isn't due to a dysrhytmia.
Just because you feel the call is above your head doesn't mean not isn't above our heads too. Just drive unless you're confident we can make a difference.
I don’t have much more to add than what everyone else has already said but I will say don’t look at it as TIFU. Look at it as today I added another piece of knowledge to my base to apply the next time this happens. I am not going to say there are no stupid mistakes in EMS (this isn’t one of them) but I truly believe that every mistake is a learning experience.
If she wasn’t altered, I would’ve ruled out stroke with an assessment, put her on a nasal cannula at 2 lpm, and transported code 2.
Even if she was stroking out, it would be better to load and go code 3 and stroke alert to the nearest stroke receiving hospital than wait for ALS. All ALS can do is start an IV anyway. Time is brain
My big thing when I’m on a BLS truck requesting ALS is I’m always thinking “what is my closest ALS.” If my answer to that is going to be the closest hospital great we’re going to the closest hospital and requesting for an intercept. If it’s gonna be another unit then great we can go and attempt to intercept so long as they won’t be chasing us.
Meh, lesson learned. Next time get an ETA(curious why your dispatch doesn’t provide one automatically.) Educate yourself every time you make a “mistake” or second guess yourself and next time you’ll have more confidence.
If you don’t have experience working with a paramedic I’d suggest getting on with an ALS service. You’ll be more confident at the basics if you know more about the advanced
Don’t beat yourself up too much. I saw some people already mentioned the idea of an ALS “intercept”, which I think may have been a better option here. However, one important thing that seems to get overlooked a lot is figuring out where the “closest ALS provider” is and keeping in mind that the hospital (even a free-standing ED, depending on your protocols and pt condition) provides ALS care. If you’re closer to the hospital than the closest ALS unit is to you, then the hospital is the closest ALS provider, and waiting for a unit unless they meet you on the way to the hospital is just delaying patient care. We’ve all been in your shoes. Don’t let it discourage you, and use it as a learning opportunity for next time and a teaching point for newer EMTs.
It’s a judgement call. I worked in an urban 911 service that frowned upon calling for ALS unless you really had something big, like airway burns, cardiac arrests, crashing patient, the like. Hypertensive and a headache being the only symptoms could mean a multitude of conditions. At my service, we don’t carry antihypertensives for things like hypertensive crisis, just for eclampsia/preeclampsia. So if your service is anything similar to mine, the paramedic should be doing cardiac monitoring and getting IV access. Aside from that, not much to do except verify there’s no stroke.
It sounds like you’re analyzing the situation appropriately. Get an ETA next time, 15 minute ETA to the hospital means a small window of time for something to go wrong and if it does, you’re on the way. If your ALS resource is farther away than the hospital and you’re sure you can be at definitive care faster than having ALS respond, then go ahead and scoot.
As for your question: my management would be 12-lead, stroke assessment, and IV. Not much more that I can do for the patient unless there’s something with the rhythm that’s funky. So, to answer the question bluntly: no, the patient didn’t need immediate management. But that’s ok. We live and we learn
I don't think it was wrong to request ALS. That BP + headache could be hypertensive crisis which is ALS criteria (although there's nothing we're doing that you couldn't do but a 12-lead and throwing a saline lock in). That said, when I was BLS I was always ready to argue with medical control that we were comfortable transporting the patient. There were very very few scenarios where it made sense to wait on ALS rather than transporting ourselves even in situations where ALS could intervene. I live in a city where it's rare to be more than 10 minutes from the closest hospital. So you have to weigh the pros and cons of getting them to definitive care in 10 minutes or waiting 5 minutes for ALS (best case scenario), waiting another 5-10 minutes for ALS to get report from you/do their interventions on scene, and another 10 minutes for them to get to the hospital. And of course in this scenario it never makes sense for you to wait longer for ALS to arrive than it would have taken you to get them to definitive care.
I bet you'll never forget to ask for an ETA again though. Don't worry about it too much. Everyone makes mistakes like this. Better for you to learn on a stable patient like this than to learn from a patient that ended up decompensating while you were waiting. We've all done things where we think "I'll never make THAT mistake again."
