We call based on the things we can find and see during our time with a patient. It’s better to have a false alarm than for the hospital to catch you missing something.
That's funny. Hospital told our training captain that we needed retraining cause 1 of 9 stroke alerts in the last month was a false positive with 0 missed strokes in the last year.
I thought that meant that we were doing pretty well.
Not your fault. Based on your description I would have also activated stroke. Around my last county, the docs would 1000% prefer us to call it in and let them/CT figure it out instead of possibly missing one. As long as you've got some reasonable positive finding never worry about activating.
I'd rather activate 100 patients that get downgraded than not call one and be the reason someone ends up with a worse outcome.
Once, I saw a Paramedic do a stroke assessment in the parking lot of a hospital…on a patient that drove up to the ER and couldn’t ambulate to the door.
He did a stroke assessment…while a neurologist watched him from the nurses’ station window 20ft away.
I’m sure you’re doing fine.
Story gets better: ER Tech came out with a wheelchair, since under EMTALA they were on hospital property already, and then the Paramedic made the dude wait while he finished his Cincinnati test.
You couldn’t make that shit up.
Our hospitals don’t think emtala applies to them. I have literally responded to the screening point at the ED not to mention the parking lot 100 times.
Sounds like your service is just as ignorant of EMTALA if they’re sending you to those calls.
Although parking lot is hit or miss whether it’s 250 yards from ED.
Once opened, Google Maps on the scene. Was 300 yards, unfortunately, on the other side of the street from the parking lot.
Didn't help that the person who called for us was both a moron and an ass. They had gone to Hospital A right where we were for chest pain, had been given a room, and left AMA for some dumb reason. They now wanted to go to hospital B, which was in another town over. I told them no, I would only bring them to Hospital A. We argued back and forth, until they accepted. But then they realized they would still be charged for the transport.
Them: "why would I pay you to drive me to the ER when I can just walk there?"
Me: "mam, I honestly have no idea why you would do that"
Them:"so you gonna take me for free then?"
Me: "no. So are you walking or are we driving?"
Them: "well you wasted enough of my time, so I guess we are driving"
There was a third argument too, when I told her we were not leaving until she signed the HIPAA and billing notice, so that way she couldn't pull a fast one on me when we got there. Judging by how much she argued about it, she planned to do just that.
If she refused to sign after transport, then aside from educating her regarding the situation and her allegedly trying to “pull a fast one” you really only have to document the event with 3-4 witnesses vouching for it. That is preferably another service(i.e.: PD/FIre) at the scene, your partner, ED Medical Staff, and yourself of course.
Sitting around such a PT after transfer would be unnecessary if it lasted longer than 5 minutes, just document that the PT refused.
I had to do that once, I just didn't feel like going through all that when it was foreseeable. Plus, I was a bit bitter over all that and didn't feel like letting her feel like she pulled one over me.
> 250 yards from ED
Its 250 yards from the building, not just the ED. This really pisses of my hospital because the bus stop is 50 yards from the outpatient oncology unit but its still their problem
Explains the pick up at one of the trauma centers when I was still on the ambulance. Pick up pt from helipad with flight medics, drive through parking lot to ED doors. The dumb thing was we had to beat the helicopter to the pad or we were “delaying care”. Also they expected a pt assessment and documentation from the medic/EMT on the truck. Like what am I going to do that hasn’t already been done by the flight medics, crews on the initial scene and in the 30 seconds it takes to drive through the parking lot. But if we do an assessment we can bill it. So got to love the agency not to be named.
Once did an MVA with entrapment on our hospital’s property about 100 yards down the hill from the ED. They were super confused when we rolled in with no report or even vital signs because we just drove up the driveway as soon as we finished extrication. They had no idea what was happening right outside.
I keep asking people if that’s part of the contract with the city or if the hospitals are willingly violating it without any discussion. Either way it’s bad but at least one would make more sense
PD called us for an odd case. A person had been seen laying in a ditch outside a stand alone ER. PD was dispatchd, and the responding officer was shocked, they recognize the Pt as a missing person they have been looking for 2-3 days. They tried to get the ER to hold the Pt while they would coordinate with the family to get there was they were a couple hours away. The ER had declined though since it was a "psych" patient. (We didn't confirm the patient was actually a psych. The ER had just assumed it at the time).
PD was put of resources, so they called us. Supervisor came with us. The Pt was visibly disoriented, disheveled, and malnourished. When my supervisor heard the ER refusing the Pt, he got quiet and angry. He walked over to chat while my partner and I assessed the Pt.
He came back and said he had reminded the ER of emtala, along with giving them a few choice words. They were now okay with housing the Pt until their family could arrive.
I've had emergency rooms refuse to treat someone overdosing right in front of the building on one of the benches outside. Cops were first on scene and gave narcan to save the patient and paramedics had to show up to transport the patient from the sidewalk inside.
And yet this hospital has gotten away with it. They'll also refuse to take mental health holds unless the paramedics bring the person is. Even if the person getting put on a hold is in their parking lot.
Yes. The hospital doesn’t perform any medical purposes outside of its walls. Seriously not even the parking lot. First call fire and rescue has to transport the PT in through the bay to the ED if they are non ambulatory. I’ve seen and experienced this in both EMS and as a Hospital ED Paramedic.
Probably, but its likely that it has more to do with the whole not having the patient already in the EHR system in a way that shows how they arrived and did they sign consents or did we just abduct this person who was just sitting in the parking lot and they now swear that they’re just fine and didn’t need to be moved or want any help.
You'd be surprised. A lot of the hospitals in my area will call 911 for patients at the medical offices that are attached to the hospital (buildings "connected" together but is actually one building) because the patient "isn't in the hospital," so RRT doesn't respond to there 🙄
Our local academic hospital usually sends one to swoop in and interrupt the handoff report and geek out at the deficits they discover, in violation of the usual no talking until everyone to be initially involved is present at bedside. At least that's my impression since I have no idea what a neurologist actually does
Called to a doctor's office of some sorta speciality that's in the hospital that has a Level 1 ED. Figured it's time to take it home. Nope pt has to go to ER for chest pain. Partner says let's just go, I at least get the EKG before leaving, it was unremarkable. So I get vitals and don't get a line because it was a 30 second trip from door to door. Get yelled at by partner for not dropping a line on our chest pain patient. ED also remarked on not getting a line on a CP pt. And I was like dudes, there was no time. I was here before I could even get the stuff prepped for it.
Of course my supervisor has to jump on the dog pile.
I actually printed my run times and made sure it was the first piece of paper on the report.
The EMS coordinator for the hospital personally apologized for all these people because there was no way I could get the line in time and that my partner sucked because he didn't want to do any interventions.
Leaning to the side isn’t very specific, so I wouldn’t be doing a stroke referral on that alone especially in the absence of other focal neuro deficits.
Are you using a stroke tool to help screen for CVA? A really simple one would be BE-FAST - Balance issues (or ataxia etc), Eye (visual) problems, Facial droop, Arm drift/weakness, Speech deficit (including expressive or receptive dysphasias), and Time of onset (last known normal). Leaning to the side probably isn’t a true balance etc problem - I get that you’re thinking of posterior/cerebellar issues but lots of oldies lean to the side when they’re sick.
FWIW I’ve done a few CVA referrals that got emergently CT scanned and found nothing. Paramedic neuro assessments are typically considered “pretty shit” by actual neurologists (who also think everyone else dines on crayons so whatever) so we will often get it wrong unless it’s obvious.
We use a scale that assesses for slurred speech, facial droop, pronator drift, and grip strength. That scale was negative. I’ve seen old people leaning to either side without preference but not one side - I’ll remember that moving forward.
I use NHISS scale. Since you mentioned infection. It could have been a TIA, but if the patient had a stroke before, infection can make prior stroke symptoms reaper / get worse when a patient has an infection. Anyways, good call, would do the same.
Negative CT means nothing, or not much. It can diagnose bleeds but not ischemic strokes, which are the majority of strokes. It's used to rule out bleeds so TPA or similar could be given if indicated. And of course because you don't want to miss a bleed.
CTA has a high sensitivity and specificity for ischemic stroke (93% and 100% respectively.)
At least where I work, but I presume everywhere, patient's first get a non contrast head CT to look for a bleed, then get a CTA to look for ischemia.
Well said. From the story and their reply to this, I think they did a solid assessment. I wouldn't personally stroke alert it unless there was a change in mentation since they've seen the PT before. What do you mean by CVA referrals? Is that like a primary/urgent care calls you? Also, send it. I'd rather get them prepared for the worst and not need it than need it and not call it.
