Blood Pressure: ALS v. BLS

[sirengirl]

Alright sooo.... Today I got a call for diarrhea at an indipendent nursing home. I get up to the patient and she's 89, A&Ox3, currently feels okay, diarrhea x3 in the past 30 hours. On meds for depression, insomnia, hypertension, and something else that was unrelated. Sitting in bed, ambulatory, pretty pleasant to talk to. So I get her vitals. BP machine is taking forever. Note that the county at this time is going insane with calls and our squad in fact turned down about 5 requests for assist from the county b/c our units were on calls already. BP machine finally gets back to me- 214/160 (or some other similar diastolic).

Immediately I take it on the other arm- it's the same range. Pt states she did in fact take her blood pressure medication this morning. I call for ALS, as my protocols state anything above 210 should be called in, and re-take manually as our BP machines have been known to be :censored:. Again, over 210. So we chill for about 10 mins until ALS arrives. It's the firemedics on the engine from the station closest us, as their truck and the second closest truck are already on calls. I explain that initial CC was diarrhea x3 and I called for BP over 210.

This is where my question starts.

The medic took her BP, by this time it was just under 200/97 or so. Pt has no s/s, no complaints other than the diarrhea, no pains, aches, droop, slurring, aphasia, headache, tingling, tightness, sob, nothing. Medic 1 looks at Medic 2 and shrugs. Medic 1 then says to me,

"We don't treat unless it's over 220/140."

Then they pack their :censored: and vamos.

WITHOUT an ECG.

Was I wrong to call them? Or were they wrong not to check her cardiac? Should I have demanded that the medics run an ECG or was I right to let it slide and transport my patient for her initial diarrhea complaint? I discussed it with a fellow EMT at my station who believes I should have made them run the 12-lead, but as a general rule I don't question those with more training than me. I'm scared to death that this is going to come back as asymptomatic hemmoragic stroke or something- recently ALS turned over a call w/o SaO2 and w/o ECG to one of our teams and it turns out the poor man was having a silent MI.

Thoughts?

 

[bigbaldguy]

First of all I'm curious. You use machines to take BP and you're bls? What kinda a swanky outfit you running with lol. We do manual first here machine second and I don't know of many bls services that use auto bp at all.

Sounds like there is a disconnect between your bls protocols and your als protocols. If yours say to call als for xyz then you call als for xyz. You're just following your orders. That bp on a woman that age who should theoretically be dehydrated from the diarrhea and has her bp controlled by medication would set my alarm bells ringing as well.

I agree it seems like an ECG would have been a good idea just to be on the safe side. I can't see how this would come back on you though. You did what you were trained to do and called in the big boys and they poo poo'd your call. If anything comes of it then it will be on them not you.

 

[sirengirl]

First of all I'm curious. You use machines to take BP and you're bls?

....should theoretically be dehydrated from the diarrhea...

Pretty swanky, I guess. All our units have auto BP machines which also have pulse ox. They have a very high rate of being crap, as I mentioned earlier, but we recently complained enough to get a bunch of new ones and they've been working good.

And yeah she was mildly dehydrated- enought to tent a little when I checked turgor.

I talked with our education assistant chief, who said that getting all our protocols on with the county's has been an uphill battle; the county services 3 major cities and we service one small city. Our med director is local only an doesn't meet with the county.

Like I said, I'm just worried about heart condition slipping through or the possibility of a cranial bleed somewhere. An 89y/o woman who has taken her BP meds and not been active, in fact has been sitting in bed, should not have a BO over 200....

 

[LucidResq]

I think it's pretty simple... it's sad that they care more about a 20 mmhg difference in a systolic pressure than this patient or your request. Even if there's not much they can do treatment-wise, they have more assessment abilities... ALS was requested and this ain't for "my shoulder hurts" - a hypertensive crisis can lead to very severe consequences.

 

[Lifeguards For Life]

There's 63 mmHg difference between your reported diastolic, and the diastolic obained by fire.

140 may be worth a worry, 97, not so much.

You seem to think an ekg will show a brain bleed?

A 12 lead wouldn't hurt. I probably would of done one just as a courtesy to the BLS crew.

 

[Lifeguards For Life]

You definitely weren't wrong though. you did good kid.

 

[sirengirl]

You seem to think an ekg will show a brain bleed?

It's not that I think an ECG would show a bleed- I know it wouldn't. But being as the pt does have a cardiac history I wanted to make sure the BP wasn't indicative of a cardiac problem. OR there was the possibility of a bleed. Either way an ALS assessment would have helped.

 

[Shishkabob]

You seem to think an ekg will show a brain bleed?

No, and I don't think she insinuated as much, but a 12/15-lead COULD help with a differential.



However, without any S/S, highly doubtful anything would have been done for the patient at the ALS level. We have 2 different Beta blockers, and multiple vasoactive drugs on my truck, but I'm not touching any of them just because I don't like a number.




Should a 12-lead have been done? Yes. Any treatments? Don't know.

 

[Lifeguards For Life]

However, without any S/S, highly doubtful anything would have been done for the patient at the ALS level. We have 2 different Beta blockers, and multiple vasoactive drugs on my truck, but I'm not touching any of them just because I don't like a number.

Only S/S here is diarrhea 3 times over 30 hours, if fire correctly read the bp.

OP what were the vitals, and did you take a manual bp?

 

[sirengirl]

Only S/S here is diarrhea 3 times over 30 hours, if fire correctly read the bp.

OP what were the vitals, and did you take a manual bp?