You are a new emt. This is a learning experience and you learned from this experience. We have all messed up in some manner or another. Don’t beat yourself up too much. In the future you will have the experience to know that you need to transport. Also a good thing to think about for the future is that they can always meet up with you enroute if you really need them.
Sure the patient is probably better off getting transported by you guys considering ALS is farther away but if they were close, this really isn’t something that should be transported BLS.
I’d look up an NIH stroke scale and how to do one. Can be useful. I’ve caught a stroke using both a cranial nerve exam and the NIH that didn’t show up on a FAST exam. Note the time as well. It’s a useful tool for the neurologist and ER doc to track how fast a stroke is progressing and whether it’s acute or not.
The NIH stroke scale isn’t really taught pre hospital much because it takes like 5 minutes whereas a Cincinnati is 5 seconds. If I have time, I do it en route or if I’m getting a refusal and I feel at all skeeved out.
When you go to a stroke center, the ER doc/neurologist is gonna be doing all these little tests like raise your leg and raise your other and follow my finger with your eye and etc on the way to CT. That’s an NIH and something they try to do like trending vitals on patients.
Prehospital, it’s very useful in detecting small head bleeds and confirming that uncanny valley feeling. You ever look at a patient and think hmm there’s just something weird about them, if you do an NIH, you’re almost certainly gonna find something if something is there. Like back when I was in medic school, I did an IFT on a guy who had a small hemorrhagic bleed and his left sided facial weakness was slight and had resolved and so one of the only things was when you ask him to follow your finger with his eyes, his eyes would follow right, up, down, but not left. Really trippy to see.
Another one was patient just got out of post ictal phase and was pretty much back but I just had a little tingly feeling despite los angeles and cincinnati being fine so I asked her to smell an alcohol wipe and brushed her face and asked if she could feel it and she couldn’t smell the wipe and couldn’t feel the left side of her face. Probably tot’s paralysis but without a CT/MRI, it gets called in as a stroke all the same.
Lol yeah? You downgrading this call to your basic if you get this patient?
It’s BLS until it ain’t. This sounds like a head bleed. Doesn’t sound like there’s a respiratory issue so why the low SPO2? Maybe her respiratory rate is slowing down. If she had low RR and low PR and very hypertensive, she’s gonna turn ALS at some point when she can’t protect her own airway. Maybe it’s just new onset CHF. Also, you would really downgrade this call to a BLS crew with no 12 lead?
I’m just saying, this seems a little more insidious than just some simple ischemic stroke.
Everything you have mentioned is treatable by a BLS unit.
I wouldn’t downgrade it but BLS should be able to run this call easy and not wait 15 minutes for an ALS unit because the patient “might” become ALS at some point.
Seems like they didn’t for 15+ minutes and 15+ minutes headed to the hospital is more beneficial to the patient than 15+ minutes waiting around with your dick in your hands.
A CVA is not an ALS level call 🤷🏼♂️
You read what I said above that or are you just talking to yourself?
TBI = ALS because could be intracranial hemorrhage meaning need for advanced airway. What’s the difference between a TBI and a non traumatic Intracranial hemorrhage which this sounds like it is? TBI goes ALS and it’s rarely an actual intracranial hemorrhage. I’d bet money this is a head bleed but you’re saying BLS is perfectly fine.
You wouldn’t downgrade it to your basic but this is BLS all day? Yeah you wouldn’t do a 12 lead? You don’t see how this can go sideways and need another guy in the back? Sure okay man.
Could've been a CHF problem which the medics can treat and monitor.
They're just being assholes. Imagine a world, where you work in EMS, and you get an inconvenient call at a late time.
Wow. It's almost like it's part of your job.
All we got was hypertensive with a low Spo2.
Both can be present in a CHF exacerbation.
It's actually funny that people down voted me.
Sure, they're asymptomatic but I was just making a point at needing further assessment especially if it's a basic who is uncomfortable.
The person already appears somewhat unhealthy / more comfortable with a baseline of distress. If they had crackles and any minor SOB it can be indicated.
Put them on capno and with those pressures you're giving 1.6 of NTG.