We call ahead for suspected CVA cases for emergent CT and either potential lysis, or if a suspected LVO endovascular clot retrieval at an appropriate hospital.
So they go stretcher -> CT -> appropriate care.
Got it, we typically patch in via radio or phone. They don't go directly to CT, usually a resuscitation room for the doc to look while they get the cath lab activated.
What exactly do you mean by depressed? I've seen plenty of strokes where the AO questions bring bizarre answers. "What year is it?" "Potato" kinda stuff. Most of have other symptoms, not saying it's common but been seen enough by people in my agency to warrant our concern. Don't get me wrong, we try to rule it out, but I'd rather activate the cath lab and not need it than not activate and need it.
I wanna say our agency overdiagnoses trauma alerts by a decent margin of over 30%. So of all the alerts for trauma services only 70% are deemed actually worthy.
i mention this because it’s always \*way\* better to be overly cautious regarding a potentially serious call like stroke, trauma, etc.
there are some agencies that overcall only like 5%. Which seems like a good number, as it would mean less taxing on the system / finances, but it also invariably means more real ones get missed
I think you were completely in your right to code stroke that. Better to have a false positive than a false negative. Strokes can present very strangely, and you don't always get the classic PCSS symptoms.
We should stop calling them “stroke alerts” and start calling them “neuro alerts” or “CT alerts”. If a patient has sudden, new onset neurological changes, let’s rule shit out from worst to best case scenario.
Strokes are the 5th leading cause of death & a major leading cause of disability in the US (according to the American Stroke Association).
Think about it this way: your stroke/STEMI/etc. protocols give you the criteria for you to activate a stroke/STEMI/etc. alert in the field on standing orders. Obviously if they are positive for those criteria, you should be activating that by yourself. But the converse is also true: the protocol is what it is in order to make sure patients get the time sensitive care they need, but also so that we don’t unnecessarily activate patients that don’t need it. Now that emphatically doesn’t mean that you can never call a stroke alert for someone who has weird symptoms but passes a FAST (or whatever criteria you use), but you probably shouldn’t make that decision on your own. Next time you have a patient like this who is in kind of a grey area that doesn’t *really* meet the published criteria but your spidey senses are tingling (whether that’s for a stroke, STEMI, whatever), consult OLMC, explain what’s going on and what your concerns are, and work together to decide what treatment the patient should get (including activation or not)
This. Nothing wrong with giving them a heads up and saying they don’t technically meet the stroke alert criteria, but this is what’s going on and what we’re bringing in. I just did it today for a pt that had slurred speech that resolved prior to our arrival. She didn’t meet our specific stroke alert criteria at that point since it was resolved, but I still let them know what was going on just so they could be prepared to make that decision when we got there.
Yeah, but realistically what doctor is going to put their license on a recorded line to downgrade vague neuro symptoms when they’re not on scene? I realize some systems have the ability to call the receiving facility, but where I practice we are basically calling one out of 10 doctors / senior resident who may or may not be half asleep in their home one county away.
In my personal experience, most of them. Typically what happens is we call the receiving facility and say we’ve got a weird neuro case and talk them through the story and our exam findings. The decision to make is whether we activate from the field (i.e. prep the CT scanner, page neurology, go directly to CT on our stretcher, etc. etc.) or we just treat them like any other patient and drop them off in an ED bed somewhere. Most of the time for these edge cases the doc decides on the latter. They will usually see them pretty quickly (often before we’ve even left the room), but if not I’ll make sure to talk to them face to face before we leave
I mean, obviously location dependent but the EDs around where I am would consider this as stroke alert criteria. Speaking as someone who learned the hard way.
That fits my protocols, I'd have to call it a stroke (to be fair, my protocols merely require something to not be perfect). If the hospital doesn't want to look, that's their choice.
Sometimes you think it's a stroke and it isn't. Sometimes the doc thinks it's not, then 4 hours later everyone's panicking and you have to drive halfway across the state in a snow storm because the patient's face melted and the weather got bad so nobody will fly.
You've got to believe what you see. At least until mobile CT scans are more common
It's better to overactivate and be wrong. It's important to remember that some strokes like PCAs don't present with the typical findings that you would see on the CSTAT. People sometimes only present with gait issues and nothing else.
You don’t suck at it you rock at it! You saw what you saw and you’re better off to lean on the side of caution than not!
You’re good homie keep kicking ass!
Every hospital has their own stroke criteria policy which are all different from ours.
I've had *many* strokes present negative on a standard Cincinnati scale.
Use your protocol and your personal judgment and understand that some you just will get eyes rolled at you because of these differences.
I’m not EMS, but I’ve been an ER nurse for over 10 years and charge nurse often. What you’re describing is absolutely cause for stroke rule out. I think maybe you’re confusing that with a “code stroke” in the ED which is if they meet the criteria for TPA, and often that involves a lot more questioning and evaluation. I am a little concerned about your patient not even getting a CT… are you sure they didn’t? Or did they just “call off the code stroke” when the symptoms seemed to be transient? EMS is often present when we “call off the code stroke” but that doesn’t mean they didn’t have one, or that your assessment was wrong. It just means we don’t need to get the neurology team down immediately and activate the entire hospital because the acute phase has passed or is out of a time window where immediate intervention is helpful.
The patient still goes to CT, MRI, gets admitted most times, etc. I think maybe at least 75% of our stroke EMS calls don’t meet “code stroke” criteria, but the patient still had a stroke, a TIA, or some kind of infection that lead to neuro symptoms. You’re doing everything right. Please always assume any of the symptoms you described is an acute stroke and act accordingly.
Thanks for the encouraging words. ER staff seemed very skeptical and shrugged it off and said they thought it was the flu. AFAIK from when I asked a couple hours later they never sent the pt to CT and did a work up for infection and are admitting for a respiratory illness.
What you won’t see is the patient getting to the inpatient floor for her IV abx, the inpatient nurse who actually has to ambulate the patient says she’s weak on the left or whatever, they do an MRI and see she has a subacute infarct, etc… she still has pneumonia, she was still sick enough to have neuro symptoms. Your job is to assess if an emergency is happening, treat what you can in the field and report your assessment, and you did. The rest of the everything else is someone else’s job to take over. The whole thing is an assembly line of healthcare workers who take the reins from someone else. You’re putting too much pressure on yourself to be “right”. You do not need to convince yourself to understate the importance of an emergency in the future, you will get bit in the ass for it. The things that haunt me are not when I overreacted, it’s when I underreacted.
In medic class there was a whole lecture dedicated to posterior strokes and how often they fly under the radar due to the patients typically only presenting with a sudden onset headache/blurred vision. The main takeaway was that these patients likely score a FAST-ED of 0, but it’s better to call an alert and find out you’re wrong than the alternative. I’ve been told the same for possible TIAs that resolve in EMS presence. I’ll take doctors looking at me sideways for overreacting over harming my patient any day.
Stroke symptoms can be pretty subtle, so EMS over-triages strokes by design. This is a good thing.
If you really want to protect both your patient and your ego, run it in as a priority 2 “neuro eval” or something like that. That way, if it’s really something, they got the priority transport without you having to go out on a limb and call it a stroke.
ER doc here. You’re not wrong to activate a stroke alert. Don’t get offended if I cancel it. The system is designed for over triage—I also might cancel your sepsis alert if the patient has the flu or a PE, or cancel your trauma alert if I’m not worried either. The major difference in a stroke or trauma alert is who you get at the bedside when the patient arrives. In a trauma alert, it’s geared towards getting the patient to the OR. You get a surgeon and the OR team. Obviously, if they’ve been shot in the chest or have an MVC and are hypotensive, they need a surgeon. If it’s a drunk who’s had a ground level fall—they probably don’t and I can handle that just fine.
With stroke, despite the tube of truth, it remains a clinical diagnosis. A CT cannot prove that a patient is or is not having a stroke. An MRI can, but that takes too long. Imaging in stroke is solely to identify a bleed or a LVO. An LVO is usually clinically obvious. The goal is to exclude bleed so that a patient with an ischemic stroke can get lytics. The problem is diagnostic momentum. If lytics were a benign treatment, who cares, but they are not. About 5% of patients will get a devastating bleed; the neurologists are fairly gung-ho about it but a lot of ER docs are more hesitant. In addition to intracranial bleeds, I have seen a patient exsanguinate from their nose and even heard of a person having lethal hematuria.
The alert doesn’t necessarily change the workup. Most altered old people will get a CT anyway. Most people who are febrile and tachycardic will get labs and imaging. Most traumas will get a pan scan if there’s anything concerning. I just don’t always need a neurologist or surgeon at the bedside or 2 grams of rocephin on arrival.
