Tag: Emergency

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.

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

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.

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“………..”

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

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Did you know it’s National EMS Week?

Did you know that May 17-23, 2015 is National EMS Week?  There are over 825,000 certified EMS providers in the United States.  In addition to being an exciting job, it’s also a dangerous one – with an estimated 27,800 ED visits annually by EMS providers as patients themselves!

While donating to a local rescue squad is a great way to show your support for EMS Week, I can tell you from first hand experience that a simple gesture to say “thank you” goes a long long way to keep an EMS provider motivated and inspired.


TeamLouka Gets a Sweet “Thank You”

A few years ago on a hot Summer day, Amir and I were dispatched to a house for a child having a seizure.  The little girl had a history of frequent seizures, so her parents were pros at giving her Diastat, her emergency medication designed to stop a seizure.  By the time we arrived just a few minutes later, her seizure had stopped, and her Dad just asked that we check her vital signs.  He had spoken to her Neurologist who agreed she could stay home if her heart rate, blood pressure and breathing were all stable.  Fortunately, everything checked out ok, so the family was able to avoid another hospitalization.

As we collected the equipment and marched back downstairs, we heard the Dad pop the top on two bottles and shout “I really want to thank you both!”  Hoping not to embarrass or insult him, Amir and I discussed the best way to tell him we couldn’t accept an alcoholic “thank you” while on duty.  As we rounded the corner to the kitchen, we saw him holding two ice-cold bottles of Coca-Cola.  We drove away feeling appreciated and recharged – ready to take on whatever 911 call came next.

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The sweetest kind of “Thank You”

Hopefully you won’t have to have such a close encounter with your local EMS providers, but don’t let that stop you from giving the next crew you see a pat on the back.

~ Steph

Ups and Downs of My Intern Year in Emergency Medicine

Everyone warns you that Intern year is hard. It’s a year of little sleep; a rollercoaster of emotions both good and bad. Frustration and guilt in wanting to know everything NOW, because everything you don’t know might be what matters for this patient, this time. And trememndous successes. Some of the things I did this year, I really can’t believe I was able to do. And survive. Mostly, I’ve learned a lot about myself, and have been reminded yet again, that I work with an amazing group of people.


UP – Running a trauma when I thought I could never do it

I have a distinct memory of standing in the Trauma Bay at Norfolk General Hospital, watching the Trauma Team work its perfectly organized chaotic magic. I paid particular attention to the young female physician leading the whole thing – inserting an airway, calling out physical exam findings, doing an eFAST ultrasound to look for bleeding. I remember hoping, wishing I could ever have her confidence and calm demeanor. That thought was followed quickly by being thankful I wasn’t yet in that spotlight myself. I could never do that, right? In September I ran my first Delta Trauma at a Level I Trauma Center, and I survived to do it again.

VCU Medical Center Resuscitation Bay, Richmond, VA
VCU Medical Center Resuscitation Bay, Richmond, VA

DOWN – Those 2-week stretches not seeing my husband

I had no idea how much I need my husband to help me feel like a normal, healthy, centered human being. Amir and I had about four 2-week stretches this year where he was on nights and I was on days, or vice versa. One day we were so desperate for a date we coordinated a 20 minute coffee meet-up at the au bon pain in the hospital. Let’s not talk about what the house or laundry pile looked like during those stretches.  This is the video we play each other if we ever need a pick-me-up:


UP – Procedures, procedures, procedures

Open Thoracotomy

Paracentesis

Lumbar Puncture

intubations, central lines, suturing, joint reductions, even a c-section… you get the idea. I get to work with my hands a lot.


DOWN – Crying in the ICU

So I’m a crier. Always have been. I have distinct memories of my dad trying to help me with math homework as a kid, me getting frustrated and crying (my stress response), and my dad getting frustrated because I was crying. “What’s crying going to solve?” he used to ask me, which of course, made me cry more.

To be honest, I was expecting to cry multiple times the first few months of residency. tumblr_inline_mhsu6v3NBF1qz4rgpI actually made it to late February before it happened. Combine working 12-14 hours a day, 11 days in a row, with little sleep, food, potty break or non-medical human interaction (one of those 2-week stretches) – and now add to that a dozen of the sickest patients in the hospital. I broke down – red face, tears, snot, the whole nine yards. The nice thing about Intern year though is that everyone around you has been there, so I had about 4 senior residents plus 3 PAs sharing their crying stories right along with me to help pick me up. And that’s what you learn to do – pick yourself up, learn and keep going.


UP – Finally learning my way around the hospital (which is actually 4 hospitals)

Anyone who works in an old hospital knows how the building just gets added onto over the years, creating a behemoth maze of windowless hallways and floors that don’t match up. “Take the elevator to the 5th floor of North Hospital, turn left and you’ll be on the 1st floor of Main Hospital.” As if there weren’t enough to learn as an Intern.


DOWN – Cancer. I diagnose a lot of cancer.

I didn’t go into Oncology for a reason. It takes the smartest, strongest, most energized people to be cancer doctors. As an Emergency Physician, I expected to treat people with cancer, but I hadn’t thought of cancer as something I would diagnose. I guess I assumed that people would present to their PCP with concerning symptoms, get an outpatient workup and diagnosis by a specialist. But people do come to the ED for hematuria (blood in the urine), anorexia (lack of appetitie), back pain and weakness. And sometimes at the end of the workup, it’s cancer.


UP – Baby Mint Mochachino for a dying patient

Baby Mint Mochachino made with honor
Baby Mint Mochachino made with honor

I’ve seen a lot of amazing, caring people do a lot of touching things in the medical setting, but one moment stands out from this year. I had a patient who had chosen to pursue hospice care. He couldn’t stop telling me how beautiful his wife was and how he looked forward to seeing her soon. He had stopped eating and drinking days ago, so when he asked me for a “real coffee,” I was intrigued. He’d requested a cup of coffee from the medical student who poured him a cup of the hospital grade mud available to all employees. His dying wish was to have a real cup of coffee. How reasonable. I went to the ABP counter, told the story to the barista, and she whipped up the only coffee worthy of such a role – a baby mint mochachino, which she made with honor and pride in her work, even adjusting the temperature down to avoid any burned tongues.


So that’s it – Intern year is coming to a close, and July 1 I’ll be a “Senior Resident,” fraught with its own challenges and lessons to be learned.