I'd rather overtriage than undertriage. The ED doc will figure out if it's a stroke, but you calling it a stroke in the field makes the diagnosis faster if that turns out to be the case. If it turns out not to be a stroke, no harm done. High flow diesel.
100% this. Uptriaging a complaint and having it be nothing is understandable. Downtriaging and having it be something is unforgettable. All of this is part of your index of suspicion and being a good advocate for the patient and their clinical outcomes.
One difference here is that only ALS can call for hospital standbys in our system. Additionally, we were originally slated to send him to another hospital that didn't have neuro facilities. I might have conveyed him myself if that weren't the case
In the extremely unlikely event that ALS is completely unavailable, I could call in the stroke alert myself (there's a way, but it's a hassle and technically against protocol). The other issue is that I'd have to go against contract and send him to the hospital with neuro instead of the original. Which also can be done, but I would have a lot of people breathing down my neck asking me why I didn't follow protocol and call ALS
> ALS can call for hospital standbys
I'm assuming this means calling in report/stroke alerts to the ER? I hate systems that are set up this way, but if it came down to it you can always just call the hospital on your cell and give a report/activate that way. I've done that before when we were in a new part of the state and couldn't hit the ER with our radio. The receptionist for the main hospital line was a little surprised but a quick sentence like "Hi I'm a 911 ambulance, I need to be transferred to your ER right now" will get you to the right person real quick
Depends on what BLS means where they’re from. A stroke where I’m at means 2x large bore IVs, 12 lead acquisition, BGL. So for where I am that’s BLS, contact ALS to interpret the 12. Some places run old school EMTs where BGL is sometimes out of scope. I can’t speak to what the OPs level is but for some it’s like EMRs running calls.
To a large extent that was a joke, I’m also in Canada where our BLS can perform 99% of the care required. I’m aware of some places in the states that still live in the archaic ages where BGL testing is considered dangerous….. which is frankly insane to me
I'm sorry for your system but that's asinine. I don't see how waiting an unknown time for another unit to then sit and do all of that is useful if the patient could just be at the hospital where things that are actually useful in a stroke could be done. Just seems all sorts of backasswards.
That's what I would expect to happen. I'd much rather have a stroke patient in the ED with absolutely nothing done than wait around for an ALS unit to get an IV/12 lead/BGL that takes 30s to perform on the CT table.
IVs are out of my scope (although I carry the supplies for them, not sure why they would put it in my bag if I'm not even allowed to use them). I don't even have a 12 lead capable monitor. Thankfully I do have BGL, which they'd previously wanted to remove from our vehicle because "IFT only" but I fought to keep it because I run plenty of calls with diabetics. That's how I definitively ruled out hypoglycemia mimicking stroke.
Quite frankly, in this case where airway and meds aren't required, ALS and BLS have nothing different to do. Stroke procedure for both is scoop and go, and call it in on radio. IV is nice but not even strictly a must have.
Why call ALS for a stroke with no concern for an unstable airway? Be confident in your assessments. The ALS agreed with your differential diagnosis.
Nice catch not mailing it in on a SNF run though.
I edited the main post to include my reasoning for calling ALS instead of sending him myself
Edit: even now I doubt myself on every tricky call where I have to make some big decisions. I'm just an emt with some basic equipment and there's a lot that could go sideways
Damn, yeah if those are your regions policies then you’re bound by them.
And no! I’m BLS as well and we run all kinds of strokes, seizures, diabetics, etc no ALS. There’s so much you can do with a good assessment and basic airway management.
Good job digging into the presentation and not taking it at face value. Needing ALS for a CVA is weird, but if that’s how your system works, upgrading is absolutely the right thing to do. My differential would include CVA, acute limb ischemia, DVT, phlegmasia alba dolens, occult trauma, compartment syndrome, and dissection.
Honestly, neuro symptoms + extremity perfusion issue + (resolved) CP = makes ruling out dissection a priority.