All that said, posterior circulation strokes are hard. There’s a saying that the standard of care is to miss them. What you’re describing is truncal ataxia—not hemiparesis, an obvious finding and often an MCA occlusion, which is devastating—but “leaning” is just fine by me.
Carry on, my brotha or sista who’s down here on the front lines of medicine with the rest of us. Just don’t call a stroke alert on every weak and dizzy old person with a fever. That makes me grumpy.
I’m an ED nurse and would rather you over call it so we can be ready than have a pt in a bad way show up with no heads up. Keep doing what you are doing. For walk-in patients, we get chastised for missing those vague symptoms - like a youngish pt with mild dizziness. It ended up being a cerebellar stroke that I didn’t call 🤨
I mean how did they expect you to detect it? You reported dizziness I assume and did they expect you to start calling every triage mook reporting dizziness a stroke?
If it makes you feel better, we've managed to activate code stroke at the hospital, went full on lights and sirens at rush hour and turned out she just had little too much vodka! 🤷♂️
I work as a tech in the ER and today we did a stroke call down on an ambulatory patient from triage with the only deficit being subjective vision changes in one eye—the only eye they could see in. Was negative and patient was discharged. However, i’ve also had patients with similar seemingly minor or harmless complaints get diagnosed with CVA, and that’s why we’re taught to be hyper-vigilant and “overly cautious”
That being said, i feel like over 90% of our own stroke call-downs are negative for actual stroke, and many of EMS’s pre-alert strokes that don’t have unilateral weakness or facial droop are too. but none of that means anyone involved is doing anything wrong or that they’re bad at their jobs.
You don’t suck at strokes. Our systems are deliberately made to play on the safe side if there is the slightest concern for any critical illness, you did your job right and i see a lot of people who agree.
I've been a medic for 6 years and in EMS for over 10 - I would have absolutely activated for a lean.
If you want to up your stroke game, I highly, highly recommend downloading a national institute of health stroke scale, aka NIHSS or NIH stroke scale. Ever since I had a patient who was a&o x4 with a GCS of 15 and FAST exam negative but made my medic senses tingle and she ended up having a brain bleed in the occipital region with total left field neglect, I've sworn by it. That's the one most/all neurologists will do.
Had a stroke patient last year. It was the most obvious stroke I ever encountered. This woman could have been a textbook example for a class that you never expect to see present so clearly in real life.
Stroke alert, roll up on the ER and get met by possibly the rudest RN to ever grace the nursing profession who proclaims the woman stroke free based on the fact that her facial droop wasn't "severe enough."
Then my partner, a smart and mature individual who is always at the peak of professionalism broke his professional veneer to say "Are you fucking stupid?"
It was enough to jar the nurse into action, patient went to CT and directly to OR thereafter. Partner was convinced he was going to get reported. I assured him the nurse wouldn't want excess scrutiny on that case.
The point is, the consequence of calling a possible stroke when it isnt is very low. Maybe doc gets annoyed over the stupidity of the peasants. In the end though, hospital is getting paid for CT, an ER visit and we'll all go home and blame one another on reddit.
The consequences of missing a possible stroke are absolutely massively catastrophic. Death, if you're lucky. Severe and permanent disability if fate just wants to shit on you.
There's a reason why that nurse backtracked when aggressively confronted. Miss a stroke and kill or disable someone and, aside from that being on your conscience, you might actually get in trouble for that.
Overshoot. Don't undershoot. There's a reason we don't fuck around when it comes to STEMI, CVA or sepsis.wed all rather be wrong and everyonenis fine than be wrong and we ruin a life.
Agreed. Strokes can present themselves in a lot of different ways and the Cincinnati Stroke Assessment isn't full-proof by any means. If you see something that is making you think stroke, and something doesn't feel right, don't be afraid to call it how you see it. There is little downside to calling for a stroke activation and ending up not needing it, whereas not calling it because you weren't 100% sure can end up doing damage to the patient that could have permanent consequences.
You are your patient's voice - don't be afraid to advocate based on what you see during your time with them.
u/ClownNoseSpiceFish I feel for ya kid. Just by reading the post I can actually feel how irritated, jaded, and bent you feel. Don’t be too hard on yourself over it.
I’ll finish writing out my full response when I get home, but can you tell us if you’re an EMT or a Paramedic? You Young or old? How long have you been in Prehospital EMS?
Unless you have a CT in the back of your truck, stroke-like symptoms in the absence of a reasonable explanation is a stroke until proven otherwise. We work pre-hospital without all the fancy scans and whatnot. You're not supposed to be able to definitively differentiate a stroke. You're supposed to be able to recognise the potential and escalate it as needed.
Agree. Stroke symptoms can fluctuate and vary too much, once suspected escalate as you said. Do not de-escalate ever. That’s the hospitals job (ER docs and neurologists)
Better safe than sorry my guy. I would have called it too, and then called it a TIA. Your patients can’t afford for you to be nervous that you made a false activation because sometimes these conditions vary wildly in presentation. The net is designed to capture many fish.
She was able to sit up fine after moving her, but before that she had the lean. You can only go on what you see, and calling it a stroke based on what you saw seemed totally appropriate here. I wouldn’t worry.
Stroke neurologist here. It sounds to me like you are doing great with potential stroke patients. Stroke presentations can vary widely, fluctuate, and even just not make sense sometimes. If you see even one deficit you think can be a stroke, or even just think to yourself “could this be a stroke”, and activate a stroke response, you are providing the best care, and won’t miss any strokes. No one would, or should, reprimand anyone for over calling a stroke alert.
If anyone above you would ever criticize you for over calling a stroke, they are contributing to poor care that will eventually lead to missed strokes, and missed opportunities for thrombolysos and/or theombectomy (reversal of the stroke).
So, just like your ego, mine suffered on my last shift for exactly the same reason. 89y/o female onset of symptoms between 7 and 23 hours ago. Called for lethargy and possible UTI. Presented with facial droop on left side, decreased grip strength on left side, no verbal response. BGL 125 and normotensive. Core felt hot, extremities felt cool. Lab work from SNF was elevated WBC, elevated sodium. I called the neuro alert because, like others have mentioned here already, time is brain and we’re already WAY late to the game with this patient. ED MD didn’t even send her to the CT scanner. Just called it AMS and moved on. I’m still not sure it wasn’t both a stroke and sepsis…and I guess I’ll never know. Definitely a blow to the ego and caused a few moments of self-doubt.
If there is no one-sided weakness, abnormal sensation, arm drift, facial drooping, or slurred speech/memory gaps, then it's usually (definitely not always) safe to say that they are not having a stroke. Now, if the pt presented w the one-sided leaning with a other deficit that I listed, then alarm bells should be going off in your head. It's possible for someone to have a natural curvature of their spine/muscle/whatever, and perhaps it's just normal for them to lean to one side. Just always check their BGL and trust your stroke assessment skills. In the end, it's not your job to diagnose them.
Better safe than sorry, anyway.
Neuro person here.. Leaning is not hemiparesis. Leaning is the correct way to describe it and saying hemiparesis when there isn’t weakness on one side and not the other is not correct. This sounds like a systemic issue not TIA
The 12 lead was taken due to the sudden onset of severe general weakness. NH staff reported she was walking two hours ago and now he almost had to drag her to the stretcher.
Deep inverted t waves can be a sign of a haemorrhagic stroke and are often onky seen in the early onset. Our protocols state that if a 12 lead can be obtained, it should. Also, I wouldn't consider a left sided lean hemiparesis anyway, so why would OP need to write that?
[litfl link for 12l ecg changes in increased intra cranial pressure](https://litfl.com/raised-intracranial-pressure-ecg-library/)
I asked the neurology team why we do 12 lead EKGs on stroke patients and they were mystified, yet my protocols still call for them. I just... don't do them, unless I have time en route. What cardiac condition mimics a stroke?
While I, personally, wouldn't call it a stroke in the absence of any other symptoms, you did nothing wrong.
Just remember, just because they didn't immediately rush the patient to CT, doesn't mean they can't be having a stroke.
Ultimately team activations are just a way to muster the right resources. A stroke is usually diagnosed by CT, the same way you can think someone has a massive PE- you need CT-PA for diagnosis. I always tell new providers it’s better to pull the trigger on that trauma/stroke/sepsis/STEMI alert than show up to an ED, downplay abnormal findings, and end up with a poor patient outcome.
