What do you guys think of the decision I made?

[Dan216]

Transported an 82 y/o female patient the other day for a cva. Patient tested positive for right sided facial droop, arm drift, unequal grip strength, and slurred speech. History of hypertension. Blood pressure reads 174/94. Pulse: 84 respirations: 18 B/G 94.

Dropped patient off at the hospital and completed the call. Fast forward a few more hours and we get called back to transfer the patent to another hospital with a higher level of care. Hospital is running NaCl TKO.

Got the patient in the ambulance and vitals are the same as earlier in the day. Patient had been given roughly 350 ml of normal saline by this point and I decided to close/lock the IV.

My reasoning behind this is that the patient already has hypertension and with a possible stroke why would I want to continue adding pressure? Patient was fine throughout entire transport and remained the same. I'm just getting questioned and getting grief by the head of my fire department's EMS Corporation because I wasn't told to lock the IV.

Did I make a bad call? Thanks.

 

[ricardoj]

Is the issue that you locked the IV, or that you operated beyond your scope of practice in doing so? (I'm not familiar with EMT-Basics in Idaho and what they can/not do)

 

[Akulahawk]

Going with what I know, I would say that you didn't make a good call when you shut off the KVO line. Having a running line means that the line is open and available. Keeping it KVO doesn't add much fluid and isn't likely to push the patient into fluid overload. If the that line clotted off, you may not have the means available to you to clear the line and you may not be able restart the line if you can't clear it. Also, if the line clotted off, you just committed the receiving facility to having to start yet another line.

Most of the stroke patients I've had that are hypertensive are kept hypertensive to maintain/maximize cerebral perfusion.

What I wonder about is if the hospital you originally transported the patient to was a stroke center. If it wasn't, you might have done the patient a further disservice.

 

[STXmedic]

Exactly what Akula said. The patient's BP may have been high out of necessity to maintain perfusion to the brain (it may have also just been chronic HTN). Regardless, a line running KVO isn't going to significantly impact the BP or fluid status (if the patient also has renal failure, I may be a little more cautious).

And if the patient so clearly met stroke criteria, why was he/she not taken to a stroke center to begin with?

 

[medicsb]

KVO or just a capped saline lock is not an issue either way, really. If they had a saline lock in place, it soundn't clot off. I used to D/C KVO fluids for transport all the time if a saline lock was in place. But your logic for d/c'ing the fluids doesn't really hold up.

 

[Tigger]

Transported an 82 y/o female patient the other day for a cva. Patient tested positive for right sided facial droop, arm drift, unequal grip strength, and slurred speech. History of hypertension. Blood pressure reads 174/94. Pulse: 84 respirations: 18 B/G 94.

Dropped patient off at the hospital and completed the call. Fast forward a few more hours and we get called back to transfer the patent to another hospital with a higher level of care. Hospital is running NaCl TKO.

Got the patient in the ambulance and vitals are the same as earlier in the day. Patient had been given roughly 350 ml of normal saline by this point and I decided to close/lock the IV.

My reasoning behind this is that the patient already has hypertension and with a possible stroke why would I want to continue adding pressure? Patient was fine throughout entire transport and remained the same. I'm just getting questioned and getting grief by the head of my fire department's EMS Corporation because I wasn't told to lock the IV.

Did I make a bad call? Thanks.

Did the sending facility have orders for an IV TKO during transport? If so, you need to talk to the sending staff about your reservations prior to leaving and just going off your own plan. Obviously hospitals write imperfect orders but more often than not they are a result of communication between the sending and receiving facilities.

Not to mention that your rationale is not ideal and while that BP is hypertensive, it falls short of anything resembling a hypertensive crisis.

 

[teedubbyaw]

You're correct in thinking that the patient probably doesn't need fluids, but as has been said, keeping that site available is important if the patient is truly suffering a stroke, which is time sensitive. However, the 3hr window from when you guys were called back is a little odd.

 

[TheLocalMedic]

Think about this: 350 ml is not a lot of fluid, imagine drinking a third of a liter of water. If that is all they received in the hours they were in the ED, then that's not exactly flooding them with fluids or going to have any impact on their blood pressure. Especially when that patient is NPO already (i.e. not drinking anything else).

Here's my advice to EMT-B's: Don't touch it if you don't know what it does.

 

[Akulahawk]

KVO or just a capped saline lock is not an issue either way, really. If they had a saline lock in place, it soundn't clot off. I used to D/C KVO fluids for transport all the time if a saline lock was in place. But your logic for d/c'ing the fluids doesn't really hold up.

One of the things we don't know is if the extension set was set up to properly be converted over to a lock. What I do know is that the OP elected to D/C a running KVO line. I'm not opposed to the idea. Having a properly converted lock, IMHO, is a good thing.

I would not normally expect to D/C an IV line in a stroke patient who is hypertensive and presumably is not showing signs of fluid overload. I'm also thinking that the OP is a Basic. Normally speaking, converting a running line to a lock is out of scope for a Basic. I understand the fear of causing fluid overload problems. KVO vs SL is not that big of an issue. The patient has had 350 mL of fluid in the "several hours" since arrival at the ED. That's less than a quart of water, or one big glass of water. If that patient has urinated since being dropped off at the ED in the first place, that 350 mL might actually be simply replacement for what was lost. That's not likely to significantly worsen the patient's hypertension "problem" at any rate.