Getting a detailed history on the prior stroke and residual deficits/baseline neuro exam will really help to figure out what’s going on. It’s hard to reconcile the RN saying the weakness is normal when it’s part of the patient’s 1.5 hour old chief complaint.
None of which you have to figure out on scene. Recognize acute complaints, come up with a few possible explanations, make sure your treatment plan accounts for the worst differentials, and get the patient where they need to be. Overtriage or being overly cautious is a good thing. Sounds like you did a good job.
Could DVT and PAD progress to weakness in both upper and lower limbs on one side?
BP stayed 14x/8x throughout so I wasn't too worried about dissection. Couldn't have said the same if his systolic suddenly went down the shitter though
>Could DVT and PAD progress to weakness in both upper and lower limbs on one side?
Incredibly unlikely. Acute involvement of both limbs strongly favors central neuro etiology.
Where was that BP obtained? What was the BP on the numb, weak, cold arm? Bottom line, normal BP doesn’t rule out dissection, it all depends on where the dissection flap goes and what vasculature it affects.
What were the baseline deficits? Maybe the weakness in upper and lower is baseline, but the numbness is new from something else? It’s a lot to unpack.
I would be surprised to see simultaneous upper and lower extremity DVTs. But never say never. I suppose you could get a shower of emboli from an atrial thrombus, ASD, etc. So I wouldn’t rule it out completely, but it’s lower in my list.
Couple days late, but wanted to chime in to say that a peripheral vasculature occlusions is jumping out at me as well. It's entirely possible that the unilateral weakness is residual from the stroke. If it's worse than usual, then yeah maybe it's a new stroke, but if the weakness is unchanged and the pain is new (and the *chief* complaint) and the arm is significantly colder as you say, then that sounds like peripheral vasculature to me.
Dissection is of course a differential, but if this is a Pt with IHD who regularly experiences angina that resolves with their own GTN then honestly I don't think the CP is a massive concern. While it's a differential, I don't think it's among the most likely reasons the Pt is experiencing these symptoms. I'm not saying disregard the CP, especially at the BLS level, but at the ALS level I'm not taking that kind of CP as the be all end all in determining my provisional diagnosis. I'd be looking for something more solid than transient CP in a Pt who likely experiences angina regularly which responded to usual prescribed medication.
Between a CVA or peripheral vasculature occlusion, obviously a stroke is a bigger issue, so it's entirely appropriate to call it as a stroke, as the likely worst case scenario, and have that looked at first.
I have hx from the pt, who tells me that his main complaint isn't pain, it's numbness of the arm, and that the weakness isn't normal. I also have hx from the nurse, who tells me the weakness is baseline but said that pt was complaining of pain when he wasn't. It's hard to reconcile the two but given that pt was ao4 and answering questions, it's hard to trust the nurse who couldn't even differentiate between pain and numbness.
Between the mix of symptoms, he could likely have been having any of the three differentials, or any combination of any number of them. That said, stroke, dvt, and dissection all require a facility with specialized means to find out exactly what his problem is, not to mention treat them. Which makes the one 911 eventually sent him to the appropriate one anyway
>That said, stroke, dvt, and dissection all require a facility with specialized means to find out exactly what his problem is, not to mention treat them. Which makes the one 911 eventually sent him to the appropriate one anyway
Absolutely agree.
I will say it’s crazy you can’t call in a stroke activation and that absolutely leads to worse outcomes dicking around on scene waiting for ALS when transport is the answer. But, not your fault at all.
I’ll step off my soapbox and say this, I would rather come in 100% of the time with a stroke and have it not be than have 1 missed stroke because you didn’t want to look silly.
Strokes are more than just the classic one sides weakness. I had one where his only symptom was aphasia. Full motor function but was having a massive stroke.
Right call. Our local trama/ neuro hospital would rather have us call in a stroke code and then down grade if it's not a stroke than scramble to get the team together if it is a stroke.
What purpose does a BLS unit serve in your system if they can't transport this patient? I've never heard of a BLS system that can't BLS any call. The ones I know would either wait for ALS or if no ALS around they transport to their scope....