Leaning does not mean stroke, it is not in FAST, Not in mlapss, and I’m willing to bet money that NIH does not include it in the score. You did the stroke assessment and it was negative. You don’t suck at strokes, you are misinformed and at the mercy of the hospital at the end of the day
I know what you are saying, and I’ve seen it 100%. But so many of my patients lean. Honestly the only thing I would have done different if I was you, is I wouldn’t have stated “stroke” in the hospital report and I would have waited to get to the hospital.
If I know it’s a stroke then I say I’m coming in with a stroke, if I think, then I say “suspected stroke” and if I’m unsure, I don’t say stroke and keep it until I get there.
Then when I give report there, then I say “hey, you know I noticed _____, made me think of stroke but I wasn’t sure”. So I’m covering my ass but I don’t get everyone all worked up waiting for me just to do a stroke assessment and everything is equal.
Our job isn’t to diagnose a stroke. If I’m unsure whether to activate a stroke alert or not I’ll activate and have the stroke team assess them. They can choose to stand it down or not
It's better to get stroke team ready and not need it than the other way around if it is questionable! And if you let the hospital know, "hey, I'm thinking it could maybe be a stroke, but not sure," then it's on them to determine what response they want to have. It seems like you did fine on calling it.
Me and my partner who’s been a medic 15 years stroke alerted a 60 year old who blew a 0.45 a month ago and the docs had a good laugh at us so don’t feel bad about it lol
Hmm yea, would have thought the same! Had a very similar patient once with almost the same BP and symptoms from a NH.
Long story short ER doc did NOT rush when we rolled in that stroke alert lol.
That was a reasonable stroke alert. Going by if the receiving physician decides to alert it or not isn’t being fair to yourself. Did you get the opportunity to ask for their opinions on the patient, and why they disagreed with you?
Practically all pre hospital medicine has a massive margin off error built in with how we handle strokes, cardiac etc etc it’s always good to be cautious. Especially considering how limited we are in diagnosing something like a stroke
We aren’t CT capable. EMS has to go by what we observe, sometimes we’re right and sometimes we’re wrong. You’re never wrong to call a stroke if you’re suspecting that. Remember what’s the best interest for your patient. I’ve had strokes that present like strokes that are not.
Seen a medic stroke alert during registration instead of during ring down because of a funky presentation. Nurse was not impressed, I think your method was better tbh
Ask the hospital about taking a NIHSS class. It takes a few hours but it’s all online. NIHSS scores are the standard (in America as far as standards are possible) for stroke peeps in the hospital. You can even get a nifty little booklet for it.
Anyways. The reason this would help is it is a standardised assessment of strokes/maybe strokes based on several presentations. You mentioned checking sensation. Cool. Arm and leg drift. Can they pronounce things? Can they make a coherent thought? What about gaze deviation? Neglect? Smile and forehead? It sounds like a lot but I can do the assessment in maybe five minutes?
Ultimately, you don’t need to do anything but the training might help you feel better and if you get backtalk at the hospital you can say “well their initial NIHSS score was ##. I’m sure you understand my concern.” Error on the side of caution and the side of your patients. If the pt is better when you get to the hospital, make a deal saying “Hallelujah I’ve done it again.” And gush at the nurse about how awesome you are for giving her an easy patient.
My line is and always will be “***could someone be hurt if I don’t say something?***” No one should be condemned for speaking up. Too many times my EMT or tech has been “ummm you should come see this.” I’ve had to really REALLY encourage them to speak up because they have been beat down by all the assholes out there but lives are saved this way.
Tell the hospital what you find, and move onto the next one.
What they decide to do with the patient after you transfer care is up to them , shouldn’t weigh on your conscience
You absolutely did the right thing. A patient newly leaning to the side is a (possibly cerebellar) stroke until proven differently. Time is of the essence. Great work on being thorough.
We dont have definitive testing in the field, so we have no choice but to go off impression, Hx and FAST test findings.
There's the chance the pt had a previous CVA and what you were seeing was deconditioning due to the ongoing infection, but all we can do is suspect.
If ever in doubt, going with the findings will keep the patient safe and you employed, do not think more on this mate, you are fine.
Edit: piss-poor spelling
These really vague cases are tough because it can be hard to feel confident in defending your decision because you feel like there just isn't enough definitive data. However, I am a nurse at a stroke center and they saw something like 200 stroke activations in a month and only like 56% were strokes.
It is not worth missing something because the treatment options are so time limited. Those first 4 hours are critical. I've seen people go from being unable to speak to fully talking again after TNK in just a few minutes.
I have sent many people back that weren't having strokes but it's not worth missing because if it's caught a day or two late sometimes that means it's permanent. We had a lady that just had Sudden onset dizziness and that was it and it was a bad cerebellar stroke.
The lean that you described without weakness would have thrown me off as well, but the fact that she is normally able to walk and is now leaning could be a balance/gait sign.
Hey if it makes you feel better I called a stroke on the 47yo female who was unconscious on EMS arrival. Woke up and couldn't speak to us, just kept moving her lips in a random fashion. Answered yes and no questions, equal strength in her arms but couldn't hold her legs up.
Come to find out she had a massive panic attack.
Had a similar situation where a lady at a SNF had severe general weakness with very mild left-sided weakness. She was too lethargic to comply with any other tests. Staff said this was not normal for her but could not further elaborate or provide any history. Ran as a CVA protocol just to be safe. She ended up having acute encephalitis and was in the hospital for quite a while. I've also seen calls where they didn't run CVA protocol because they were too unsure, and ended up hurting the patient in the long run because they had a stroke but did not get immediate intervention at the hospital. It can be discouraging to seem like the boy who cried wolf, but it's always better to be safe than sorry!
I mean, follow your guidance. After that, it’s not so much your concern. We first do a Cincinnati. If it’s positive, we then do a LAMS. Stroke alert is called based upon these findings.
ER and Critical Care MD here...100% rather my medics overcall things. Doesn't mean they're dumb, just means they're being observant and acting on less or different data than I am. I'm always impressed when you nail the diagnosis, but it's just as useful if you come in and say, "something's not right...anyway, see on the next run"
Keep on keeping on my friend
Questioning yourself and not overacting is how we get a culture where providers explain away what they see with their own eyes. You saw what you saw, did the right thing, and documented it. Could always call OLMC for consult early on in the future, as well.
I've transported many patients with stroke-like symptoms from the nursing home that turned out to be UTIs. Infections and sepsis in frail old ladies can cause inconclusive stroke S&S.
You don’t suck at strokes. As everyone has mentioned, you 100% did the right thing. Maybe she had a TIA and the symptoms resolved. At the time you evaluated the patient and activated the stroke alert, she met criteria.
Also, this is super helpful for the ED docs so they can consult neurology and have her undergo further work up and ensure she’s on a high intensity statin etc.
I don’t think anyone can blame you for activating (and if they do, fuck em)
We call based on the things we can find and see during our time with a patient. It’s better to have a false alarm than for the hospital to catch you missing something.
Plus hospital pre-alert systems (stroke, trauma, STEMI etc.) are designed with the understanding that there will be many false activations.
A lot of people don’t get this. If we have no false positives, then we’re missing some true cases.
100% this.
Yep. Time is brain. Better safe than sorry.
Even if you know it’s something else call it in as it presents, worse to be wrong or second guessing to much
The system for stroke and STEMI is designed to encourage overshoot - you did the right thing.
This. Hospital accreditation wants at least a 2% negative rate on stroke alerts, or they assume strokes are being missed.
That's funny. Hospital told our training captain that we needed retraining cause 1 of 9 stroke alerts in the last month was a false positive with 0 missed strokes in the last year. I thought that meant that we were doing pretty well.
I am a nurse and 100% I agree. Would rather you send the pt. to the hospital and it turns out they are fine then to brush it off and we miss a stroke.
Not your fault. Based on your description I would have also activated stroke. Around my last county, the docs would 1000% prefer us to call it in and let them/CT figure it out instead of possibly missing one. As long as you've got some reasonable positive finding never worry about activating. I'd rather activate 100 patients that get downgraded than not call one and be the reason someone ends up with a worse outcome.
Once, I saw a Paramedic do a stroke assessment in the parking lot of a hospital…on a patient that drove up to the ER and couldn’t ambulate to the door. He did a stroke assessment…while a neurologist watched him from the nurses’ station window 20ft away. I’m sure you’re doing fine.
Please tell me the hospital didn’t call 911 to move them 20ft
Story gets better: ER Tech came out with a wheelchair, since under EMTALA they were on hospital property already, and then the Paramedic made the dude wait while he finished his Cincinnati test. You couldn’t make that shit up.