I stand by my assertion above that shutting off the KVO line was not the right call. I do know that the protocols that I'm familiar with state that a Basic may only shut off a running line under very specific circumstances and none of those circumstances appeared to be present. Would I have converted the line to a lock? Perhaps, but it would have been properly done, and would not be for the fear of fluid overload absent any signs or symptoms of it.

Bad Judgment was used.

 

[CentralCalEMT]

I am also wondering why this was a BLS level transport. In most systems, a recent CVA going to a higher level of care would be an ALS level transport. Does your area only have BLS? I am assuming you work in a highly rural system where most patient's go to the local hospital for stabilization and then to a higher level of care if the local hospital can not handle them?

 

[DesertMedic66]

I am also wondering why this was a BLS level transport. In most systems, a recent CVA going to a higher level of care would be an ALS level transport. Does your area only have BLS? I am assuming you work in a highly rural system where most patient's go to the local hospital for stabilization and then to a higher level of care if the local hospital can not handle them?

What more is ALS going to do for the CVA patient who was already at a hospital then a BLS crew?

 

[CentralCalEMT]

What more is ALS going to do for the CVA patient who was already at a hospital then a BLS crew?

Mainly secure the airway if the patient goes downhill on a lengthy transport. The patient all ready has deficits, so it is not unreasonable to think that they can deteriorate further and not be able to maintain their own airway. Also, generally if a patient is on telemetry, which a patient having a CVA will be, and they are going to a ICU or tele unit at another hospital, in many systems they have to be transported on a cardiac monitor. Maybe your system is different, but in the 3 systems I have worked in, that is how the hospitals were.

 

[SeeNoMore]

Well it depends what exactly the ALS crew is capable of doing based on their scope of practice. If we are talking about a single Paramedic, they may not be doing much other than cardiac monitoring and pain management in most regions. Having the ability to treat seizure activity is also lost with BLS crews , at least in my area. Acute CVA patients being transported for immediate intervention or ICU care would likely benefit from SCTU transport so that transport of blood products, meds to control HTN , RSI, sedation etc would be available. Either way I think acute CVA patients should not be transported BLS.

 

[IDMT 1]

Given the age of the patient and possible history, it is a good idea to keep an IV going KVO just due to the fact that it will allow venous access. As long as the pressure remains stable and the lungs sound good and fluid free then I would let the IV run.

 

[Merck]

I suppose, knowing little of the EMT-B scope, that from a license/job perspective perhaps you overstepped. I guess it seems a bit odd to me since there is no way a decision like that would even register here.

From a patient care/medical perspective, it made zero difference.

 

[medicdan]

What more is ALS going to do for the CVA patient who was already at a hospital then a BLS crew?

In general ?CVA patients are on a cardiac monitor for at least 24 hours post symptoms for the possibility an arrhythmia caused the clot and that the rhythm is intermittent.

 

[Clare]

Stopping the IV had no difference, one litre of fluid is going to do nothing for this patient anyway so I fail to even see why it was started in the first place. As far as I am concerned you did nothing wrong. If your boss gives you grief over it tell him to go look up the maintenance of plasma osmolality.

I am wondering why you didn't take the patient directly to the other hospital and avoid the need for a transfer? Provided symptom onset was < 3.5 hrs ago they should be take directly to a hospital capable of CT and thrombolysis even if the transport time is longer than to the closest hospital.

 

[Akulahawk]

Stopping the IV had no difference, one litre of fluid is going to do nothing for this patient anyway so I fail to even see why it was started in the first place. As far as I am concerned you did nothing wrong. If your boss gives you grief over it tell him to go look up the maintenance of plasma osmolality.

I am wondering why you didn't take the patient directly to the other hospital and avoid the need for a transfer? Provided symptom onset was < 3.5 hrs ago they should be take directly to a hospital capable of CT and thrombolysis even if the transport time is longer than to the closest hospital.

While a liter of fluid won't mean much in the long-run for the patient, the OP seems to be an EMT Basic. Their protocols are usually very specific about when they may stop a running line. As far as I can tell, none of those situations appeared to have developed. The OP very likely exceeded the authorized scope of practice. Even if the OP is authorized to do IVs, if the existing (now stopped) line clots off, then another line will have to be started at some point.

As to why an IV was started in the first place, hospitals generally start a line on everyone that's admitted. This is usually for vascular access, should it be necessary.

Might I have converted the line to a lock? Perhaps... but I would have done so properly so the possibility that the line would clot off would have been minimized. I do NOT want to lose an existing line. It means that the patient needs to be poked at least twice more. Once by me and at least once more by the receiving hospital because they have no QA/QC control over my practice... and because a field provider started the line, it must be considered a "dirty" start so they'd pull it within 24 hours (or sooner) after arrival.

 

[DrParasite]

I am also wondering why this was a BLS level transport. In most systems, a recent CVA going to a higher level of care would be an ALS level transport.

oh good, I thought I was the only one who thought that was the first thing wrong with the scenario.....

What more is ALS going to do for the CVA patient who was already at a hospital then a BLS crew?

That actually has nothing to do with it... but rather, if you have a sick patient (ie, being transfer to a stroke center for acute care), than it would typically required a paramedic or nurse to monitor the patient, and be transferred by a SCTU crew, in case something went wrong.

I wouldn't lose too much sleep over it, but I would have asked the sending hospital if there was a reason they wanted the IV KVO during the transport, before closing it. I don't see how much difference it would make, nor do I think it is hurting the patient to keep it flowing at a KVO rate.

 

[Handsome Robb]

If get destroyed by QA if I didn't attend this patient.

Why an ALS crew? There's a prime example right here in this thread.