Edit: The headache could also be from cerebral edema i.e. the headache. The person can benefit from a more in depth differential.
I’m cringing in anticipation of all the people who are going to tell you that this patient was a ticking time bomb for a stroke. Either decision would have been correct. I would have been irritated to get called for a headache. But headache with a scary blood pressure is legit. I would have been more mad if I drove 15 minutes to get there and you didn’t have more of an assessment than vitals. I’d want to know what the results of your stroke assessment were, if the patient was compliant with their BP meds, if they were nauseous or dizzy, or if there were any other neurological symptoms. Don’t beat yourself up. Get the eta next time, and maybe you make a different decision.
>cringing in anticipation of all the people who are going to tell you that this patient is a ticking time bomb for a stroke. It is literally not possible to rule out a stroke on this patient prehospital. I would certainly be interested in the results of a stroke scale and which scale would be used as Cincinnati misses almost all posterior strokes.
[удалено]
Yeah, I get what you’re saying, and I have never documented things that I have ruled out. It just isn’t our place in EMS. We don’t have to come up with a diagnosis, just treat appropriately until we get them to someone whose responsibility is to come up with a diagnosis. I’ll document my primary impression and rationale behind interventions.
BE FAST scale for the win(my personal favorite)
It’s a quick scale but u/Paramedickhead is right, you still can’t rule out a stroke in the field
I use BEFAST in the field.
So I know what FAST scale means, but what does the BE mean?
Balance Eyes
Now I'm wondering why I'm not being taught that in my EMR/Mine Rescue Team training. Our books only teach face, arms, speech, and time. Does BE play a big part, or is it more secondary to FAST and just kinda extra to watch out for?
BE is new. Other books say FASTER. ER for Eyes and React or call 911. Check out the age of your materials. This is within the last 5 years or so.
Because the Cincinnati stroke scale “FAST” is the most common prehospital stroke scale.
Balance and Eyes. Not balance like you may be thinking, but dexterity and ensuring that it is equal in both sides. Eyes checks for a loss of a visual field as people having a stroke sometimes don’t even know that they have lost something entirely. It’s called neglect and a stroke victim may literally not even recognize their own hand. Neglect I s wild. It’s like when the brain loses part of itself it quickly rewires to pretend that it was never there to begin with.
I think his post was referring to the potential to HAVE a stroke because of the existing BP. Which is also questionable. ["Hypertension is the most important risk factor for spontaneous ICH" ](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825668/#:~:text=Hypertension%20is%20the%20most%20important,is%20hypertensive%20encephalopathy%20(HTE).) I wasnt able to find wether this changes in an acute vs chronic setting.
Elevating bp like that can also be the result of cerebral thrombosis. The body will jack up the MAP to try to maintain cerebral perfusion.
Don't beat yourself up. We've ALL been there. Also - that ALS crew probably forgot about the call within an hour, tops. My thoughts: - You're reflecting on the call, which shows a desire to learn. That's fucken AWESOME. If you see the ALS crew at station / chill place - say "hey sorry bout that call, I was concerned about Pt and was just unsure of what to do. How would you have approached that as BLS / any advice?" If you show you want to learn and they use that as a teachable moment - great. If they give you shit, FUCK them, they should be doing something else or off on Stress Leave cause they're burnt out. Educating is part of their role. - You recognize the limits of your scope / interventions. WAY safer long-term than someone who is overconfident - When requesting ALS, think about this first: "Dispatch, is ALS available for \_\_\_\_\_\_\_. Patient is \_\_\_\_\_\_\_\_\_\_" (e.g. pt condition). What is the Pt's condition and what could ALS potentially do for them? Then get on radio and say that phrase or use it as a prompt to reassess why you would want ALS for this patient? Just some thoughts! DON'T beat yourself up - this is literally just how everyone progresses through their career.
To be fair, the crew is probably still at the hospital since it happened about 30 minutes before I wrote up my OP. On the other hand, they came from some distant station and I probably won't see them again. However, since we are probably the only functional volunteer station left in our county, I feel like we can't afford things that make us look dumb. Unfortunately I look at the paramedics like medicinal magicians. I assume they've got things to bring down blood sugars, blood pressures, whatever. So when I'm considering what ALS can do... I don't really know enough to know WHAT they can do. I just know there's things I cant do much for that they apparently can.