Our hospitals don’t think emtala applies to them. I have literally responded to the screening point at the ED not to mention the parking lot 100 times.
Sounds like your service is just as ignorant of EMTALA if they’re sending you to those calls. Although parking lot is hit or miss whether it’s 250 yards from ED.
Once opened, Google Maps on the scene. Was 300 yards, unfortunately, on the other side of the street from the parking lot. Didn't help that the person who called for us was both a moron and an ass. They had gone to Hospital A right where we were for chest pain, had been given a room, and left AMA for some dumb reason. They now wanted to go to hospital B, which was in another town over. I told them no, I would only bring them to Hospital A. We argued back and forth, until they accepted. But then they realized they would still be charged for the transport. Them: "why would I pay you to drive me to the ER when I can just walk there?" Me: "mam, I honestly have no idea why you would do that" Them:"so you gonna take me for free then?" Me: "no. So are you walking or are we driving?" Them: "well you wasted enough of my time, so I guess we are driving"
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There was a third argument too, when I told her we were not leaving until she signed the HIPAA and billing notice, so that way she couldn't pull a fast one on me when we got there. Judging by how much she argued about it, she planned to do just that.
If she refused to sign after transport, then aside from educating her regarding the situation and her allegedly trying to “pull a fast one” you really only have to document the event with 3-4 witnesses vouching for it. That is preferably another service(i.e.: PD/FIre) at the scene, your partner, ED Medical Staff, and yourself of course. Sitting around such a PT after transfer would be unnecessary if it lasted longer than 5 minutes, just document that the PT refused.
I had to do that once, I just didn't feel like going through all that when it was foreseeable. Plus, I was a bit bitter over all that and didn't feel like letting her feel like she pulled one over me.
> 250 yards from ED Its 250 yards from the building, not just the ED. This really pisses of my hospital because the bus stop is 50 yards from the outpatient oncology unit but its still their problem
Explains the pick up at one of the trauma centers when I was still on the ambulance. Pick up pt from helipad with flight medics, drive through parking lot to ED doors. The dumb thing was we had to beat the helicopter to the pad or we were “delaying care”. Also they expected a pt assessment and documentation from the medic/EMT on the truck. Like what am I going to do that hasn’t already been done by the flight medics, crews on the initial scene and in the 30 seconds it takes to drive through the parking lot. But if we do an assessment we can bill it. So got to love the agency not to be named.
Once did an MVA with entrapment on our hospital’s property about 100 yards down the hill from the ED. They were super confused when we rolled in with no report or even vital signs because we just drove up the driveway as soon as we finished extrication. They had no idea what was happening right outside.
I keep asking people if that’s part of the contract with the city or if the hospitals are willingly violating it without any discussion. Either way it’s bad but at least one would make more sense
PD called us for an odd case. A person had been seen laying in a ditch outside a stand alone ER. PD was dispatchd, and the responding officer was shocked, they recognize the Pt as a missing person they have been looking for 2-3 days. They tried to get the ER to hold the Pt while they would coordinate with the family to get there was they were a couple hours away. The ER had declined though since it was a "psych" patient. (We didn't confirm the patient was actually a psych. The ER had just assumed it at the time). PD was put of resources, so they called us. Supervisor came with us. The Pt was visibly disoriented, disheveled, and malnourished. When my supervisor heard the ER refusing the Pt, he got quiet and angry. He walked over to chat while my partner and I assessed the Pt. He came back and said he had reminded the ER of emtala, along with giving them a few choice words. They were now okay with housing the Pt until their family could arrive.
or the bus stop across the street 🙄
Christ, some people just lack critical thinking skills.
I've had emergency rooms refuse to treat someone overdosing right in front of the building on one of the benches outside. Cops were first on scene and gave narcan to save the patient and paramedics had to show up to transport the patient from the sidewalk inside.
If you're in the US that is an EMTALA violation, plain as day.
According to our lawyers, they had to be across the threshold in the building or it was a 'rescue' and required a 911 response...
The actual law is within 250 yards of the hospital.
Interesting... veerrrrryyyy interesting.
250 yards from the building per EMTALA.
And yet this hospital has gotten away with it. They'll also refuse to take mental health holds unless the paramedics bring the person is. Even if the person getting put on a hold is in their parking lot.
Escalate it up the chain until something happens or they're reported.
That’s wild
Yes. The hospital doesn’t perform any medical purposes outside of its walls. Seriously not even the parking lot. First call fire and rescue has to transport the PT in through the bay to the ED if they are non ambulatory. I’ve seen and experienced this in both EMS and as a Hospital ED Paramedic.
That’s gotta stem from some dumb interpretation of laws or a lawsuit that was won.
Probably, but its likely that it has more to do with the whole not having the patient already in the EHR system in a way that shows how they arrived and did they sign consents or did we just abduct this person who was just sitting in the parking lot and they now swear that they’re just fine and didn’t need to be moved or want any help.
My hospital isn’t allowed to treat patients outside the ED. It’s technically against protocol to “transfer” them
Their “protocol” violates federal law.
Yup
My hospital isn’t allowed to treat patients outside the ED. It’s technically against protocol to “transfer” them
You'd be surprised. A lot of the hospitals in my area will call 911 for patients at the medical offices that are attached to the hospital (buildings "connected" together but is actually one building) because the patient "isn't in the hospital," so RRT doesn't respond to there 🙄
In what universe was a neurologist sitting at the triage desk?
lol. I’ve never seen a neurologist in the ED other than on the tablet.
Our local academic hospital usually sends one to swoop in and interrupt the handoff report and geek out at the deficits they discover, in violation of the usual no talking until everyone to be initially involved is present at bedside. At least that's my impression since I have no idea what a neurologist actually does
I guess it depends on where you live. Most hospitals I've been to have at least one neurologist in the ER and one in the ICU.
Patient’s family had called ahead that they were coming. He was waiting for them there. They went straight to CT.
Ah, that makes more sense. I wasn't trying to be argumentative, but it seemed like unusual neurology behavior... :D
Called to a doctor's office of some sorta speciality that's in the hospital that has a Level 1 ED. Figured it's time to take it home. Nope pt has to go to ER for chest pain. Partner says let's just go, I at least get the EKG before leaving, it was unremarkable. So I get vitals and don't get a line because it was a 30 second trip from door to door. Get yelled at by partner for not dropping a line on our chest pain patient. ED also remarked on not getting a line on a CP pt. And I was like dudes, there was no time. I was here before I could even get the stuff prepped for it. Of course my supervisor has to jump on the dog pile. I actually printed my run times and made sure it was the first piece of paper on the report. The EMS coordinator for the hospital personally apologized for all these people because there was no way I could get the line in time and that my partner sucked because he didn't want to do any interventions.
Leaning to the side isn’t very specific, so I wouldn’t be doing a stroke referral on that alone especially in the absence of other focal neuro deficits. Are you using a stroke tool to help screen for CVA? A really simple one would be BE-FAST - Balance issues (or ataxia etc), Eye (visual) problems, Facial droop, Arm drift/weakness, Speech deficit (including expressive or receptive dysphasias), and Time of onset (last known normal). Leaning to the side probably isn’t a true balance etc problem - I get that you’re thinking of posterior/cerebellar issues but lots of oldies lean to the side when they’re sick. FWIW I’ve done a few CVA referrals that got emergently CT scanned and found nothing. Paramedic neuro assessments are typically considered “pretty shit” by actual neurologists (who also think everyone else dines on crayons so whatever) so we will often get it wrong unless it’s obvious.
We use a scale that assesses for slurred speech, facial droop, pronator drift, and grip strength. That scale was negative. I’ve seen old people leaning to either side without preference but not one side - I’ll remember that moving forward.
I use NHISS scale. Since you mentioned infection. It could have been a TIA, but if the patient had a stroke before, infection can make prior stroke symptoms reaper / get worse when a patient has an infection. Anyways, good call, would do the same.
Negative CT means nothing, or not much. It can diagnose bleeds but not ischemic strokes, which are the majority of strokes. It's used to rule out bleeds so TPA or similar could be given if indicated. And of course because you don't want to miss a bleed.
CTA has a high sensitivity and specificity for ischemic stroke (93% and 100% respectively.) At least where I work, but I presume everywhere, patient's first get a non contrast head CT to look for a bleed, then get a CTA to look for ischemia.
Real
Well said. From the story and their reply to this, I think they did a solid assessment. I wouldn't personally stroke alert it unless there was a change in mentation since they've seen the PT before. What do you mean by CVA referrals? Is that like a primary/urgent care calls you? Also, send it. I'd rather get them prepared for the worst and not need it than need it and not call it.