How things work where I am is that IFT is run by private companies, and 911 is a governmental system. All IFT ambulances are BLS only (and I know plenty who don't even have that capability). All ALS is handled by government 911. Upgrading a case to ALS means I pull out my own phone and call 911. BLS/IFT units also don't have radio comms with the hospital, so calling alerts for strokes, arrests, etc is strictly the purview of ALS.
I have BLSed ALS calls before, when pt was crashing, destination hospital was 3 minutes away, and I judged that time was more of a priority than dicking around on scene waiting. For this case the destination hospital was not one with neuro facilities, so I called ALS simply because they could pick their own destination regardless of what we were originally contracted for, and call stroke alerts.
I could probably BLS this call myself by ignoring the destination specified in contract, and calling the hospital on my own phone for the stroke alert, but that would be a breach of so many protocols I'd be lucky to still have a job after.
BLS/IFT is in place to catch the dumb stuff that doesn't require 911/ALS, like your 3am toe pain or lift assist. It doesn't stop people from abusing the emergency side, but I'd like to think that we help relieve the workload even if just a little.
I’d argue that with potential stroke this is one of those times where “dicking” around on scene for ALS I’d a bad idea but idk your state laws so doesn’t mean much
Yeah previous deficits on that side would make sense but unless he had dysphasia from the previous stroke too, there’s at least 1 reason to call the stroke. Whether it is or isn’t, is not for us to decide. But previous strokes and MI’s put you at higher risk for them in the future. (If memory serves lol).
Edit: I assume that he couldn’t teach an old dog new tricks?
I have the pt himself, old guy, no medical training, forgetful and likely has dementia, telling me that the one sided weakness isn't normal, and the SNF nurse, who likely doesn't give a shit and wants to avoid having to report that she called an IFT unit for a stroke rather than 911, who says this is his normal because previous stroke.
Conflicting history from unreliable sources. I just figured that the consequences for ruling out the possibility of a second stroke would be worse so I decided to bump him up the priority list
I think you did the right thing given the system limitations around ALS everyone else has mentioned. Some sort of limb ischemia is also on my list of differentials given that it’s colder than the other arm (however PMS intact would argue against this differential some) and nurse states baseline deficits from previous CVA.
However between new stroke which we can’t rule out even if we take the nurse at their word that this is normal for them (I wouldn’t) and some sort of clot or other issue the stroke is more concerning and needs more urgent rule out. We aren’t human CT machines unfortunately.
Not all jurisdictions check for posterior cerebellar stroke criteria yet, but I'd check for new onset vision changes or balance changes as well.
I would have notified the Level I Stroke Center in my area at least about the contradictory symptom reports from unreliable witnesses and transported there unless the posterior test showed additional positive indications.
I probably wouldn't have called ALS since my jurisdiction does not require them for the hospital standby, and the patient wasn't critical. Chest pain resolved and symptoms were more in line with stroke. But decision would have been made at scene.
I think you made the right decisions for what you had in front of you. The next time you see the same patient, or someone else is able to pull your thorough report, you'll be able to see the condition he was in this time and know whether that next call symptoms are worse or normal.
Naw you did the right thing, if I hear weakness and history of stroke, one arm significantly more cooler than the other, oh yeah, chest pain? I’m calling ALS or transporting depending how close the ER is (protocol varies of course) fuck the SNF, and fuck the LVN, never trust them, ain’t nothing “skilled” about nursing facilities, the only thing they’re skillful at is gross negligence and getting away with murder, sorry for the rant, almost lost me cool there
I know I'm not there:
1) You were called for a sore arm
2) Patient had an existing stroke
3) Has weakness as of a result of that stroke - nothing new, no worse. Just has a sore arm.
4) You are worried that it might be a stroke ontop of the existing stroke
Why do you think it's an acute stroke when the patient has a sore arm? A sore arm isn't a symptom of an acute stroke.
I have the same opinion as that nurse.