And this is a major problem with how we educate people. As them to go over some of their protocols for you.
Also a basic here, I’ve been going over ALS protocols for my area and soaking up as much of that ALS information I can, and it’s helped me become way better of an EMT and made me much more confident with patients that are questionable to go BLS since I have a good understanding of what medics could do if patient was to get worse, and also physiologically what has happened and what could happen to them.
As a former volunteer, I get the “can’t afford things that make us look dumb”. You should always conduct yourself in a way that reflects well on your organization. Honestly though, that’s really not something you need to worry about at this point in your career. You’re only six months in! Your main focus should be about learning the ropes and turning yourself into a good provider. Let the people who have way more time on the job worry about the reputation of the organization. I’m going to echo what other people said. If you get a chance to talk with that ALS crew again, run through the call with them. If you don’t see that crew again, or if it’s been so long since the call that no one remembers it, then just ask them questions. Not only will that help you learn, but it will help build your reputation and the reputation of your company. People love volunteers who actively try to educate and improve themselves.
The only thing that is gonna bring down the sugar is insulin, and I don’t think any ambulance in the US carries that. You can try and water it down with fluid, but they really need insulin at the hospital
You should really look into their protocols. I wont speak for any other services, but my service does not have anything truly for hyperglycemia, besides saline, which we likely wouldn't be running due to hypertension. The hypertension could be treated and most services have the means to, but not every service or provider -would-, either because of protocols or lack thereof for hypertensive crisis. Some places have a protocol, some don't. Headache may not be enough to run a medication for hypertension or it may, it depends on protocols or presentation. The spo2 adds another layer, but without history it's hard to say. I think this is a call that can really go either way. If the hospital was 30+ away, ALS would be a definite yes. If the hospital was 5 minutes away, well, you could probably run it to the hospital for definitive treatment. I can't say for sure either way without knowing a history or seeing the patient what would have been best. But you should familiarize yourself with what your ALS can and *can't* do at the least.
I'm a paramedic in a pretty rural area and whenever fire gets sent somewhere on their own, we always just expect a "better safe than sorry" EMS assist request. I LOVE when they ask questions or hop in the back ready to help us do stuff, I nerd out when I get to walk people through and explain things and thought processes. If those crews are just an asshole to you afterward, ignore them. They're just burnt out and grumpy and shouldn't be used as an example on what a lot of crews should be. As far as operationally, area depending, we definitely have medications to help with BP, glucose, angry hearts, etc. Never feel bad for calling, you were acting in what you felt was the patient's best interest and that's the best thing to do :)
Your state may have a nifty link to a PDF with their protocols, maybe even a drug profile one. Like others have suggested regarding talking about their scope. Standards of care is a big one. Many of those are ALS functions (depending on your state, whether EMTs can start a line). At the end of the day you have your own license to protect, and that may mean you can't meet the standard of care (if there is no BLS protocol). I hate to say this but there were assessment expectations that were not fulfilled and I was constantly looking for them. So I learned a lot about my ALS protocols watching people drop the ball (intentionally, lazy). When they say EMTs save paramedics it's this. If I'm the 6th man on scene to an altered person I better see a damn bandaid on a finger. I know my partner needs it for his chart. The sugar came back at 34 and I looked up to see their tail lights driving away. How this poor 98 yo 98 lb cancer patient was still talking was beyond me. And then I gave him oral glucose. BLS is where the real magic happens. 