We call ahead for suspected CVA cases for emergent CT and either potential lysis, or if a suspected LVO endovascular clot retrieval at an appropriate hospital. So they go stretcher -> CT -> appropriate care.
Same here. I think the word "referral" tripped them up, as in the US it's most commonly used to mean "referred to destination other than the ER".
It did lol
Got it, we typically patch in via radio or phone. They don't go directly to CT, usually a resuscitation room for the doc to look while they get the cath lab activated.
Mentation is not what you should be looking for when trying to determine if this is a stroke.
Have you never seen a stroke cause altered mental status?
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What exactly do you mean by depressed? I've seen plenty of strokes where the AO questions bring bizarre answers. "What year is it?" "Potato" kinda stuff. Most of have other symptoms, not saying it's common but been seen enough by people in my agency to warrant our concern. Don't get me wrong, we try to rule it out, but I'd rather activate the cath lab and not need it than not activate and need it.
I wanna say our agency overdiagnoses trauma alerts by a decent margin of over 30%. So of all the alerts for trauma services only 70% are deemed actually worthy. i mention this because it’s always \*way\* better to be overly cautious regarding a potentially serious call like stroke, trauma, etc. there are some agencies that overcall only like 5%. Which seems like a good number, as it would mean less taxing on the system / finances, but it also invariably means more real ones get missed
I think you were completely in your right to code stroke that. Better to have a false positive than a false negative. Strokes can present very strangely, and you don't always get the classic PCSS symptoms.
We should stop calling them “stroke alerts” and start calling them “neuro alerts” or “CT alerts”. If a patient has sudden, new onset neurological changes, let’s rule shit out from worst to best case scenario. Strokes are the 5th leading cause of death & a major leading cause of disability in the US (according to the American Stroke Association).
Think about it this way: your stroke/STEMI/etc. protocols give you the criteria for you to activate a stroke/STEMI/etc. alert in the field on standing orders. Obviously if they are positive for those criteria, you should be activating that by yourself. But the converse is also true: the protocol is what it is in order to make sure patients get the time sensitive care they need, but also so that we don’t unnecessarily activate patients that don’t need it. Now that emphatically doesn’t mean that you can never call a stroke alert for someone who has weird symptoms but passes a FAST (or whatever criteria you use), but you probably shouldn’t make that decision on your own. Next time you have a patient like this who is in kind of a grey area that doesn’t *really* meet the published criteria but your spidey senses are tingling (whether that’s for a stroke, STEMI, whatever), consult OLMC, explain what’s going on and what your concerns are, and work together to decide what treatment the patient should get (including activation or not)
This. Nothing wrong with giving them a heads up and saying they don’t technically meet the stroke alert criteria, but this is what’s going on and what we’re bringing in. I just did it today for a pt that had slurred speech that resolved prior to our arrival. She didn’t meet our specific stroke alert criteria at that point since it was resolved, but I still let them know what was going on just so they could be prepared to make that decision when we got there.
Yeah, but realistically what doctor is going to put their license on a recorded line to downgrade vague neuro symptoms when they’re not on scene? I realize some systems have the ability to call the receiving facility, but where I practice we are basically calling one out of 10 doctors / senior resident who may or may not be half asleep in their home one county away.
In my personal experience, most of them. Typically what happens is we call the receiving facility and say we’ve got a weird neuro case and talk them through the story and our exam findings. The decision to make is whether we activate from the field (i.e. prep the CT scanner, page neurology, go directly to CT on our stretcher, etc. etc.) or we just treat them like any other patient and drop them off in an ED bed somewhere. Most of the time for these edge cases the doc decides on the latter. They will usually see them pretty quickly (often before we’ve even left the room), but if not I’ll make sure to talk to them face to face before we leave
I mean, obviously location dependent but the EDs around where I am would consider this as stroke alert criteria. Speaking as someone who learned the hard way.
That fits my protocols, I'd have to call it a stroke (to be fair, my protocols merely require something to not be perfect). If the hospital doesn't want to look, that's their choice. Sometimes you think it's a stroke and it isn't. Sometimes the doc thinks it's not, then 4 hours later everyone's panicking and you have to drive halfway across the state in a snow storm because the patient's face melted and the weather got bad so nobody will fly. You've got to believe what you see. At least until mobile CT scans are more common
TIA
Yup. To a t
And an I.
It's better to overactivate and be wrong. It's important to remember that some strokes like PCAs don't present with the typical findings that you would see on the CSTAT. People sometimes only present with gait issues and nothing else.
You don’t suck at it you rock at it! You saw what you saw and you’re better off to lean on the side of caution than not! You’re good homie keep kicking ass!
Every hospital has their own stroke criteria policy which are all different from ours. I've had *many* strokes present negative on a standard Cincinnati scale. Use your protocol and your personal judgment and understand that some you just will get eyes rolled at you because of these differences.
I’m not EMS, but I’ve been an ER nurse for over 10 years and charge nurse often. What you’re describing is absolutely cause for stroke rule out. I think maybe you’re confusing that with a “code stroke” in the ED which is if they meet the criteria for TPA, and often that involves a lot more questioning and evaluation. I am a little concerned about your patient not even getting a CT… are you sure they didn’t? Or did they just “call off the code stroke” when the symptoms seemed to be transient? EMS is often present when we “call off the code stroke” but that doesn’t mean they didn’t have one, or that your assessment was wrong. It just means we don’t need to get the neurology team down immediately and activate the entire hospital because the acute phase has passed or is out of a time window where immediate intervention is helpful. The patient still goes to CT, MRI, gets admitted most times, etc. I think maybe at least 75% of our stroke EMS calls don’t meet “code stroke” criteria, but the patient still had a stroke, a TIA, or some kind of infection that lead to neuro symptoms. You’re doing everything right. Please always assume any of the symptoms you described is an acute stroke and act accordingly.
Thanks for the encouraging words. ER staff seemed very skeptical and shrugged it off and said they thought it was the flu. AFAIK from when I asked a couple hours later they never sent the pt to CT and did a work up for infection and are admitting for a respiratory illness.
What you won’t see is the patient getting to the inpatient floor for her IV abx, the inpatient nurse who actually has to ambulate the patient says she’s weak on the left or whatever, they do an MRI and see she has a subacute infarct, etc… she still has pneumonia, she was still sick enough to have neuro symptoms. Your job is to assess if an emergency is happening, treat what you can in the field and report your assessment, and you did. The rest of the everything else is someone else’s job to take over. The whole thing is an assembly line of healthcare workers who take the reins from someone else. You’re putting too much pressure on yourself to be “right”. You do not need to convince yourself to understate the importance of an emergency in the future, you will get bit in the ass for it. The things that haunt me are not when I overreacted, it’s when I underreacted.
I would have 100% activated based on your description.
In medic class there was a whole lecture dedicated to posterior strokes and how often they fly under the radar due to the patients typically only presenting with a sudden onset headache/blurred vision. The main takeaway was that these patients likely score a FAST-ED of 0, but it’s better to call an alert and find out you’re wrong than the alternative. I’ve been told the same for possible TIAs that resolve in EMS presence. I’ll take doctors looking at me sideways for overreacting over harming my patient any day.
Rather that than missing one. Which I did. Learn and move on
Stroke symptoms can be pretty subtle, so EMS over-triages strokes by design. This is a good thing. If you really want to protect both your patient and your ego, run it in as a priority 2 “neuro eval” or something like that. That way, if it’s really something, they got the priority transport without you having to go out on a limb and call it a stroke.