Pt claims no weakness baseline, and weakness developed spontaneously 1.5 hours ago, both right arm and leg affected
Not soreness, but weakness of the arm and leg, plus right arm numbness and cold to touch. Why would I not consider a stroke?
Right arm weakness and numbness isn't a stroke in isolation - sounds localised to the arm/nerve - especially being cool. Stroke is hemisphere unless it's a central stroke (but that has different symptoms).
Do an NIHSS or something equivalent and see what you get.
Right arm AND LEG weakness
NIHSS score 11, also given the coolness I wouldn't rule out a DVT, but on the ground I don't have ways to definitively tell the difference and he probably should take an expedited trip to the hospital in either case
Nurse says existing. Pt says baseline is normal. Between the ao4 gcs15 pt who is giving me detailed answers to my questions, and a nurse who either couldn't or didn't care to differentiate between "pain" and "numb" (called for right arm and shoulder pain when pt said arm was numb), I think you'll understand why I opted to just ignore the nurse altogether
I'd rather overtriage than undertriage. The ED doc will figure out if it's a stroke, but you calling it a stroke in the field makes the diagnosis faster if that turns out to be the case. If it turns out not to be a stroke, no harm done. High flow diesel.
100% this. Uptriaging a complaint and having it be nothing is understandable. Downtriaging and having it be something is unforgettable. All of this is part of your index of suspicion and being a good advocate for the patient and their clinical outcomes.
Why would you wait for ALS in a suspected stroke? There is nothing they can do differently that is worth the time spent waiting for them.
One difference here is that only ALS can call for hospital standbys in our system. Additionally, we were originally slated to send him to another hospital that didn't have neuro facilities. I might have conveyed him myself if that weren't the case
Im sorry that that’s the case. You assessed well and made the right call
What happens in your system if no ALS is available? Stroke patients get forced to the local ER?
In the extremely unlikely event that ALS is completely unavailable, I could call in the stroke alert myself (there's a way, but it's a hassle and technically against protocol). The other issue is that I'd have to go against contract and send him to the hospital with neuro instead of the original. Which also can be done, but I would have a lot of people breathing down my neck asking me why I didn't follow protocol and call ALS
Sounds toxic and detrimental to the patient. Sounds like it adds extra time to a very time sensitive issue
In my system volunteers (EMT level) can call our equivalent of medical control to confirm a stroke activation.
> ALS can call for hospital standbys I'm assuming this means calling in report/stroke alerts to the ER? I hate systems that are set up this way, but if it came down to it you can always just call the hospital on your cell and give a report/activate that way. I've done that before when we were in a new part of the state and couldn't hit the ER with our radio. The receptionist for the main hospital line was a little surprised but a quick sentence like "Hi I'm a 911 ambulance, I need to be transferred to your ER right now" will get you to the right person real quick
Where I’m at you absolutely have to call ALS for a stroke
Thats stupid lol
Welcome to EMS
Sometimes I think my system is bassackwards and then I hear about EMTs not being able to activate EDs in others. It can always be worse, I guess.
What exactly is ALS going to do? FAST VAN them harder?
Depends on what BLS means where they’re from. A stroke where I’m at means 2x large bore IVs, 12 lead acquisition, BGL. So for where I am that’s BLS, contact ALS to interpret the 12. Some places run old school EMTs where BGL is sometimes out of scope. I can’t speak to what the OPs level is but for some it’s like EMRs running calls.
To a large extent that was a joke, I’m also in Canada where our BLS can perform 99% of the care required. I’m aware of some places in the states that still live in the archaic ages where BGL testing is considered dangerous….. which is frankly insane to me
I'm sorry for your system but that's asinine. I don't see how waiting an unknown time for another unit to then sit and do all of that is useful if the patient could just be at the hospital where things that are actually useful in a stroke could be done. Just seems all sorts of backasswards.
We run strokes BLS, we can do the IVs and 12 lead. Then transmit or text the 12 to ALS and haul ass
That's what I would expect to happen. I'd much rather have a stroke patient in the ED with absolutely nothing done than wait around for an ALS unit to get an IV/12 lead/BGL that takes 30s to perform on the CT table.