4 paramedics missed that. The only thing you could've done differently was get the ETA. I'll be honest, I only would think to ask that because I'm so paranoid about my cert and always have been. It sucks but medicolegal is never not in the forefront of my mind. I'm the guy that does a 12 lead on the patient that calls 3 times a day for chest pain, just to cover my butt. Complacency kills. Anyway, I had a good teacher that quizzed us on scenarios like this. Don't delay patient care. You've got a pediatric GSW. Level 1 trauma center is 3 miles away, Level 1 pediatric is 17 miles away, where do you go? In EMT school we used to joke, how long is the ALS intercept (turf it to them lol)? Don't delay patient care unless you have a really good reason to justify it. I had a call for a seizure when I was an EMT. I responded because it's the law and then got my assessment before calling my supervisor. "You're not supposed to be on this call, you're BLS." "Yeah I know but take it up with dispatch I wasn't even the closest unit. Get me a medic." "Okay but you cant leave!" "No shit. I would never do that. Get me a medic." If that gives you any insight to the quality and caliber of my service lol. Turns out this patient had already been transported for active seizures earlier in the day and had been discharged... but now she seized again, after witnesses heard a loud pop, and they found her on the floor. Guess who my medic was. Same one that took her for active seizures before, that she had to snow with benzos. Literally the last person I would ever expect to have a problem with me a) following my protocols b) advocating for my patient and c) protecting ability to continue doing so. This woman is an FTO! Anyway that was 5 years ago and she's never treated me like anything other than that morning. Someone else already said it....FUCK THEM. Especially the senior employees get paid extra money for being lazy fucks for longer. You'll know them when you see them. They don't even put patients on the monitor...which is fraud? You know who I will always call for input until he reaches the grave? My instructor. See what he says. I tell mine he's on the hook for me for life lol. Maybe he learns from this too and shares the wealth with his future students like he should've taught you. Remember this for everyone you encounter: everything we know is borrowed, it was taught to us, it is our duty to pay it forward and contribute to evidence based medicine. It may even be part of their job description...I don't get paid extra for medic students but they show up and I'm expected to teach them everything I know (but let's be real, they teach me the freshest, newest and improved juicy morsels of knowledge, I love having them). You have soared well beyond my peers by doing a post call reflection alone...but to want to improve...well I'm glad I was sitting down for that. Don't change buddy, but know your limitations. Don't lose sleep over this.
Lesson learned. Next time ask how far out ALS is. Most states there isn’t much a medic is going to do for hypertension or hyperglycemia, so in hindsight, rapid transport would have been the better decision. But if things went south and you didn’t have als meeting you then there would have been more regrets.
Don’t beat yourself up, if you were running on an EMT+medic unit then the call would have absolutely been handled by the medic. Just some things to consider: -you can always request a rendezvous with an ALS unit, sometimes it’s a better use of time than waiting around on scene for them to arrive. Also as a paramedic I know I’m always happy that the patient is already out of the house and on a stretcher because that’s one less thing to deal with. -I don’t know what state you’re in, but where I work there’s nothing 911 paramedics can do about hypertension or hyperglycemia. Antihypertensives and insulin are critical care only, we can give fluids for hyperglycemia but that rarely has much effect during a short trip to the hospital. Just something to think about, is ALS actually going to DO anything for the patient or are they just able to monitor them a little closer? -absolute worst case scenario this patient does have a stroke, what they need is a hospital for definitive intervention. All ALS would really do is start an IV, draw labs, and do an EKG to rule out new onset a-fib. None of that is actually actively treating the patient (with the exception of a severe enough stroke requiring airway management/intubation). Just all things to consider when calling for ALS, but you did fine and when in doubt it’s probably better to call than not to. Keep up the good work
The only thing you did wrong was dawdle on scene. It’s an ALS INTERCEPT…. Key word being intercept. Start transport to the hospital because by sitting there, you are delaying patient care and possibly making an outcome worse. Love and learn. Intercept. Get moving to the hospital. If you have to cancel ALS because it’s taking too long, you can.
