Tag: Novice EMT

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

Interview with a Charge Nurse: How to be an EMS provider respected by the ED

I had a great response to one of my earliest posts, 5 Things I Learned in Medical School I Wish I’d Learned in EMT School, with many people asking for more tips on improving as an EMT.

Katie Arnold, Charge Nurse
Katie Arnold, Charge Nurse

With that in mind, I realized that learning how to interact with the staff in the Emergency Department (ED) is also an art not often addressed in EMS education.  Clearly you need to know and execute your protocols effectively – but how can you stand out as a respected EMS provider?  Fortunately, I’ve been friends with an awesome charge nurse named Katie Arnold since junior high.  She was kind enough to answer a few questions.


Steph: How long have you been a nurse, and how did you get to be a charge nurse?

Katie: I have been a nurse for 14 years this May 2015 – I have spent my whole career in the emergency department. I was selected for charge nurse by my manager, trained by another charge nurse and then started on my own around 2006-2007.

Steph: What do you like most about your job?

Katie: As an emergency nurse in general I love the unpredictable and unexpected. I tell new nurses, patients and their families all the time that it’s like a jigsaw puzzle: you get a piece here and a piece there but you don’t figure out the whole picture until all the pieces are in place. I love that I can have 5 patients all with the same chief complaint and each will be managed totally differently. As a charge nurse I love being a representative for the department, working with ancillary staff, patients, families, nurses, and EMS. I am there to control the flow of the department, to be a professional example for everyone and handle many administrative duties. It adds a whole other dimension to the role of nurse that allows further development of a holistic nurse.

Steph: Can you explain the goals and responsibilities of a charge nurse, in particular, ways you interact and work with EMS?

Katie: The duties are numerous and in depth. With EMS, we are the liaison between rescue and the ED. EMS providers are the eyes, ears and hands in the field; they are going to paint the picture the charge nurse needs to determine how each ambulance patient that arrives will affect the balance of the ED at every moment. You must appreciate their role in addition to the roles of the ED staff. Their resources are vastly different than the staff in the ED. I think staff nurses as well as some charge nurses lose sight of that fact.

Steph: What makes a good EMT in your mind?

Katie: A good EMT knows their role, provides an accurate concise report of what they are transporting to the ED. They demonstrate professionalism despite the stresses presented by the patient, the scene and the ED. A good EMT knows when to address concerns and when not to.

Steph: Do you have any pet peeves of EMS providers?

Katie: Lengthy reports of extraneous information and lack of recognition about valid concerns of the ED staff. One cannot expect the ED staff to appreciate EMS constraints but then not care about the concerns of the ED staff.

Steph: What can EMS providers do to make your life as a charge nurse easier?

Katie: As Charge Nurse, I have to decide what type of bed is appropriate for the patient based on the EMS report. Do they need a heart monitor, a psych bed or oxygen? Not all rooms are equipped with the same capabilities. A good report provides me with the information to make this decision. Helpful EMS providers also note when the ED is busy, and go the extra mile to be team players. Whether it’s cleaning a bed or hooking a patient up to the monitor, while not the job of the EMS provider, it helps the patient get care faster.

Steph: Which EMS providers impress you and why?

Katie: Those who are clear, concise, professional both in front of their patient and amongst colleagues on the EMS and ED side. Providers that are open to and understanding of constructive criticism.

Steph: Any tips for a brand new EMT?

Katie: I believe that when a new group of EMT’s are coming out they should have an initial interaction with a charge nurse or liaison at the ED to discuss these topics and allow for questions they may have to be asked prior to starting on the road. If that’s not done formally, then an individual EMT should feel free to introduce themselves to ED staff and seek feedback on reports.

Steph: And finally just for my own curiosity, what’s it like to be charge nurse on July 1 when the new Intern doctors start?

Katie: I love to teach and educate, so it does not bother me as it does others. ED Staff tend to become frustrated because each new class of Interns is unaware of how each ED operates with different patterns and order sets, goals and metrics. Some doctors are more receptive to that fact than others. It can drastically slow the flow of the ED and directly affect the care of the patients. New Interns are successful as long as they are willing to listen.


So there you have it, straight from the boss’s mouth.  My advice, pick one thing to try and start there.  Good patient reports are 90% of the game.  Once you nail that, the rest falls into place.