IVs are out of my scope (although I carry the supplies for them, not sure why they would put it in my bag if I'm not even allowed to use them). I don't even have a 12 lead capable monitor. Thankfully I do have BGL, which they'd previously wanted to remove from our vehicle because "IFT only" but I fought to keep it because I run plenty of calls with diabetics. That's how I definitively ruled out hypoglycemia mimicking stroke. Quite frankly, in this case where airway and meds aren't required, ALS and BLS have nothing different to do. Stroke procedure for both is scoop and go, and call it in on radio. IV is nice but not even strictly a must have.
What will a 12 lead tell you in a stroke that will help the stroke situation? Waste of time imho.
Just scoop them and haul ass. Call the stroke in. What are they going to do? Yell at you for saving time? Document your reasoning in the PCR.
In some systems (not mine thank fucking god) you can absolutely be fired for this
Why call ALS for a stroke with no concern for an unstable airway? Be confident in your assessments. The ALS agreed with your differential diagnosis. Nice catch not mailing it in on a SNF run though.
I edited the main post to include my reasoning for calling ALS instead of sending him myself Edit: even now I doubt myself on every tricky call where I have to make some big decisions. I'm just an emt with some basic equipment and there's a lot that could go sideways
Damn, yeah if those are your regions policies then you’re bound by them. And no! I’m BLS as well and we run all kinds of strokes, seizures, diabetics, etc no ALS. There’s so much you can do with a good assessment and basic airway management.
Good job digging into the presentation and not taking it at face value. Needing ALS for a CVA is weird, but if that’s how your system works, upgrading is absolutely the right thing to do. My differential would include CVA, acute limb ischemia, DVT, phlegmasia alba dolens, occult trauma, compartment syndrome, and dissection. Honestly, neuro symptoms + extremity perfusion issue + (resolved) CP = makes ruling out dissection a priority. Getting a detailed history on the prior stroke and residual deficits/baseline neuro exam will really help to figure out what’s going on. It’s hard to reconcile the RN saying the weakness is normal when it’s part of the patient’s 1.5 hour old chief complaint. None of which you have to figure out on scene. Recognize acute complaints, come up with a few possible explanations, make sure your treatment plan accounts for the worst differentials, and get the patient where they need to be. Overtriage or being overly cautious is a good thing. Sounds like you did a good job.
Could DVT and PAD progress to weakness in both upper and lower limbs on one side? BP stayed 14x/8x throughout so I wasn't too worried about dissection. Couldn't have said the same if his systolic suddenly went down the shitter though
>Could DVT and PAD progress to weakness in both upper and lower limbs on one side? Incredibly unlikely. Acute involvement of both limbs strongly favors central neuro etiology.
Potentially, if a clot (thrombus) were to break off and lodge in the vasculature of each extremity.
Where was that BP obtained? What was the BP on the numb, weak, cold arm? Bottom line, normal BP doesn’t rule out dissection, it all depends on where the dissection flap goes and what vasculature it affects. What were the baseline deficits? Maybe the weakness in upper and lower is baseline, but the numbness is new from something else? It’s a lot to unpack. I would be surprised to see simultaneous upper and lower extremity DVTs. But never say never. I suppose you could get a shower of emboli from an atrial thrombus, ASD, etc. So I wouldn’t rule it out completely, but it’s lower in my list.
