Category: EMS

Emergency Medicine, EMS

Understanding the Origins of the Cincinnati Prehospital Stroke Scale

We all learned it in EMT-B class.  The Cincinnati Prehospital Stroke Scale (CPSS) is the core assessment tool for EMS providers to evaluate possible stroke patients in the field.  But, have you ever wondered where it came from?  Why does it have 3 parts? Why test speech and not eyesight?  What part of the brain is really injured? Let’s take a deeper dive.

What is the CPSS?

For a quick review, the CPSS is comprised of three individual tests, each of which get interpreted as either normal or abnormal by the EMS provider.   The tests as well as interpretation are summarized in the table below.

Components of the Cincinnati Prehospital Stroke Scale
Adopted from Kothari, et al, 1996 

Test

Normal

Abnormal

1

  

Facial Droop

 

 Patient smiles or shows teeth Both side of face move equally One side of the face does not move as well as the other (or not at all)

2

  

Arm Drift

 

 Patient extends arms out, closes eyes, and holds in place x 10 seconds Both arms move the same, or both arms stay in position One arm does not move or drifts downward compared to the other

3

  

Speech

 

 Patient repeats “You can’t teach an old dog new tricks” Patient repeats back correct words with no slurring of words Patient can’t speak, says the wrong words, or slurs words

The CPSS is positive if any one of the three tests is deemed abnormal.  In studies comparing Physicians vs EMS providers when performing the CPSS, when performed by an EMS provider, if the patient scored positive for one component, the sensitivity was 59%, meaning just over half of the patients who indeed had a stroke were identified by the EMS provider as having a stroke.  The specificity was 89%, meaning that 89% of people who had a positive CPSS (1/3 components) indeed had a stroke.  In other words, they caught just over half of the true strokes, but they also obtained a positive CPSS on some patients that didn’t have a stroke. The best example is a patient who is intoxicated.  They likely have slurred speech, and therefore a positive CPSS, but aren’t actually having a stroke.  Most tests in medicine are like this, you miss some, and you catch some that don’t really have the disease.  We call these false negatives and false positives.  Oh, and did I mentioned that EMT-Bs scored just as reliably as the Paramedics in the study?

The CPSS intentionally misses some strokes

To understand what the CPSS is looking for, it’s important to know a bit about the history of how it was created and why.  The CPSS was developed at the University of Cincinnati Medical Center in 1997.  tPA had just been approved by the FDA in June 1996.  The CPSS is derived from the NIH Stroke Scale (NIHSS).  You can read more about it here, but simply put, it’s a 15 part assessment where the patient gets scored according to their symptoms.  The NIHSS was developed to identify neurological deficits that correspond to specific geographic tissue damage in the brain.  MDCalc offers a great online calculator for helping determine a patient’s NIH Stroke Scale score.  The NIHSS was condensed down, with some categories eliminated and some combined, to make the CPSS simple and easy to use, but also to help identify those patients who would be potential candidates for tPA.   Not all strokes are created equal, and not all strokes are elligible for tPA, even if identified within the 4.5 hour time window.  Strokes of the anterior cerebral artery and middle cerebral artery are better tPA candidates that other types of stroke.  The CPSS focuses on identifying those strokes, but not posterior strokes for example.

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The future of the CPSS and prehospital stroke identification

As I mentioned, the CPSS is not designed to detect things like posterior circulation strokes that affect the cerebellum, the balance center of the brain.  Historically, efforts focused on early identification of tPA candidates.  As new surgical and pharmacological advancements develop for other types of stroke, there’s a greater emphasis on early identification of all strokes.  As such, there’s a lot of research going on right now studying new or modified prehospital stroke assessment tools.  One front-runner is the B-FAST, which adds one more test to the CPSS to test for balance, and potentially identify posterior circulation strokes.  The posterior circulation (basilar artery in the diagram above) supplies blood flow to the cerebellum, the balance center of the brain.