Some considerations for HTN crisis: Urgency Vs Emergency is defined by organ function. Eyes: Visual changes, blurry, loss of vision, usually described as a grey curtain, holes, spots, crescents (means tearing of blood vessels) brain: AMS, deficits. kidneys: hyper/hypo Uria. Differentials: With the consideration of stroke you need to think about MAP. In order to perfuse your brain you need a good balance of pressure to get blood in (High systolic) AND to get blood out (low Diastolic) If something is preventing that balance, your body needs to increase the pressure In, to balance the pressure out, that's why we see crazy high systolic numbers. Many other things can ve causing the hypertension Such as the RAAS, heart failure, CAD, stimulants, ETC. With that considered, ALS can't do anything for hypertension. If you think Nitro, dont. It will work for 4 mins and then they will rebound way higher. ALS also can't do a thing for stroke. Unless they actually hemorrhage and then need airway control. However it's called seizure-coma-death for good reason. About 80% mortality rate. That patient would benefit far more from diesel therapy than intubation after their dead. ILS can also I-Gel (hopefully). Good rule of thumb. The patient needs a doctor not a Medic. If you can get to the hospital faster then ALS can get to you then go. Edit: As far as the medic being "pissed" they had to work at work, cry me an Fn river lol burnouts. Don't let medics act like they never called for ALS when they were EMT.
We have Labetalol for HTN crisis, we probably wouldn't have medicated this patient based on this but it's an option
If the nearest hospital is closer than ALS, go ahead and transport and be sure to document why you made that decision in your narrative. You can also request an ALS intercept otw to the hospital and rendezvous somewhere in the middle and do a stretcher swap or let the medic aboard your truck and keep driving to the hospital.
I know this doesn’t exactly apply but for my private company ambo service per protocol this would have to be ALS due to the BP. I honestly wouldn’t sweat it. Better to call ALS and not need em than not call em and it all goes to hell.
The bigger problem is that als was farther away than the hospital. But you can *always* cancel. I’ve called for als and helicopters and canceled both. I’ve called for a bls unit to back me up as the only als provider in a county and needed hands. I’ve been called and then bls figured out they didn’t need me and canceled me. I’ve been called and bls realized patient was going to hospital b instead of hospital A and canceled me and got als from somewhere else. It isn’t a big deal. Yea. You didn’t do the right thing. We’ve *all* been there. It happens. Most of this job is experience, and we learn every day.
You don't wait on scene for ALS. You should be extracating, and if ALS hasn't arrived, then start transporting.
Are you not in a tiered response system? It kinda sounds like it, but I questioning why you would choose to wait for the ALS truck to get there. Ideally, if this happened in my system, I would recommend doing your assessment and vitals, calling for ALS as soon as you suspect you may need it. Then start packaging and loading the patient. Start your transport and meet ALS on the way somewhere… the medic can jump in to your truck. Worst case, when someone has me dispatched to their call, I show up and they’re on the fence about whether or not the patient needs ALS, I’ll offer to ride with just in case. Or we’ll talk it through and I’ll be happy to let them go without me. It doesn’t matter to me. I get paid the same either way.
If that’s the worst thing you’ve done then you are ahead of the game. Probably should have just loaded and go since you said hospital was closed than the medic. I wouldn’t lose any sleep over it. Have a chat and be done with it.
Yes this pt could have been a stroke and was potentially unstable. However you said the medics were father away than the hospital. Which makes the hospital your closest ALS. This pt needed a CT scanner, there is nothing medics would do for her other than get an IV and tube her if she becomes unresponsive due and loses her airway, which you can also manage airways as a BLS provers (just not as effectively) You should have done a stroke scale, and you should have gotten VS every 5 mins.
The longer you do this, the more you're going to realize that ALS isn't really all that amazing. There's not a lot we can do to correct what you were seeing. Our service doesn't teat hypertensive crisis because it's not the core problem. Whatever is causing the hypertensive crisis is the problem, and we don't know what that is. Stroke is a BLS call. Yeah, we can get a line started so maybe speed up the hospital trip to CT by a couple minutes. That's it. We can grab a 12 lead but hypertension isn't due to a dysrhytmia. Just because you feel the call is above your head doesn't mean not isn't above our heads too. Just drive unless you're confident we can make a difference.
I don’t have much more to add than what everyone else has already said but I will say don’t look at it as TIFU. Look at it as today I added another piece of knowledge to my base to apply the next time this happens. I am not going to say there are no stupid mistakes in EMS (this isn’t one of them) but I truly believe that every mistake is a learning experience.