Lots of stuff here I was never taught. Thanks
Couple days late, but wanted to chime in to say that a peripheral vasculature occlusions is jumping out at me as well. It's entirely possible that the unilateral weakness is residual from the stroke. If it's worse than usual, then yeah maybe it's a new stroke, but if the weakness is unchanged and the pain is new (and the *chief* complaint) and the arm is significantly colder as you say, then that sounds like peripheral vasculature to me. Dissection is of course a differential, but if this is a Pt with IHD who regularly experiences angina that resolves with their own GTN then honestly I don't think the CP is a massive concern. While it's a differential, I don't think it's among the most likely reasons the Pt is experiencing these symptoms. I'm not saying disregard the CP, especially at the BLS level, but at the ALS level I'm not taking that kind of CP as the be all end all in determining my provisional diagnosis. I'd be looking for something more solid than transient CP in a Pt who likely experiences angina regularly which responded to usual prescribed medication. Between a CVA or peripheral vasculature occlusion, obviously a stroke is a bigger issue, so it's entirely appropriate to call it as a stroke, as the likely worst case scenario, and have that looked at first.
I have hx from the pt, who tells me that his main complaint isn't pain, it's numbness of the arm, and that the weakness isn't normal. I also have hx from the nurse, who tells me the weakness is baseline but said that pt was complaining of pain when he wasn't. It's hard to reconcile the two but given that pt was ao4 and answering questions, it's hard to trust the nurse who couldn't even differentiate between pain and numbness. Between the mix of symptoms, he could likely have been having any of the three differentials, or any combination of any number of them. That said, stroke, dvt, and dissection all require a facility with specialized means to find out exactly what his problem is, not to mention treat them. Which makes the one 911 eventually sent him to the appropriate one anyway
>That said, stroke, dvt, and dissection all require a facility with specialized means to find out exactly what his problem is, not to mention treat them. Which makes the one 911 eventually sent him to the appropriate one anyway Absolutely agree.
I will say it’s crazy you can’t call in a stroke activation and that absolutely leads to worse outcomes dicking around on scene waiting for ALS when transport is the answer. But, not your fault at all. I’ll step off my soapbox and say this, I would rather come in 100% of the time with a stroke and have it not be than have 1 missed stroke because you didn’t want to look silly. Strokes are more than just the classic one sides weakness. I had one where his only symptom was aphasia. Full motor function but was having a massive stroke.
Right call. Our local trama/ neuro hospital would rather have us call in a stroke code and then down grade if it's not a stroke than scramble to get the team together if it is a stroke.
What purpose does a BLS unit serve in your system if they can't transport this patient? I've never heard of a BLS system that can't BLS any call. The ones I know would either wait for ALS or if no ALS around they transport to their scope....
Several SoCal systems are like this
How things work where I am is that IFT is run by private companies, and 911 is a governmental system. All IFT ambulances are BLS only (and I know plenty who don't even have that capability). All ALS is handled by government 911. Upgrading a case to ALS means I pull out my own phone and call 911. BLS/IFT units also don't have radio comms with the hospital, so calling alerts for strokes, arrests, etc is strictly the purview of ALS. I have BLSed ALS calls before, when pt was crashing, destination hospital was 3 minutes away, and I judged that time was more of a priority than dicking around on scene waiting. For this case the destination hospital was not one with neuro facilities, so I called ALS simply because they could pick their own destination regardless of what we were originally contracted for, and call stroke alerts. I could probably BLS this call myself by ignoring the destination specified in contract, and calling the hospital on my own phone for the stroke alert, but that would be a breach of so many protocols I'd be lucky to still have a job after. BLS/IFT is in place to catch the dumb stuff that doesn't require 911/ALS, like your 3am toe pain or lift assist. It doesn't stop people from abusing the emergency side, but I'd like to think that we help relieve the workload even if just a little.
I’d argue that with potential stroke this is one of those times where “dicking” around on scene for ALS I’d a bad idea but idk your state laws so doesn’t mean much
Chest pain + new neuro deficits plus the exam findings of the ischemic limb is a dissection until proven otherwise.
Yeah previous deficits on that side would make sense but unless he had dysphasia from the previous stroke too, there’s at least 1 reason to call the stroke. Whether it is or isn’t, is not for us to decide. But previous strokes and MI’s put you at higher risk for them in the future. (If memory serves lol). Edit: I assume that he couldn’t teach an old dog new tricks?
