Why is a stoke considered an ALS call?

[DrParasite]

seriously, why?

ok, please bear with me on this one. we had a stroke call yesterday. 64 year old man sycopied while watching the NBA finals. LOC for a split second, then was only responsive to verbal stimuli. BP was 200+/120 on both arms. hx of MI 12 years ago, 5 angioplasties since then. no allergies, no meds per his wife, not other information. in my BLS opinion, he was having (or had) a massive stroke. mental status deteriorated to painful stimuli during transport.

anyways, we are a BLS ambulance with 4 people, 3 of whom are EMTs. we are on scene in less than 5 minutes, arrive, realize it is a stroke (not an MI as was dispatched), and load him up to go to the hospital. on scene time is less than 10 minutes. ALS arrives maybe 5 minutes after we do, we tell them to meet us in the truck. we probably sat around in the rig for another 5-7 minutes while they did their assessment. then they finished, and we drove really fast to the hospital.

so my question is, why did we need medics? the only thing they did was start an IV, monitor and transport. so they added another 5 minutes of on scene time to start an IV. the person needed rapid transport to an ER where thrombolitics could be administered, as well as a CAT scan and other stuff pre hospital providers can't do. yes, their is always the possibility of the patient arresting, but you can always over err on the side of caution (see broken arm thread).

me, personally, I think strokes should be considered a BLS emergency (assuming you don't run ALS ambulances). crew arrives, gives oxygen, puts patient in ambulance, goes really fast to hospital, turns patient over to RN and MD who can do something to start reversing the damage caused by the stroke.

any other opinions?

[mittlesmertz]

Interesting comments, Dr P.
I agree, a true CVA should be treated just like a serious trauma. Spend the minimal amount of time on scene and get the pt to the nearest hospital that can treat him appropriately.
Yes, ideally it's an ALS transport, due to the possibilty of worsening level of LOC requiring airway protection.
This potential must be weighed against the amount of time wasted in waiting for ALS to arrive. I say more than 10 minutes, and start going to the ED. MAybe they can catch up to you enroute.
As an EMT you can ventilate, perhaps a combitube if needed. Checking a sugar level is important to rule out hypoglycemia, often mis-diagnosed as a CVA. But this should be a BLS skill as welll.
Again, if it was me, I'd want the quickest route to the ED possible.
Nothing it that ALS rig will stop the stroke's progression, unless you're way out in the sticks and they carry thrombolitics.

[strippel]

CVAs used to be BLS here. ALS was dispatched, but the usually did not ride along, unless there was a decrease in LOC, or the possibility of airway issues. Back then BLS was BLS, and ALS was ALS, different vehicles like you there in Jersey. We are now mostly transporting ALS units.

Now, anything close to a CVA must be ALS. (We don't with TIA- resolved...with history) Since both hospitals in town are "Primary Stroke Centers", all patients must be ALS, a protocol change. They keep track of symptom start time, so they can get them into the CT, and start anticoagulants within 3 hours.

As I wrote on the ALS board a while ago, both hospitals are agressive. One is even very interventional. They can put anticoagulants directly into the clot, and even do a cath, and physically yank the clot out.

[BD6413]

We run some Stroke Calls BLS only and some with ALS based on the information received at the communications center.

Some require it and some don't. Every Patient CVA or Not is going to be diffrent so basically go with it. A good EMT can make the determination weather ALS is needed or not and be able to make the right decision and Re-Call the ALS. However a patient with Syncope and a Cardiac Hx. I might keep the Medics coming if they were close but I will not waist time on a scene waiting - My usual on scene times even for a cardiac arrest average 4-6 minutes

Now lets talk about 4 people on an ambulance ???? Plus two medics. where does the patient ride ? :rolleyes:

[dburnemti]

Ok I agree that the difinitve care for a CVA is transport to the hospital. In the case of ALS arriving and doing their assessment on-scene in the back of the unit and delaying transport was a misjudgement in my opinion. It should have been done en-route. A good history of onset of symptoms should have been gained already by the first arriving BLS car. IV in this situation, en-route.

Nothing it that ALS rig will stop the stroke's progression, unless you're way out in the sticks and they carry thrombolitics.

Here in my area there are some services that carry thrombolitics but as far as I know they cannot be given to a stroke Pt due to the fact that there has to be a CT done to rule out a bleed.

[IAMedic]

I have run CVA's as both a BLS and ALS provider. Never while I was a BLS provider did anything ever happen that would make me question the need to stay BLS. However, if they patient's condition worsens and loses their airway, then possibly my BVM wouldn't be the best choice, depending on transport times. Also, Hemorrhagic Strokes have been known to cause seizures, resp. depression/arrest, heart rate irregularities, etc. in their patients due to increased ICP.

So, I understand that 99% of your CVA/TIA's will never need Advanced care, it's that 1% that will make you pucker and wish you had someone else there. So, I guess it's a department policy and their decision to make based on your area and resources available.