~ Steph

5 Things I learned in Medical School I wish I’d learned in EMT School

Granted, it’s been 10+ years since I went through EMT school, but I still remember the gist of it. I remember often thinking the course was being dumbed down – taught to the lowest common educational denominator, which at least in the State of VA can be a GED. I actually think that’s fine – someone with a GED can do a great H&P, start CPR when needed and fashion a pretty good sling out of cravats. But EMT class is often the entry point for many folks with capability and ambitions to continue well-beyond the EMT level. I’m a firm believer in setting expectations high – assume your students want to learn as much as possible, and believe that they can. Don’t assume that they can’t understand why. Looking back on medical school and a year of Emergency Medicine Residency, I’ve complied a few things I wish I had known earlier.

1. Appendicitis pain presents around the belly button for a reason

As an EMT, I never understood why appendicitis often presented as periumbillical pain. Understanding things helps me remember better than mere memorization – that’s true for many people.  The classic presentation (50-60% of patients) for appendicitis is pain that starts near the belly button and migrates to the right lower quadrant. To understand this migration, you just need to know a bit about how the abdomen is innervated. When the appendix first gets inflamed, it’s still small and isn’t pushing against other structures. The pain one feels is deep, visceral pain (think “gut”), which happens to follow a course along the midline of the abdomen, known as the splanchnic nerves. This is why patients perceive pain in the middle of their abdomen even though the appendix is located in the right lower quadrant.  As the inflammation and infection worsen, the appendix swells and begins to irritate the muscle and tissues of the abdominal wall, producing pain in the right lower quadrant.

2. Vitals really are as important as everyone says they are

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Abby Hoobler, EMT-E auscultates to determine heart rate

I will concede that my EMT instructors definitely tried to tell us this. Often though, vitals are taught in the second lesson in EMT class, just after the chapter on consent and other medical-legal issues. It’s taught up front in a focused lesson, but really should be a longitudinal study. We spend much more time up front focusing on how to take those vitals, and less time as we go along learning how to interpret and act on those vitals.  Ask yourself – how long is your differential diagnosis for hypotension?  Bradycardia?

indexcards-planning
Vital Sign DDx Carry Cards

If you’re struggling for more than 5, try this: at the top of an index card, write “hypotension.”  List all the diagnoses you can.  Now make similar cards for hypertension, bradycardia, tachycardia, respiratory depression, tachypnea, hypothermia and hyperthermia.  Carry the cards with you on shift.  Ask colleagues to help expand your list.  Pay attention to which conditions appear on multiple cards.  You’ll be surprised how much you can learn.  And next time you feel like you are doing EMT-B&%$# work by taking vitals, you’ll realize you’re probably the most important person on scene.

3. If you communicate well, doctors and nurses WILL listen to your turnover

We want to hear your turnover, if nothing else because you’ve probably asked 70% of what we will, and that will save us time. Being assertive, confident and organized in your presentations is 99% of the battle. Believe it or not, we also really really wish we could have access to the patient care report you wrote. Those initial vital signs and early medication administrations can affect medical decision-making downstream, especially if your patient gets admitted.

4. Stomas, Fistulas, Ports & Other Medical Devices

The EMT curriculum fails to educate providers about common medical procedures and indwelling devices. I never learned about the pieces and parts of a foley, colostomy, mediport or dialysis fistula, yet in any given day, 40-50% of EMS calls can be to Specialized Nursing Facilities (SNFs) where patients have problems with any or all of these devices. We do an ok job with complex devices like LVADs, but there are tremendous gaps otherwise.  Here’s one to start:

Stoma – Any man-made hole through skin or tissue that connects a normally internal structure to the outside world. So, the hole in someone with a trach is a “tracheostomy;” the bag attached to the hole coming out of someone’s abdomen and intestines is a “colostomy,” just like the drain in the head of a kid with hydrocephalus is a “ventriculostomy.” If you want to know the grossest thing on the planet regarding stomas, look up “Philadelphia Sidecar” on UrbanDictionary.  Yes, it’s a thing.

5. Normal Values for Basic Labs

Along the same lines as above, many patients are sent to the ED by a doctor due to an abnormal lab value.  Arguably, if the lab is concerning enough that the doctor wants the patient seen emergently in the ED, then you should probably know the normal range for that value, and what to expect if it’s high or low.  If you responded to an urgent care center for a potassium of 8.2, would you think to call a Paramedic?  I know I wouldn’t have 5 years ago.  Turns out hyperkalemia can kill you, but you don’t get to learn that until Paramedic School.  Whenever I need something complex explained eloquently, I always turn to my friends at KahnAcademy.

Familiarize yourself with the components of a Basic metabolic Panel (BMP) and a Complete Blood Count (CBC) and you’ll be 95% of the way there.

Check out the follow-up to this post, written by my husband, Amir: “5 things I learned in EMT School that I wish I learned in Medical School.”

~Steph

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Oceanfront Sunrise, Virginia Beach, VA