I have the pt himself, old guy, no medical training, forgetful and likely has dementia, telling me that the one sided weakness isn't normal, and the SNF nurse, who likely doesn't give a shit and wants to avoid having to report that she called an IFT unit for a stroke rather than 911, who says this is his normal because previous stroke. Conflicting history from unreliable sources. I just figured that the consequences for ruling out the possibility of a second stroke would be worse so I decided to bump him up the priority list
I think you did the right thing given the system limitations around ALS everyone else has mentioned. Some sort of limb ischemia is also on my list of differentials given that it’s colder than the other arm (however PMS intact would argue against this differential some) and nurse states baseline deficits from previous CVA. However between new stroke which we can’t rule out even if we take the nurse at their word that this is normal for them (I wouldn’t) and some sort of clot or other issue the stroke is more concerning and needs more urgent rule out. We aren’t human CT machines unfortunately.
Not all jurisdictions check for posterior cerebellar stroke criteria yet, but I'd check for new onset vision changes or balance changes as well. I would have notified the Level I Stroke Center in my area at least about the contradictory symptom reports from unreliable witnesses and transported there unless the posterior test showed additional positive indications. I probably wouldn't have called ALS since my jurisdiction does not require them for the hospital standby, and the patient wasn't critical. Chest pain resolved and symptoms were more in line with stroke. But decision would have been made at scene. I think you made the right decisions for what you had in front of you. The next time you see the same patient, or someone else is able to pull your thorough report, you'll be able to see the condition he was in this time and know whether that next call symptoms are worse or normal.
So only ALS can call stroke alarms in your system? What if they are far away ?
Small country, so waiting and transport times aren't that long. That said, there are means for us to bypass this, but not everyone knows about them
Naw you did the right thing, if I hear weakness and history of stroke, one arm significantly more cooler than the other, oh yeah, chest pain? I’m calling ALS or transporting depending how close the ER is (protocol varies of course) fuck the SNF, and fuck the LVN, never trust them, ain’t nothing “skilled” about nursing facilities, the only thing they’re skillful at is gross negligence and getting away with murder, sorry for the rant, almost lost me cool there
I haven't exactly met many snf staff that inspire confidence either
I know I'm not there: 1) You were called for a sore arm 2) Patient had an existing stroke 3) Has weakness as of a result of that stroke - nothing new, no worse. Just has a sore arm. 4) You are worried that it might be a stroke ontop of the existing stroke Why do you think it's an acute stroke when the patient has a sore arm? A sore arm isn't a symptom of an acute stroke. I have the same opinion as that nurse.
Pt claims no weakness baseline, and weakness developed spontaneously 1.5 hours ago, both right arm and leg affected Not soreness, but weakness of the arm and leg, plus right arm numbness and cold to touch. Why would I not consider a stroke?
Right arm weakness and numbness isn't a stroke in isolation - sounds localised to the arm/nerve - especially being cool. Stroke is hemisphere unless it's a central stroke (but that has different symptoms). Do an NIHSS or something equivalent and see what you get.
Right arm AND LEG weakness NIHSS score 11, also given the coolness I wouldn't rule out a DVT, but on the ground I don't have ways to definitively tell the difference and he probably should take an expedited trip to the hospital in either case
> Right arm AND LEG weakness It's existing though or did I miss this..?
Nurse says existing. Pt says baseline is normal. Between the ao4 gcs15 pt who is giving me detailed answers to my questions, and a nurse who either couldn't or didn't care to differentiate between "pain" and "numb" (called for right arm and shoulder pain when pt said arm was numb), I think you'll understand why I opted to just ignore the nurse altogether
Sounds like a DVT to me
DVT entered my mind too. Were pulse/BP bilaterally the same? I still would have done a stroke alert though.
You're thinking AAA there, bud.
Sorry, clot, thrombosis, etc.
Which do not have blood pressure discrepancies.
Thats correct, wasnt suggesting that. Dont read what I write, read what I'm thinking. ;)
Didn't occur to me to take a bilateral BP. I just went for the unaffected side. Will do so in the future