In my situation, we have 1 full-time Medic on 3 rotating shifts with a BLS volunteer driver. With our new schedule we work 12-hours 8a-8p and take call for 12-hours on 8p-8a shift. We are usually the only medic on during the shift and answer all calls for the hospital, city, and surrounding areas no matter if it's a transfer or 911. If we are out on a call or there is no other paramedic available, then the ambulance is usually staffed by BLS volunteer crew members. So they will pretty much run CVA's by themselves, unless the patient is worse than they expected or they don't want to write the report ;) ...that's when they call for an off-duty P Assist to the scene and hopefully one is available. We have 3 Full-Time Medics and 3 volunteer RN Exception/Medics.

[croaker260]

OK, do all CVA’s get “real” (actually used for something) ALS interventions, no. But most if not all should have prompt ALS available.
They way you get that to the patient depend on the system. Sometimes its an automatic ALS response, sometimes its BLS then ALS, sometimes its BLS to the hospital in smaller systems with (hopefully) short transport times, and in some places it is even BLS with an Air medical response (like much of rural Idaho).

The reasons for ALS as I see it:

Seizure control: Face it ...it is a neurological insult and Seizures are a risk.

Airway Control: Previously mentioned, but very important and can not be over emphasized. Depending on the ALS service...this may be simply Oral ETT when they loose all Gag, It may be a Nasal tube, or even RSI in some services or ER's. In those patients who need airway control to oxygenate and prevent aspiration (both important) the sooner this is available (by what ever means available in your system, as discussed above) the better. Equally important is (hopefully) getting a medic who knows not just when to intubate but when not to as well...another thread really but a valuable thought none the less.

Finally, Good assessment. This is the most important of the three. There are some EMT's who can compose their thoughts, do a detailed assessment, and who are familiar with the various stroke scales to report to an MD via phone or radio or whatever to activate a stroke team when available, but for everyone of those there are 5 who do an "OK assessment" (bare bones), and 5 more who barely find the patient for some reason. TO BE TRUE THIS CAN BE SAID OF SOME MEDICS AND DOCTORS AS WELL. But the point is a medic is ...generally speaking, better equipped through training and equipment on hand to catch all the weird stuff that often masquerades as a stroke (not that those wont need a rapid transport too) and in some rare cases intervene. LET ME BE CLEAR: I AM NOT FLAMING EMTS...(I can think of One EMT ..now a medic going to PA school.. who as an EMT could read 12 leads better than most doctors...)...but unless you get the EMT who goes beyond the text book out of professional pride, there is a reasonable chance he may misdiagnose, under treat, or miss key assessments that will be helpful later on.
I have seen "CVA's" that were bad UTI's, opiate overdoses, and even extra-pyramidial symptoms (EPS). I have seen dehydration from hyperglycemia, and hypoglycemic coma, all misdiagnosed because of age of the patient and misinformation used in place of good assessments.
Its not the EMT's fault, its just that these are things that are not well covered (generally speaking) at the EMT level either through initial or ongoing training. Not that well (IMHO) at the medics level either, but that is improving.

Respectfully submitted...
Steve

[RoryEl]

Unless your dispatchers have a better method of obtaining info from family members who are freaking out over their loved one then ours do then there is not anyway of determining what you've got till someone arrives on-scene. This places an addition burden on two tiered systems

Granted, by and large, there isn't a lot that you're going to be doing other than basic ALS and transport but you're not prepared to manage the complications in the event one does occur. I've seen and treated two pts in status epilepticus s/p CVA. In a two tiered system with BLS as primary dispatch one of these would be DOA due to rigidity that resolve only after Valium 5 mg IVP. Also, one must consider that occasionally we do see those head injuries, spontaneous bleeds, etc who could benefit from EtCO2 monitoring and titration of ventilation to CO2 of 35mmHG.

I'm sure many of you have read the post where basically some states and some medics don't want BLS using SpO2, glucometers, or potato guns. It seems some (not picking on any one in particular - just the tenor of may past threads) want it both ways, we don't think BLS is competent to use these basic tools or we think you're competent to handle critical patients?

Due to the nature of the injury it is a ALS transport whether or not you have to use aggressive ALS techniques. Lets put it into a clearer perspective. Who do you want directing your care, a new grad MD straight from medical school or a credentialed ER doc. Whom do you think the public wants taking car of their family member. This is all relative though, when in the boonies and only BLS is available then run with it.

[RyanEMVFD]

Because our protocols say so.

[Weruj1]

I vote for ALS >....... why ? First the continuing decline of consciousnes, and may need air way support. Second as some stated seizures, thirdly, arrythmias can occur. I agree that the majority of patients do not beneift or warrant much ALS care and it is to "ward off evil spirits"........also if the s/s apeard for a long time >+6 or so hours no matter how fast you drive it wont change much of the outcome.