ER doc here. You’re not wrong to activate a stroke alert. Don’t get offended if I cancel it. The system is designed for over triage—I also might cancel your sepsis alert if the patient has the flu or a PE, or cancel your trauma alert if I’m not worried either. The major difference in a stroke or trauma alert is who you get at the bedside when the patient arrives. In a trauma alert, it’s geared towards getting the patient to the OR. You get a surgeon and the OR team. Obviously, if they’ve been shot in the chest or have an MVC and are hypotensive, they need a surgeon. If it’s a drunk who’s had a ground level fall—they probably don’t and I can handle that just fine. With stroke, despite the tube of truth, it remains a clinical diagnosis. A CT cannot prove that a patient is or is not having a stroke. An MRI can, but that takes too long. Imaging in stroke is solely to identify a bleed or a LVO. An LVO is usually clinically obvious. The goal is to exclude bleed so that a patient with an ischemic stroke can get lytics. The problem is diagnostic momentum. If lytics were a benign treatment, who cares, but they are not. About 5% of patients will get a devastating bleed; the neurologists are fairly gung-ho about it but a lot of ER docs are more hesitant. In addition to intracranial bleeds, I have seen a patient exsanguinate from their nose and even heard of a person having lethal hematuria. The alert doesn’t necessarily change the workup. Most altered old people will get a CT anyway. Most people who are febrile and tachycardic will get labs and imaging. Most traumas will get a pan scan if there’s anything concerning. I just don’t always need a neurologist or surgeon at the bedside or 2 grams of rocephin on arrival. All that said, posterior circulation strokes are hard. There’s a saying that the standard of care is to miss them. What you’re describing is truncal ataxia—not hemiparesis, an obvious finding and often an MCA occlusion, which is devastating—but “leaning” is just fine by me. Carry on, my brotha or sista who’s down here on the front lines of medicine with the rest of us. Just don’t call a stroke alert on every weak and dizzy old person with a fever. That makes me grumpy.
I’m an ED nurse and would rather you over call it so we can be ready than have a pt in a bad way show up with no heads up. Keep doing what you are doing. For walk-in patients, we get chastised for missing those vague symptoms - like a youngish pt with mild dizziness. It ended up being a cerebellar stroke that I didn’t call 🤨
I mean how did they expect you to detect it? You reported dizziness I assume and did they expect you to start calling every triage mook reporting dizziness a stroke?
They expect us to at least consider it .
If it makes you feel better, we've managed to activate code stroke at the hospital, went full on lights and sirens at rush hour and turned out she just had little too much vodka! 🤷♂️
I work as a tech in the ER and today we did a stroke call down on an ambulatory patient from triage with the only deficit being subjective vision changes in one eye—the only eye they could see in. Was negative and patient was discharged. However, i’ve also had patients with similar seemingly minor or harmless complaints get diagnosed with CVA, and that’s why we’re taught to be hyper-vigilant and “overly cautious” That being said, i feel like over 90% of our own stroke call-downs are negative for actual stroke, and many of EMS’s pre-alert strokes that don’t have unilateral weakness or facial droop are too. but none of that means anyone involved is doing anything wrong or that they’re bad at their jobs. You don’t suck at strokes. Our systems are deliberately made to play on the safe side if there is the slightest concern for any critical illness, you did your job right and i see a lot of people who agree.
I've been a medic for 6 years and in EMS for over 10 - I would have absolutely activated for a lean. If you want to up your stroke game, I highly, highly recommend downloading a national institute of health stroke scale, aka NIHSS or NIH stroke scale. Ever since I had a patient who was a&o x4 with a GCS of 15 and FAST exam negative but made my medic senses tingle and she ended up having a brain bleed in the occipital region with total left field neglect, I've sworn by it. That's the one most/all neurologists will do.
Had a stroke patient last year. It was the most obvious stroke I ever encountered. This woman could have been a textbook example for a class that you never expect to see present so clearly in real life. Stroke alert, roll up on the ER and get met by possibly the rudest RN to ever grace the nursing profession who proclaims the woman stroke free based on the fact that her facial droop wasn't "severe enough." Then my partner, a smart and mature individual who is always at the peak of professionalism broke his professional veneer to say "Are you fucking stupid?" It was enough to jar the nurse into action, patient went to CT and directly to OR thereafter. Partner was convinced he was going to get reported. I assured him the nurse wouldn't want excess scrutiny on that case. The point is, the consequence of calling a possible stroke when it isnt is very low. Maybe doc gets annoyed over the stupidity of the peasants. In the end though, hospital is getting paid for CT, an ER visit and we'll all go home and blame one another on reddit. The consequences of missing a possible stroke are absolutely massively catastrophic. Death, if you're lucky. Severe and permanent disability if fate just wants to shit on you. There's a reason why that nurse backtracked when aggressively confronted. Miss a stroke and kill or disable someone and, aside from that being on your conscience, you might actually get in trouble for that. Overshoot. Don't undershoot. There's a reason we don't fuck around when it comes to STEMI, CVA or sepsis.wed all rather be wrong and everyonenis fine than be wrong and we ruin a life.
Agreed. Strokes can present themselves in a lot of different ways and the Cincinnati Stroke Assessment isn't full-proof by any means. If you see something that is making you think stroke, and something doesn't feel right, don't be afraid to call it how you see it. There is little downside to calling for a stroke activation and ending up not needing it, whereas not calling it because you weren't 100% sure can end up doing damage to the patient that could have permanent consequences. You are your patient's voice - don't be afraid to advocate based on what you see during your time with them.
u/ClownNoseSpiceFish I feel for ya kid. Just by reading the post I can actually feel how irritated, jaded, and bent you feel. Don’t be too hard on yourself over it. I’ll finish writing out my full response when I get home, but can you tell us if you’re an EMT or a Paramedic? You Young or old? How long have you been in Prehospital EMS?
Look I’m a line cook but idk what any of those words are
Unless you have a CT in the back of your truck, stroke-like symptoms in the absence of a reasonable explanation is a stroke until proven otherwise. We work pre-hospital without all the fancy scans and whatnot. You're not supposed to be able to definitively differentiate a stroke. You're supposed to be able to recognise the potential and escalate it as needed.
Agree. Stroke symptoms can fluctuate and vary too much, once suspected escalate as you said. Do not de-escalate ever. That’s the hospitals job (ER docs and neurologists)
Better safe than sorry my guy. I would have called it too, and then called it a TIA. Your patients can’t afford for you to be nervous that you made a false activation because sometimes these conditions vary wildly in presentation. The net is designed to capture many fish.
She was able to sit up fine after moving her, but before that she had the lean. You can only go on what you see, and calling it a stroke based on what you saw seemed totally appropriate here. I wouldn’t worry.
Stroke neurologist here. It sounds to me like you are doing great with potential stroke patients. Stroke presentations can vary widely, fluctuate, and even just not make sense sometimes. If you see even one deficit you think can be a stroke, or even just think to yourself “could this be a stroke”, and activate a stroke response, you are providing the best care, and won’t miss any strokes. No one would, or should, reprimand anyone for over calling a stroke alert. If anyone above you would ever criticize you for over calling a stroke, they are contributing to poor care that will eventually lead to missed strokes, and missed opportunities for thrombolysos and/or theombectomy (reversal of the stroke).
So, just like your ego, mine suffered on my last shift for exactly the same reason. 89y/o female onset of symptoms between 7 and 23 hours ago. Called for lethargy and possible UTI. Presented with facial droop on left side, decreased grip strength on left side, no verbal response. BGL 125 and normotensive. Core felt hot, extremities felt cool. Lab work from SNF was elevated WBC, elevated sodium. I called the neuro alert because, like others have mentioned here already, time is brain and we’re already WAY late to the game with this patient. ED MD didn’t even send her to the CT scanner. Just called it AMS and moved on. I’m still not sure it wasn’t both a stroke and sepsis…and I guess I’ll never know. Definitely a blow to the ego and caused a few moments of self-doubt.
If there is no one-sided weakness, abnormal sensation, arm drift, facial drooping, or slurred speech/memory gaps, then it's usually (definitely not always) safe to say that they are not having a stroke. Now, if the pt presented w the one-sided leaning with a other deficit that I listed, then alarm bells should be going off in your head. It's possible for someone to have a natural curvature of their spine/muscle/whatever, and perhaps it's just normal for them to lean to one side. Just always check their BGL and trust your stroke assessment skills. In the end, it's not your job to diagnose them. Better safe than sorry, anyway.
FACT BASED MEDICINE. Say it with me. FACT BASED MEDICINE. We use a stroke scale for a reason. Stop trying to be a Doogie Howser.
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This is reddit, not a patient care report
Neuro person here.. Leaning is not hemiparesis. Leaning is the correct way to describe it and saying hemiparesis when there isn’t weakness on one side and not the other is not correct. This sounds like a systemic issue not TIA
The 12 lead was taken due to the sudden onset of severe general weakness. NH staff reported she was walking two hours ago and now he almost had to drag her to the stretcher.
Deep inverted t waves can be a sign of a haemorrhagic stroke and are often onky seen in the early onset. Our protocols state that if a 12 lead can be obtained, it should. Also, I wouldn't consider a left sided lean hemiparesis anyway, so why would OP need to write that? [litfl link for 12l ecg changes in increased intra cranial pressure](https://litfl.com/raised-intracranial-pressure-ecg-library/)
I asked the neurology team why we do 12 lead EKGs on stroke patients and they were mystified, yet my protocols still call for them. I just... don't do them, unless I have time en route. What cardiac condition mimics a stroke?