B – Balance, tested by having the patient walk

F – Face, same as CPSS

A – Arms, same as CPSS

S – Speech, same as CPSS

T – Time, to remind us that time is brain

If you want to impress with your turnover on your next stroke patient, be sure to test for balance disturbances by (carefully) ambulating your patient.  If the patient stumbles or can’t walk without assistance, that’s a pertinent positive.  In the original Cincinnati study by Kothari, the CPSS missed 13 patients with stroke, but 10 of those were posterior circulation strokes, notoriously difficult to diagnose clinically, and often missed by even the best Emergency Medicine physicians.

 

As always, feel free to share any tips you have on helping assess for stroke in the field.

~Steph

Some references:
Kothari R1, Hall K, Brott T, Broderick J. Early stroke recognition: developing an out-of-hospital NIH Stroke Scale. Acad Emerg Med. 1997 Oct;4(10):986-90.
Kothari RU1, Pancioli A, Liu T, Brott T, Broderick J. Ann Cincinnati Prehospital Stroke Scale: reproducibility and validity. Emerg Med. 1999 Apr;33(4):373-8.
Emergency Medicine, EMS, Patient Anecdotes

Caring for criminals: How to provide good medical care to people who have done bad things

As an Emergency Medicine Physician and EMS provider, I get a lot of questions about my job.  #1 “What’s the worst thing you’ve ever seen?”  #2 is “How do you stay motivated and not let it get to you?” And #3 is what I’ll address in this post, “How do you take care of murderers, rapists and other people who have done horrible things?”

It’s an unfortunately common scenario: high-speed MVC, multiple vehicles, one DOA (dead on arrival), two adults in critical condition, being flown by helicopter as the highest level trauma alert, alcohol involved.  And all too often, Paramedics, Nurses and Physicians have to take care of everyone involved, including the intoxicated driver that caused the mayhem.  How do you have compassion, empathy and care for someone that by all evidence just killed someone in a completely preventable way?  I’ve been in Emergency Medicine for 11 years, and I still struggle with this.  It’s never easy, but I’ve found a few strategies to help cope.

1. Don’t Ask, Don’t Tell

A few months back I was taking care of an ICU patient that I knew was a prisoner in a maximum security prison due to the vigilant watch by 2-3 armed security guards at all times.  Clearly he had done something bad, but for me, knowing exactly what would only potentially worsen the medical care I could give him, not improve it.  So I didn’t ask, I didn’t Google.  Unfortunately someone else did, and shared it with the whole team.

Turns out he beheaded a total stranger, a husband and a father of two, because he didn’t have cash in his wallet when he tried to rob him.  Once I learned that, I couldn’t unknow it.  I struggled to walk in his room each morning with a smiling face and open, non-judging mind.  For the human in me, it was a battle I had to consciously fight.  My advice to anyone who might care for inmates or anyone in police custody, don’t ask, and encourage the whole team not to ask.  And if you find out, don’t tell.  99% of the time it’s not relevant to patient care, and can only cause you (and everyone else on the team) to make mistakes.

2. Be an Advocate

Incarcerated people have difficulty accessing medical care.  Although prisons and jails have a medical clinic, studies show that prisoners get less frequent and timely care for both chronic and acute conditions.  A 2009 report published in the American Journal of Public Health, unearthed some worrisome stats:

  • “Among inmates with a persistent medical problem, 13.9% of federal inmates, 20.1% of state inmates, and 68.4% of local jail inmates had received no medical examination since incarceration.

  • Prior to incarceration, slightly more than 1 in 7 inmates were taking a prescription medication for an active medical problem routinely requiring medication (as defined in the Methods section). Of these, 3314 federal (20.9%), 43 679 state (24.3%), and 28 473 local jail inmates (36.5%) stopped the medication following incarceration.

  • Only a small portion of prison inmates (3.9% of federal and 6.4% of state inmates) with an active medical problem for which laboratory monitoring is routinely indicated had not undergone at least 1 blood test since incarceration. However, most local jail inmates with such a condition (60.1% [SE = 1.8%]) had not undergone a blood test.

