Digest

This episode of EMS 2020 begins with an apology for initial audio issues and introduces a case involving a 39-year-old male with altered mental status. The podcast details the EMS system, Caffeinated County Medical Response, and the role of community paramedics. The patient, found stumbling and unresponsive, deteriorates en route to an urgent care. Initial assessments reveal a low heart rate and altered consciousness. Despite a history of drug addiction and a suspected medication change, the paramedic, Joe, suspects a stroke. He effectively uses writing as a diagnostic tool when verbal communication fails. The episode critiques the Field Training Officer's (FTO) unprofessional response to the stroke alert and emphasizes the importance of clear communication and feedback in FTO training. The discussion delves into the complexities of aphasia, differentiating Broca's and Wernicke's areas, and the critical need to prioritize stroke assessment over intoxication. It also covers transport decisions amidst hospital diversions and the applicability of stroke assessment for BLS providers, concluding with the patient's successful thrombectomy.

Outlines

00:00:00

Introduction and Case Presentation

The episode starts with an apology for audio issues and introduces EMS 2020's mission. A new case is presented: a 39-year-old male with altered mental status, detailing the EMS system, Caffeinated County Medical Response, and the role of community paramedics.

00:15:16

Initial Call and Patient Deterioration

The crew responds to an urgent care for the patient, who becomes unresponsive with a low heart rate en route. A fire response and community paramedic are added. Upon arrival, the patient is unresponsive but perfusing, with the doctor reporting he was found stumbling.

00:21:29

Patient Assessment and Differential Diagnosis

Initial assessment reveals the patient is responsive to pain, breathing normally, with a pulse in the mid-50s. The differential diagnosis includes stroke, trauma, and intoxication, with immediate assessments planned.

00:27:17

Patient Transfer and History Update

The patient becomes more alert during transfer. A possible facial droop is noted, and it's learned the patient has a history of drug addiction, with a suspected medication change contributing to his condition.

00:33:39

Ambulance Assessment and Stroke Suspicion

In the ambulance, the patient exhibits slurred, incoherent speech. Vital signs are obtained, and despite intoxication theories, Joe suspects a stroke, using writing as a diagnostic tool when verbal communication fails.

00:37:14

Transport Decisions and FTO Dynamics

Joe requests transport to a stroke center, facing hospital diversion. The FTO's questioning of Joe's certainty is deemed unprofessional, highlighting issues in FTO communication and training.

00:50:31

Transport and Hospital Arrival

The transport to Leaf Broth Medical proceeds with lights and sirens. The patient's condition remains stable, and upon arrival, the ED staff takes the case seriously.

00:52:45

Case Review and FTO Communication

The hosts review the case, emphasizing Joe's effective stroke diagnosis and the FTO's inadequate response. The discussion shifts to the critical role of clear, consistent communication and feedback from FTOs.

01:00:32

FTO Training and Skill Development

Being an FTO is presented as a specialized skill requiring passion for teaching, empathy, and clear communication. The impact of FTO selection on agency culture and the importance of constructive criticism are discussed.

01:07:24

FTO Habits and Communication Strategies

A valuable FTO habit, the "pregame" with three questions for trainees, is introduced. The limitations of urgent care and the importance of respectful patient interaction are also noted.

01:11:00

Stroke Assessment, Aphasia, and Treatment

The utility of repeat stroke assessments, understanding aphasia (Broca's and Wernicke's areas), and the complexity of brain function in stroke presentation are explained. Prioritizing stroke over intoxication and treatment considerations are discussed.

01:27:46

BLS Role and Thrombectomy

The applicability of stroke assessment and treatment for BLS providers is highlighted. The episode concludes with the patient's successful thrombectomy and the decision against clot-busting medication due to his history.

Keywords

Q&A

• What was the initial problem with the audio quality in the podcast?

  The host, Chris, realized about 30 minutes into the recording that he had been using the wrong microphone, which affected the audio quality for the first part of the episode.

• What is the purpose of EMS 2020?

  EMS 2020 reviews real out-of-hospital calls to provide educational opportunities for listeners and aims to make the content humorous while discussing critical incidents.

• What was the patient's initial presentation and history?

  The patient was a 39-year-old male found stumbling and falling into shrubbery, presenting with altered mental status. He has a history of drug addiction, and the doctor suspected a medication change might be a factor.

• How did Joe determine the patient was likely having a stroke?

  When the patient was non-compliant with verbal communication, Joe provided paper and a pencil. The patient wrote "My mind is appropriate" and confirmed he believed he was having a stroke, indicating a potential communication deficit beyond intoxication.

• What is the significance of the FTO's reaction to the stroke alert?

  The FTO's questioning of Joe's decision to declare a stroke alert ("Are you sure?") is criticized as unprofessional. Effective FTOs should support their trainees' clinical judgment and guide them, not undermine their decisions.

• Why is consistent communication and feedback crucial in FTO training?

  Trainees should never be surprised by their performance evaluation at the end of an FTO phase. Regular, clear feedback from the FTO helps trainees identify strengths and weaknesses, allowing them to address deficits proactively.

• How should FTOs be selected and viewed within an EMS agency?

  FTOs should be seen as a specialty, not just a promotion. Agencies should select individuals passionate about teaching, empathetic, and skilled in communication, rather than simply those who have been with the agency the longest.

• What is the difference between Broca's aphasia and Wernicke's aphasia?

  Broca's aphasia (expressive aphasia) affects speech production, making it difficult to speak fluently or form words, while language comprehension remains largely intact. Wernicke's aphasia (receptive aphasia) impairs language comprehension, leading to fluent but nonsensical speech (word salad) and the patient's unawareness of their errors.

• Why is it important to perform repeat stroke assessments?

  Repeat stroke assessments are crucial for tracking symptom progression or improvement. This information is vital for communicating with the hospital, potentially identifying a TIA, and providing a more accurate picture of the patient's neurological status.

• Should intoxication be considered before or after a potential stroke?

  A potential stroke should always be investigated before considering intoxication. The "order of operations" prioritizes ruling out a stroke, as it is a time-critical, life-threatening condition that requires immediate intervention.

• Can BLS providers effectively assess and manage stroke patients?

  Yes, many aspects of stroke assessment and management are within the scope of BLS providers. Recognizing speech changes, performing basic neurological assessments, and initiating transport are crucial skills that EMTs can utilize effectively.

Show Notes