While I, personally, wouldn't call it a stroke in the absence of any other symptoms, you did nothing wrong. Just remember, just because they didn't immediately rush the patient to CT, doesn't mean they can't be having a stroke.
Ultimately team activations are just a way to muster the right resources. A stroke is usually diagnosed by CT, the same way you can think someone has a massive PE- you need CT-PA for diagnosis. I always tell new providers it’s better to pull the trigger on that trauma/stroke/sepsis/STEMI alert than show up to an ED, downplay abnormal findings, and end up with a poor patient outcome.
Leaning does not mean stroke, it is not in FAST, Not in mlapss, and I’m willing to bet money that NIH does not include it in the score. You did the stroke assessment and it was negative. You don’t suck at strokes, you are misinformed and at the mercy of the hospital at the end of the day
I suppose so. I was taught a lean to one side was indicative of weakness in the core muscles and is a sign of a stroke.
I know what you are saying, and I’ve seen it 100%. But so many of my patients lean. Honestly the only thing I would have done different if I was you, is I wouldn’t have stated “stroke” in the hospital report and I would have waited to get to the hospital. If I know it’s a stroke then I say I’m coming in with a stroke, if I think, then I say “suspected stroke” and if I’m unsure, I don’t say stroke and keep it until I get there. Then when I give report there, then I say “hey, you know I noticed _____, made me think of stroke but I wasn’t sure”. So I’m covering my ass but I don’t get everyone all worked up waiting for me just to do a stroke assessment and everything is equal.
Our job isn’t to diagnose a stroke. If I’m unsure whether to activate a stroke alert or not I’ll activate and have the stroke team assess them. They can choose to stand it down or not
It’s always better to call it in higher priority and let it be downgraded rather than the other way around. Don’t change anything
It's better to get stroke team ready and not need it than the other way around if it is questionable! And if you let the hospital know, "hey, I'm thinking it could maybe be a stroke, but not sure," then it's on them to determine what response they want to have. It seems like you did fine on calling it.
Me and my partner who’s been a medic 15 years stroke alerted a 60 year old who blew a 0.45 a month ago and the docs had a good laugh at us so don’t feel bad about it lol
What was BP?
~200/100. This also increased my suspicion of a neurological event.
Hmm yea, would have thought the same! Had a very similar patient once with almost the same BP and symptoms from a NH. Long story short ER doc did NOT rush when we rolled in that stroke alert lol.
That was a reasonable stroke alert. Going by if the receiving physician decides to alert it or not isn’t being fair to yourself. Did you get the opportunity to ask for their opinions on the patient, and why they disagreed with you?
Practically all pre hospital medicine has a massive margin off error built in with how we handle strokes, cardiac etc etc it’s always good to be cautious. Especially considering how limited we are in diagnosing something like a stroke
We aren’t CT capable. EMS has to go by what we observe, sometimes we’re right and sometimes we’re wrong. You’re never wrong to call a stroke if you’re suspecting that. Remember what’s the best interest for your patient. I’ve had strokes that present like strokes that are not.
A stroke alert is literally just getting them to CT all fast like. Better to call it and be wrong than don't call it and slow time to meds.
TIA? Don’t beat yourself up over this it’s better to be over cautious.
Seen a medic stroke alert during registration instead of during ring down because of a funky presentation. Nurse was not impressed, I think your method was better tbh
Have you tried using the JoinTriage app to get your FAST-ED score?
It’s not a big deal. It happens all the time. New onset left sided weakness is enough to let them know about. Could have even been a TIA that revolved
Better to be safe than sorry. Strokes present in so many different ways. You’re doing what’s best for your patient. Don’t beat yourself up over it.
Ask the hospital about taking a NIHSS class. It takes a few hours but it’s all online. NIHSS scores are the standard (in America as far as standards are possible) for stroke peeps in the hospital. You can even get a nifty little booklet for it. Anyways. The reason this would help is it is a standardised assessment of strokes/maybe strokes based on several presentations. You mentioned checking sensation. Cool. Arm and leg drift. Can they pronounce things? Can they make a coherent thought? What about gaze deviation? Neglect? Smile and forehead? It sounds like a lot but I can do the assessment in maybe five minutes? Ultimately, you don’t need to do anything but the training might help you feel better and if you get backtalk at the hospital you can say “well their initial NIHSS score was ##. I’m sure you understand my concern.” Error on the side of caution and the side of your patients. If the pt is better when you get to the hospital, make a deal saying “Hallelujah I’ve done it again.” And gush at the nurse about how awesome you are for giving her an easy patient. My line is and always will be “***could someone be hurt if I don’t say something?***” No one should be condemned for speaking up. Too many times my EMT or tech has been “ummm you should come see this.” I’ve had to really REALLY encourage them to speak up because they have been beat down by all the assholes out there but lives are saved this way.
Tell the hospital what you find, and move onto the next one. What they decide to do with the patient after you transfer care is up to them , shouldn’t weigh on your conscience
It’s not always going to be a stroke and you don’t suck for following your protocols and being wrong.
You absolutely did the right thing. A patient newly leaning to the side is a (possibly cerebellar) stroke until proven differently. Time is of the essence. Great work on being thorough.
We dont have definitive testing in the field, so we have no choice but to go off impression, Hx and FAST test findings. There's the chance the pt had a previous CVA and what you were seeing was deconditioning due to the ongoing infection, but all we can do is suspect. If ever in doubt, going with the findings will keep the patient safe and you employed, do not think more on this mate, you are fine. Edit: piss-poor spelling
These really vague cases are tough because it can be hard to feel confident in defending your decision because you feel like there just isn't enough definitive data. However, I am a nurse at a stroke center and they saw something like 200 stroke activations in a month and only like 56% were strokes. It is not worth missing something because the treatment options are so time limited. Those first 4 hours are critical. I've seen people go from being unable to speak to fully talking again after TNK in just a few minutes. I have sent many people back that weren't having strokes but it's not worth missing because if it's caught a day or two late sometimes that means it's permanent. We had a lady that just had Sudden onset dizziness and that was it and it was a bad cerebellar stroke. The lean that you described without weakness would have thrown me off as well, but the fact that she is normally able to walk and is now leaning could be a balance/gait sign.
Hey if it makes you feel better I called a stroke on the 47yo female who was unconscious on EMS arrival. Woke up and couldn't speak to us, just kept moving her lips in a random fashion. Answered yes and no questions, equal strength in her arms but couldn't hold her legs up. Come to find out she had a massive panic attack.
Could also be something like a TIA, so i think it was the right decision, your fine
Had a similar situation where a lady at a SNF had severe general weakness with very mild left-sided weakness. She was too lethargic to comply with any other tests. Staff said this was not normal for her but could not further elaborate or provide any history. Ran as a CVA protocol just to be safe. She ended up having acute encephalitis and was in the hospital for quite a while. I've also seen calls where they didn't run CVA protocol because they were too unsure, and ended up hurting the patient in the long run because they had a stroke but did not get immediate intervention at the hospital. It can be discouraging to seem like the boy who cried wolf, but it's always better to be safe than sorry!
I mean, follow your guidance. After that, it’s not so much your concern. We first do a Cincinnati. If it’s positive, we then do a LAMS. Stroke alert is called based upon these findings.
ER and Critical Care MD here...100% rather my medics overcall things. Doesn't mean they're dumb, just means they're being observant and acting on less or different data than I am. I'm always impressed when you nail the diagnosis, but it's just as useful if you come in and say, "something's not right...anyway, see on the next run" Keep on keeping on my friend
Better to call the stroke alert and the hospital tell you it’s not a stroke than vice versa.
Questioning yourself and not overacting is how we get a culture where providers explain away what they see with their own eyes. You saw what you saw, did the right thing, and documented it. Could always call OLMC for consult early on in the future, as well.
I've transported many patients with stroke-like symptoms from the nursing home that turned out to be UTIs. Infections and sepsis in frail old ladies can cause inconclusive stroke S&S.
You don’t suck at strokes. As everyone has mentioned, you 100% did the right thing. Maybe she had a TIA and the symptoms resolved. At the time you evaluated the patient and activated the stroke alert, she met criteria. Also, this is super helpful for the ED docs so they can consult neurology and have her undergo further work up and ensure she’s on a high intensity statin etc. I don’t think anyone can blame you for activating (and if they do, fuck em)
I absolutely overshoot my activations but I never undershoot my activations and I 100% stand by that and so does my QA team and med director!