  • Following serious injury, 650 federal inmates (7.7%), 12 997 state inmates (12.0%), and 3183 local jail inmates (24.7%) were not seen by medical personnel.“

Incarcerated persons have to “prove” to prison staff they are truly sick and need to go to the Emergency Department.  Yes, many prisoners fake or exaggerate symptoms for the secondary gain of getting a break from behind bars: better eye candy, different food, and maybe some good pain medication.  But, 38-43% of inmates have chronic medical conditions, which by all evidence, may not be properly addressed and managed by the prison clinic.  When these patients present to the ED, I play it safe and assume they have been sick a few days longer than a regular person, as they probably had to fight to make their case to prison staff.  Guilty or innocent, these patients all need an advocate for their medical care.  I take pride in being that person, which allows me to keep my personal judgements out of the encounter.

3. We are guilty, too

Last week I took care of a woman addicted to IV heroin.  By all accounts, she was pitiful looking – shivering, sweating, unable to sit still.  She was also curt, demanding and liked to cuss at us.  The medical student with me asked how someone could make such poor choices and then be so demanding.  I didn’t disagree, and I found myself starting to judge.  I had to redirect my thoughts and remember that prescription opioids can be a gateway to heroin for many people.  Heroin is 1/10th the cost of prescription drugs bought on the street.  People get hurt or have surgery, and we (doctors, NPs and PAs) prescribe them pain medication.  When people can’t afford their prescription drug addictions, they turn to the cheaper alternative.  And who writes the most prescriptions for these drugs?  Us. We contribute to this, so we need to accept treating it.

handcuffs

That’s my limited advice.  It’s still a daily struggle, with some days easier than others.  Do you have any tips to offer on how to approach this difficult patient population?  If so, I’d love to hear them.  I encourage you to comment below.

~Steph

Emergency Medicine, EMS

Be Heard in the Bay: Tips for Turnover on Critical Patients

Apparently 12-1 is not an acceptable ratio when it comes to his & hers blogging… So in the interest of continued marital harmony, here’s a few thoughts to newbies on making yourself heard in the resus room.

It happens to the best of us. You’ve been sitting around the station all night and finally decide it’s safe to slip the boots off, only to be immediately reminded that the trauma gods do in fact enjoy tormenting you. On come the lights, quickly followed by a dispatcher’s pressured voice. As you glance at the clock reading 3am, a few words stand out. Gunshot wound. Bleeding. Unconscious.

For the next fifteen minutes you’re on autopilot – reflexively cutting away clothing, occluding that bubbling hole in the chest and dropping a needle down through the second intercostal space, just like you were trained. You watch the vital signs move back towards normal and you justifiably feel like a total badass. Time to load and go.

As you wheel into the trauma bay at your local Level 1, you’re confident you’ve done everything right. There’s the team, gowned and gloved, ready to take over.

IMG_1105 (1)

“………..”

Inside your brain is screaming, “Work mouth, you bastard!” Now is the time to prove to all these doctors how awesome you are, how you saved this guy’s life. “I’ve done all the hard work. Speak damn you!”

“Ummm.. This is Steve, he’s a male..”

“SPEAK UP.”

“Steve! He’s a male! And.. we found him outside the bar – the one over off Main, well Main and 3rd… closer to 4th. He has asthma and…”

“Airway’s patent! Breath sounds clear bilaterally!” It’s too late. You lost them.

Want to keep the brief attention of your ED colleagues and trauma team? Here’s how:

1. Figure out who’s doing the talking – most critical patients roll in flanked by a entourage of medics, EMTs, fire fighters and/or police. Add to that the near-limitless helping hands in a large ED and there’s usually no need for the AIC to be occupied with distracting tasks like moving the patient off the stretcher or switching O2 from the portable tank to wall supply. Instead, the AIC should be at the foot of bed, addressing the entire room. Yes, everyone – the doctors, nurses, techs, social worker, chaplain and ogling med students ALL need to hear what’s going with this guy, so be ready to project your voice and speak clearly.  And if you are the trainee, don’t disappear to clean the stretcher – stick around and listen.  It’ll be your turn before you know it.