Forgive me but I can't remember the exact numbers :/ Initial vitals are BP (left arm) 214/160 (give or take on the diastolic), HR was in the 80s, RR was 16, GCS 15. RR and GCS never changed, heart rate at second assessment was 88 (I specifically remember that one) and BP on right arm 210/high150s, third BP taken manually on left arm was 211/high150s as well. Next set was done about 10 mins later by ALS with above results. By this time HR was 79.

 

[Smash]

It's not that I think an ECG would show a bleed- I know it wouldn't. But being as the pt does have a cardiac history I wanted to make sure the BP wasn't indicative of a cardiac problem. OR there was the possibility of a bleed. Either way an ALS assessment would have helped.

Actually although it's not necessarily used to diagnose a "brain bleed", ECG changes are very common with intra-cranial hemorrhage (reported ranges betwen 25% to 100%!)

However, with the scenario presented I don't think a 12 lead in the field is going to change things for the aptient.
The trouble with any test (be it a 12 lead or an MRI) is that it is only as good as your pretest suspicion that something is going on that needs to be tested for. The best example of that is probably the ballyhoo over PE and doing D-Dimers on all sorts of people. We found that the incidence of PE was actually huge, but the significance was negligible; we just picked up that the lungs were doing their other job (clot catcher)

So for the scenario, I don't think a 12 lead really matters, and I certainly wouldn't be treating that blood pressure in the absence of any relevant symptomology.

 

[Anjel]

I would of made ALS take them.

Here if a basic doesn't feel comfortable taking the pt ALS cannot refuse to take them. We just have to have a really damn could reason not to.

With a BP that high and no explanation. I am not gonna risk the pt stroking out or something else happening.

 

[Lifeguards For Life]

I would of made ALS take them.

Here if a basic doesn't feel comfortable taking the pt ALS cannot refuse to take them. We just have to have a really damn could reason not to.

With a BP that high and no explanation. I am not gonna risk the pt stroking out or something else happening.

What reason do you have to not feel comfortable with this patient?

I doubt the BP was as high as the OP reported.(could of been but there is a huge discrepancy between her reading and the medics, as well as no accompanying signs, symptoms, complaints etc. of any real concern)

 

[Lifeguards For Life]

Actually although it's not necessarily used to diagnose a "brain bleed", ECG changes are very common with intra-cranial hemorrhage (reported ranges betwen 25% to 100%!)

Wouldn't a myriad of signs and symptoms come charging before any ekg manifestations in the case of a bleed? (I remember reading an old article discussing this, but haven't really ever heard anything else about it.)

 

[Shishkabob]

Here if a basic doesn't feel comfortable taking the pt ALS cannot refuse to take them.

That's the dumbest thing ever. If a medic deems that a patient would be ok going BLS, that should be the end of it, as their clinical decision should outweight a BLS trucks non-clinical decision.




There are calls I'm not comfortable with, but I can't slink out of my responsibilities and shoo the patient to someone else. Neither should a BLS provider. Provider comfort really shouldnt be a factor in patient care.

 

[Anjel]

What reason do you have to not feel comfortable with this patient?

I doubt the BP was as high as the OP reported.(could of been but there is a huge discrepancy between her reading and the medics, as well as no accompanying signs, symptoms, complaints etc. of any real concern)

If it was as high as the OP says, and no EKG was done to clear the pt. I would not feel ok with taking that pt. Because if something happens I am screwed.

I would have to be there to determine it too. Depending on the look of the pt, and other factors. Especially how close I am to the hospital.

 

[Lifeguards For Life]

That's the dumbest thing ever. If a medic deems that a patient would be ok going BLS, that should be the end of it, as their clinical decision should outweight a BLS trucks non-clinical decision.




There are calls I'm not comfortable with, but I can't slink out of my responsibilities and shoo the patient to someone else. Neither should a BLS provider. Provider comfort really shouldnt be a factor in patient care.

I wouldn't go as far as to say it is the dumbest thing ever. If the basic is really and truly not comfortable with babysitting a patient, I don't really know if it is fair to the patient to send them with such a provider (even if said care consists mainly of staring at them). Provider comfort shouldn't take priority, but care should be taken to ensure the patient feels that their provider is capable of caring for them.

But on the other side, is that really worth tying up an ALS unit with?

Regardless, being afraid to transport this particular patient, is weak.

 

[Lifeguards For Life]

If it was as high as the OP says, and no EKG was done to clear the pt. I would not feel ok with taking that pt. Because if something happens I am screwed.

I would have to be there to determine it too. Depending on the look of the pt, and other factors. Especially how close I am to the hospital.

What are you expecting this EKG to show?

 

[SeanEddy]

There are a few things to consider here. If your transports time to a hospital is less than the als eta, then sitting on scene doesn't do much good. Of course, I don't know your rules or your area.

Clinically speaking, you were absolutely right to call als. The risk of stroke or cardiac is significant with that bp. However, I would strongly advise against "directing" a paramedic to perform a skill that's outside of your scope. Your best bet is to document well and let the higher-ups deal with the medic.

Don't worry about this scenario. It sounds like you did the right thing.

Sent from my DROIDX using Tapatalk

 

[Anjel]

Regardless, being afraid to transport this particular patient, is weak.

It's not about comfort. It is about if something was to happen to this pt with that high of a bp for no reason and no ekg to say that it isnt cardiac related. There is nothing I could do for that pt.

If the BP was that high. But everything else about the pt was perfectly normal then no I wouldn't have a problem taking them.

For the pt, I want them to have the best resources available to them in case they decided to take a turn for the worse.