[Firefighter1219]

First and foremost, the MD says it's an ALS call. IMHO, they need O2, monitor and IV, 2 of which EMTs can't provide here.

We call a stroke alert to the receiving facility immediately upon determining such. The pt also gets to ride on the bird more often than not. The pt needs to get to an appropriate facility ASAP.

That pt sounds ALS all the way to me Dr. P. The pt needs meds to bring the BP down, has a long cardiac history including MI which should require a 12-lead to r/o an MI, pt also needs glucose check to r/o hypoglocemia, and sounds like he was going down the crapper. I'm suprised he didn't code on you. What part of that isn't ALS?

I remember hearing a saying a while back...
"Less than 8, intubate."

[Bones42]

Out of curiousity....were the ALS unit MONOC? :o In my area, they are incapable of starting an IV while in motion (always thought that the M in MICU meant "mobile") :rolleyes:

ALS is dispatched per protocols, but with hospital being less than 10 mins away, they are usually cancelled for CVA's. We have had, on occaision, reason to keep them coming but that is rare.

[ALSfirefighter]

Just to kick in another thought, one principal that is taught and is in my local ALS protocols for making a decision on whether ALS is warranted is the possibility that ALS intervention could be needed at some point. With a CVA you can't say nothing will happen enroute, also with your scenario he is hypertensive, borderline crisis and you can't pinpoint exactly if its a CVA. Also if they syncopize I ALS them, many many possible reasons.

Also having IV access helps if they have it when you get there.

[Weruj1]

did ALS say "syncopize" .............? :eek:

[IAMedic]

Originally posted by Weruj1
did ALS say "syncopize" .............? :eek:

Yes, yes he did...I don't care what you say, ALS. It's good to see ya back here, if even on occasion, Tom!! :D :p

[ALSfirefighter]

Thanks Brad. Its tough but I find a few minutes inbetween the 1 and 3 year old. Yes I did say syncopize.

[wag11c]

Don't often agree with Dr Parasite but since my grinchy heart has grown larger I must say this. I used to work in an all als system, ALS engines,ALS fire rescues and ALS ambulances. Most calls wound up with more medics then you could believe-each with their own opinion. I truly used to believe that if we just did a quick asseemnet and did a rapid transport(most e/r's less than 10 mins away), we would probably be doing the public a better service not to mention the amount of money we would save. I believe this applies to so many more calls than just "brain attacks". Of course then perhaps I would be justifying myself right out of a medic job.

[DrParasite]

Originally posted by Firefighter1219
That pt sounds ALS all the way to me Dr. P. The pt needs meds to bring the BP down, has a long cardiac history including MI which should require a 12-lead to r/o an MI, pt also needs glucose check to r/o hypoglocemia, and sounds like he was going down the crapper. I'm suprised he didn't code on you. What part of that isn't ALS?

I remember hearing a saying a while back...
"Less than 8, intubate." you know, I'll agree with you except for a few things: 1) the medics didn't give anything to lower the BP 2) didn't intubate 3) he had a stroke, not a massive heart attack, so having him code while in the rig wasn't on my list of top worries (dealing with the stroke was). and yeah, your MD might say it's an ALS call, but if your doc said a sprained ankle was an ALS call, would you still agree?

oh, and just because he had a cardiac history (12 years ago) doesn't automaticly make him ALS. if you have a finger lac on a guy who had a MI 15 years ago, do you think the patient should be ALS or BLS?

Bones, it was MedRescue 2 out of New Brunswick, not MONOC, and we were less than 20 minutes from the hospital.

you can "what if" this till the cows come home (and even long after), I just think it's stupid to tie up a medic unit on a "what if", especially if all they will be doing is monitoring and transporting.

[mittlesmertz]

Dr Parasite nails it: you can "what if" every pt you see, and if you're bored and look hard enough, you can justify all sorts of ALS interventions.

According to the survey of users of Firehouse.com, the vast majority of posters are working in smaller, rural areas, with lower call volumes. Perhaps this presents itself in the way many posters are so eager to transport everyone they see, and start IV's, give drugs, etc.

As for "less than 8, intubate", that is a prime example of cookbook medicine. Paralyzing a pt that is awake and breathing because they have a GCS of 7 is not very nice, and rather dangerous as well.

It's June, and today I dropped my 19th tube for the year. So I have a little experience with 'em; not as much as some, but I'm getting there. Please treat the procedure with the seriousness it deserves. BVM and OPA works great.

Remember the "grey logic" concept? Not all ALS pt's are the same. Some are "really sick", some are "kinda sick", and some are ALS just because they meet the protocols.
Stating that all possible CVA's need to go ALS is a ridiculous blanket statement. Let your own experience, resources, protocols, and most importantly the pt's condition, dictate the transport mode.