2. Take a deep breath – You made it. Even if the patient is actively coding, you’re here and your job is almost done. The blood splattered sidewalk, flashing lights, noise and confusion are all behind you. It’s our job to shut up and listen, and we will – for about 30 seconds. Starting your turnover in a calm and collected manner is the first sign to us those precious seconds will be well spent.

3. Age. Sex. Chief complaint/most pressing issue. – The first two always go off without a hitch. The third seems obvious, but every now and then it just takes an inexplicably long time to get around to mentioning the multiple stab wounds or EKG reading ***STEMI***STEMI***STEMI***. By the end of your first sentence we should know who your patient is and what went so wrong with their day to now be spending it with all these highly trained individuals.

4. Stay focused – This is not the time for an exhaustive presentation of the history and physical. A remote history of paronychia isn’t of much interest in someone with hemiparesis, but the time of onset certainly is. We can wait to hear she takes 500mg of Vitamin C daily, but Coumadin is a med I want to know about up front. By far this is the most difficult thing to master, because it often means reading our minds, knowing what’s important and what isn’t. A few stand out items in no particular order would be: loss of consciousness yes or no, symptoms improving or worsening, mechanism of injury, relevant surgeries, and medications including blood thinners, cardiac drugs such as beta blockers, and insulin.

5. Vitals – What are they now? Were they different at any time? What do you mean you only got one set?

6. Injuries, EKGs, physical exam and what did you do about it? – This is your chance to brag. “Patient was altered and EKG showed sinus bradycardia. I gave 0.5mg Atropine x1 with improvement in heart rate and mental status.” “The right leg was shortened with deformity at the mid-thigh. I gave 100mcg of Fentanyl and applied a traction splint.”

7. Access – ET tube, King airway, NPA? What size IVs and where are they? Did you drill IOs instead? Kudos if you did.

That’s it really. In 15-30 seconds we should hear what’s wrong with this person, how did it happen, what changes happened while he/she was with you and what did you do about it.

Giving a concise, accurate turnover takes practice. The pressure is on and your adrenaline is already up. You’re mentally exhausted, but those last few moments before he or she is off your stretcher are often the only insight doctors get into what’s going on, so make them count. Once the dust has settled, feel free to pull any of us aside for some feedback.

~Amir

FullSizeRender (6)

Emergency Medicine, EMS

Cardiac arrest survival story that’s close to home

Dr. Joseph Ornato is a well-known name in EMS here in Virginia and across the country.  If you don’t know him, he’s the Operational Medical Directory (OMD) for Richmond Ambulance Authority (RAA).  On a personal note, he also happens to be the Chair of the Department of Emergency Medicine at VCU where Amir and I are in residency.  If you have 30 minutes to spare, this is a great podcast interview of Dr. Ornato telling the story of how many of the technologies and protocols he initiated came together like a symphony to save his own life.

http://www.emsworld.com/podcast/12089587/word-on-the-street-when-your-medical-director-is-your-patient

Emergency Medicine, EMS, Virginia Beach

A few thoughts on drowning events

For 8 amazing summers, I worked as a lifeguard at Ocean Breeze Waterpark in Virginia Beach, VA.  Some of the best memories in my life are from those days.  However, unlike most lifeguard jobs – we actually saved drowning people, and A LOT of them, roughly 10-12 per day. I stopped counting my “saves” somewhere around 300.  Looking back, this job was what lead me to EMS, and ultimately to becoming an Emergency Physician.  The training provided by  Ellis & Associates (E&A) created a great foundation of water rescue, first aid, CPR and leadership skills.

E&A Eastern Regional Lifeguarding Competition - Summer 1998
E&A Eastern Regional Lifeguarding Competition, 1998

On a side note, you may be wondering how so many people can get into trouble at a water park.  It’s not like the ocean, right?  Well, I think as a society we have an inherent respect, and maybe some fear, of the ocean.  Pools however, are clear and don’t have critters, so how dangerous can they be?  People and parents let their guard down and get into trouble.

