This week has been a whirlwind of activity. I’ve been working the Monday, Wednesday, and Friday schedule this rotation and in between I’ve been educating myself. Well, refreshing and educating. I went to a module of the Fire Department’s National Registry refresher, and today I went to a stroke and neurological care symposium put on by Methodist Healthcare here in Memphis. Had a great time.
Our medical director, Joe Holley, gave a little update on the progress and updates of the new stroke guidelines. I was interested in the new guidelines for stroke care involving some issues I have pushed a reasoned out for years. The first concept was that for hypoglycemia presenting in in an acute stroke that we shouldn’t be blasting the blood sugar around with D50. The sudden increase followed by sudden drop in blood glucose is actually associated with worse outcomes. I’ve been pushing for a re-write of our hypoglycemia protocol for a while that would eliminate D50 from the protocol and replace it with 500cc of D5W, which will deliver the same amount of glucose as a 50cc carpuject of D50. I will write more on this later.
He also hit on not giving aspirin to stroke patients, which I never did anyways regardless. He also talked about something that I want to write on more in depth later, which was managing hypertension in the acute stroke presentation. The primary reasoning I’ve always thought was that the body is trying to perfuse the brain, and you can cause way more damage by taking away the reflex than worrying about a hypertensive crisis. I’d say get rid of a protocol for hypertensive crisis in the EMS setting (unless we were using Labetalol, but I digress) especially here because it seems that EVERYONE is on anti-hypertensives.
James Roberts followed Dr Holley, presenting on the Cincinnati (FAST) stroke exam vs the MEND. MEND meaning Miami Emergency Neurological Deficit exam. I like the MEND mainly because it is specific and detailed, but they recommend using the FAST to quickly screen patients because the FAST, when only 1 of the 3 signs is present, is accurate 72% of the time. By comparison, the hospitals misdiagnose stroke 25% of the time, so it’s accuracy is generally unmatched. In EMS we tend towards things that are quick, easy, and memorable, so as a screening exam FAST is unmatched. I will write more on it later as well.
Dr Marc Grossman from Miami-Dade Fire Rescue gave a presentation about how they improved survivability in stroke patients in Miami, which has been wildly successful. I think that sometimes our issue with establishing true success is that getting information on outcomes from the hospitals is like trying to rob a bank. You can try, and you may even succeed once, but the chances of getting a return diminish quickly. It seems to me at the street level that we only get back a lot of feedback on patients where we either screwed up really big (because hospitals never make mistakes) or the outcome makes them look really good.
Something new were breakout sessions, where we got to take a look at how they coil an aneurysm, how all the imaging is done (similar to a CATH lab), some information of how congenital defects are corrected and some new medications out on the market. All of it looks very promising.
“Neurosurgical Emergencies for the EMT” was then presented by Dr. Stephanie Einhaus. This was mainly a lecture over how the neurosurgeons work on different types of brain problems and also some information on a new Tennessee state law regarding brain injuries in athletes, that a neurologist or a physician has to clear an athlete to play after they have had a brain injury. The wording of the law seemed to present that it was any brain injury on the field in order to prevent secondary injury.
The Stroke Coordinator at Methodist Healthcare, Jennifer Phillips, RN, explained information that the hospital has researched regarding strokes that resulted from head bleeds, and that number was fairly low. I held a question when she was discussing treatment and symptoms regarding the corelation of capnography to maintaining proper cebral pressure, but I will write more on it later.
Lunch was awesome, thanks Kim.
It seemed that during this symposium there were a lot of people from Alabama, and keeping with that, Anne Alexandrov, a “nurse doctor,” presented on thrombolysis. The United States was the first country in the world to approve the use of tPA in acute strokes and since then we are dead last in the industrialized world using this medication in stroke. What she found while researching hospitals was that a lot of hospitals create extra excuses to not use tPA, and as a result a lot of patients that might benefit from it go untreated. She explained that chemotherapy has a 50% complication rate (I know this personally, being a former cancer patient), but you never hear oncologists tell patients that they are better off with cancer, so why when tPA has a lower complication rate do neurologists not use it?
I likened the concept to us in EMS, that we make up a lot of excuses, either it’s bred culturally or created by policy within the organization, that we don’t treat certain kinds of acute pain or painful injuries with narcotics or pain controlling/eliminating medications. Those are what I like to call “wrong.” People call us for (among other things) pain, so shouldn’t we be in the business of treating and managing acute pain? Just a thought to hang your hat on for a while.
Anyway, overall, I had a great time and if you were following my Twitter feed you certainly had a few laughs. Hopefully I will be presenting at one sometime (…ahem) and someone else can write about me!