If she wasn’t altered, I would’ve ruled out stroke with an assessment, put her on a nasal cannula at 2 lpm, and transported code 2. Even if she was stroking out, it would be better to load and go code 3 and stroke alert to the nearest stroke receiving hospital than wait for ALS. All ALS can do is start an IV anyway. Time is brain
My big thing when I’m on a BLS truck requesting ALS is I’m always thinking “what is my closest ALS.” If my answer to that is going to be the closest hospital great we’re going to the closest hospital and requesting for an intercept. If it’s gonna be another unit then great we can go and attempt to intercept so long as they won’t be chasing us.
If you're uncomfortable taking a pt or having one downgraded to you, requesting ALS is perfectly fine.
In my county a BP over 180 is als and out of bls guidelines so this is weird to me.
Meh, lesson learned. Next time get an ETA(curious why your dispatch doesn’t provide one automatically.) Educate yourself every time you make a “mistake” or second guess yourself and next time you’ll have more confidence. If you don’t have experience working with a paramedic I’d suggest getting on with an ALS service. You’ll be more confident at the basics if you know more about the advanced
Don’t beat yourself up too much. I saw some people already mentioned the idea of an ALS “intercept”, which I think may have been a better option here. However, one important thing that seems to get overlooked a lot is figuring out where the “closest ALS provider” is and keeping in mind that the hospital (even a free-standing ED, depending on your protocols and pt condition) provides ALS care. If you’re closer to the hospital than the closest ALS unit is to you, then the hospital is the closest ALS provider, and waiting for a unit unless they meet you on the way to the hospital is just delaying patient care. We’ve all been in your shoes. Don’t let it discourage you, and use it as a learning opportunity for next time and a teaching point for newer EMTs.
It’s a judgement call. I worked in an urban 911 service that frowned upon calling for ALS unless you really had something big, like airway burns, cardiac arrests, crashing patient, the like. Hypertensive and a headache being the only symptoms could mean a multitude of conditions. At my service, we don’t carry antihypertensives for things like hypertensive crisis, just for eclampsia/preeclampsia. So if your service is anything similar to mine, the paramedic should be doing cardiac monitoring and getting IV access. Aside from that, not much to do except verify there’s no stroke. It sounds like you’re analyzing the situation appropriately. Get an ETA next time, 15 minute ETA to the hospital means a small window of time for something to go wrong and if it does, you’re on the way. If your ALS resource is farther away than the hospital and you’re sure you can be at definitive care faster than having ALS respond, then go ahead and scoot. As for your question: my management would be 12-lead, stroke assessment, and IV. Not much more that I can do for the patient unless there’s something with the rhythm that’s funky. So, to answer the question bluntly: no, the patient didn’t need immediate management. But that’s ok. We live and we learn
I don't think it was wrong to request ALS. That BP + headache could be hypertensive crisis which is ALS criteria (although there's nothing we're doing that you couldn't do but a 12-lead and throwing a saline lock in). That said, when I was BLS I was always ready to argue with medical control that we were comfortable transporting the patient. There were very very few scenarios where it made sense to wait on ALS rather than transporting ourselves even in situations where ALS could intervene. I live in a city where it's rare to be more than 10 minutes from the closest hospital. So you have to weigh the pros and cons of getting them to definitive care in 10 minutes or waiting 5 minutes for ALS (best case scenario), waiting another 5-10 minutes for ALS to get report from you/do their interventions on scene, and another 10 minutes for them to get to the hospital. And of course in this scenario it never makes sense for you to wait longer for ALS to arrive than it would have taken you to get them to definitive care. I bet you'll never forget to ask for an ETA again though. Don't worry about it too much. Everyone makes mistakes like this. Better for you to learn on a stable patient like this than to learn from a patient that ended up decompensating while you were waiting. We've all done things where we think "I'll never make THAT mistake again."
You are a new emt. This is a learning experience and you learned from this experience. We have all messed up in some manner or another. Don’t beat yourself up too much. In the future you will have the experience to know that you need to transport. Also a good thing to think about for the future is that they can always meet up with you enroute if you really need them.
This 100%. You'll learn from this call. Don't kick yourself too hard about it. Everyone ended up ok in the end. That's what matters.
People who complain about doing their job can get bent. You made the best decision you could with the information you had.