Are you a good lifeguard?

Before you read any further, I encourage you to take a little test.  The two videos below both feature wave pools where there are active drowners.  It’s like a high-stakes Where’s Waldo – can you spot the drowning victim?  See if you could do the job.

Did you see the kids before the lifeguard blew the whistle to jump in?  The kid in the first video has pretty obvious flailing; the kid in the second video – much more subtle.  There’s been a great Slate.com article circulating around Facebook the last few months creating awareness that drowning doesn’t always look like what we expect.

Drowning Definitions

Before we get too deep into the medicine, let’s first talk terminology.  Many of the terms I learned as a lifeguard have fallen out of favor in the medical community.

Drowning: a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium

The Drowning Process: the period beginning with submersion into liquid, followed by breathholding.  As oxygen is depleted and CO2 can’t be expired, the patient begins developing hypercarbia (high CO2), hypoxemia (low O2), and acidosis.  As water is inhaled, the larynx spasms shut, blocking the exchange of air.  As oxygen drops further, the laryngospasm relaxes, and the patient breathes water into the lungs. Recovery from the drowning process depends on when interventions are made and the resultant level of hypercarbia, hypoxemia, acidosis and encephalopathy.

drowning process
The Drowning Process

Terms no longer used:

“Dry drowning” versus “wet drowning”: all drownings require some level of liquid, so they are all technically wet.  What was traditionally called a “dry drowning” was just someone who made it to the laryngospasm step but no further because they left the water.  “Wet drownings” went through a laryngospasm period, but advanced in the process to include inhalation of water into the lungs.

Managing Drowning Victims

You should of course follow your local protocols, but let’s talk about how the drowning mechanism affects care.  Clearly if the victim has no pulse, you’ll follow ACLS/BLS guidelines and start CPR.  If you get to a victim but can’t initiate chest compressions right away because you are oh I don’t know – in the middle of the ocean or a wave pool – at least try to give rescue breaths as you bring the victim to a more suitable place.  Remember, drowning is primarily an airway issue, so any early airway interventions will be beneficial until you can start CPR.  As of the 2010 AHA CPR updates, abdominal thrusts in a coding patient have been discarded for good old chest compressions.  So, if your drowning victim isn’t breathing, even if they have a pulse you may need to do chest compressions for management of A&B.

Regarding when to intubate, per UptoDate, “in the symptomatic patient, indications for intubation include the following:

  1. Signs of neurologic deterioration or inability to protect the airway
  2. Inability to maintain a PaO2 above 60 mmHg or oxygen saturation (SpO2) above 90 percent despite high-flow supplemental oxygen
  3. PaCO2 above 50 mmHg” which is typically unavailable prehospital.

Whether someone was pulled from fresh or salt water is not particularly relevant to prehospital care as it doesn’t change management. Consensus used to be the patients in salt water were at risk for massive pulmonary edema and electrolyte imbalance in the blood as the high sodium content of the salt water shifted in the body.  The risk and consequences of these shifts are now less worrisome than once thought.  In a 150lb (70kg) person, it actually takes inhaling 5.5 cups of water before you’ll see osmotic water shifts in the body, and twice that before you’ll see electrolyte shifts.

The greatest risk of drowning of any type is hypoxemia leading to brain damage, and they key strategy is drowning prevention.

Drowning Prevention

Prevention is by far the best strategy in managing drowning, and in the last 20 years, smart safety measures and public education programs have helped drop the overall incidence of drowning by 9%, which includes a 45.6% drop for infants (< 1 yr of age).  In fact, my good friend David Andrews who runs a water park out in California, told me that since the water park industry implemented a policy requiring kids <48″ to wear life jackets, active drowning events have declined roughly 50%.

So, if you are taking care of a drowning victim in your ambulance or ED, just follow your ACLS protocols.  And, next time you are at the water park or pool, thank the lifeguard for their diligence and dedication, and please don’t complain that your kid has to wear a lifejacket.

~Steph