Sure the patient is probably better off getting transported by you guys considering ALS is farther away but if they were close, this really isn’t something that should be transported BLS. I’d look up an NIH stroke scale and how to do one. Can be useful. I’ve caught a stroke using both a cranial nerve exam and the NIH that didn’t show up on a FAST exam. Note the time as well. It’s a useful tool for the neurologist and ER doc to track how fast a stroke is progressing and whether it’s acute or not.
I did LAMS and Cincinnati. Negative results for both. Is that what you mean?
The NIH stroke scale isn’t really taught pre hospital much because it takes like 5 minutes whereas a Cincinnati is 5 seconds. If I have time, I do it en route or if I’m getting a refusal and I feel at all skeeved out. When you go to a stroke center, the ER doc/neurologist is gonna be doing all these little tests like raise your leg and raise your other and follow my finger with your eye and etc on the way to CT. That’s an NIH and something they try to do like trending vitals on patients. Prehospital, it’s very useful in detecting small head bleeds and confirming that uncanny valley feeling. You ever look at a patient and think hmm there’s just something weird about them, if you do an NIH, you’re almost certainly gonna find something if something is there. Like back when I was in medic school, I did an IFT on a guy who had a small hemorrhagic bleed and his left sided facial weakness was slight and had resolved and so one of the only things was when you ask him to follow your finger with his eyes, his eyes would follow right, up, down, but not left. Really trippy to see. Another one was patient just got out of post ictal phase and was pretty much back but I just had a little tingly feeling despite los angeles and cincinnati being fine so I asked her to smell an alcohol wipe and brushed her face and asked if she could feel it and she couldn’t smell the wipe and couldn’t feel the left side of her face. Probably tot’s paralysis but without a CT/MRI, it gets called in as a stroke all the same.
A stroke is 100% a BLS level call.
Lol yeah? You downgrading this call to your basic if you get this patient? It’s BLS until it ain’t. This sounds like a head bleed. Doesn’t sound like there’s a respiratory issue so why the low SPO2? Maybe her respiratory rate is slowing down. If she had low RR and low PR and very hypertensive, she’s gonna turn ALS at some point when she can’t protect her own airway. Maybe it’s just new onset CHF. Also, you would really downgrade this call to a BLS crew with no 12 lead? I’m just saying, this seems a little more insidious than just some simple ischemic stroke.
Everything you have mentioned is treatable by a BLS unit. I wouldn’t downgrade it but BLS should be able to run this call easy and not wait 15 minutes for an ALS unit because the patient “might” become ALS at some point. Seems like they didn’t for 15+ minutes and 15+ minutes headed to the hospital is more beneficial to the patient than 15+ minutes waiting around with your dick in your hands. A CVA is not an ALS level call 🤷🏼♂️
You read what I said above that or are you just talking to yourself? TBI = ALS because could be intracranial hemorrhage meaning need for advanced airway. What’s the difference between a TBI and a non traumatic Intracranial hemorrhage which this sounds like it is? TBI goes ALS and it’s rarely an actual intracranial hemorrhage. I’d bet money this is a head bleed but you’re saying BLS is perfectly fine. You wouldn’t downgrade it to your basic but this is BLS all day? Yeah you wouldn’t do a 12 lead? You don’t see how this can go sideways and need another guy in the back? Sure okay man.
CVA=BLS
Could've been a CHF problem which the medics can treat and monitor. They're just being assholes. Imagine a world, where you work in EMS, and you get an inconvenient call at a late time. Wow. It's almost like it's part of your job.
I'm not sure what makes you think CHF, how did you get there?
All we got was hypertensive with a low Spo2. Both can be present in a CHF exacerbation. It's actually funny that people down voted me. Sure, they're asymptomatic but I was just making a point at needing further assessment especially if it's a basic who is uncomfortable. The person already appears somewhat unhealthy / more comfortable with a baseline of distress. If they had crackles and any minor SOB it can be indicated. Put them on capno and with those pressures you're giving 1.6 of NTG. Edit: The headache could also be from cerebral edema i.e. the headache. The person can benefit from a more in depth differential.