I'd never been to the patient before although the person I was working with told me that the household was a regular place to visit. Two people lived there, an elderly man and his wife. He has diabetes and leg ulcers and finds it hard to get around the house due to Parkinson's disease. His wife has quite far reaching dementia although she is physically fitter than her husband.
Social carers come around a couple of times a day.
Apparently the normal calls to this house are for him feeling unwell with his diabetes or for her hurting herself moving around the house.
We arrived on blue lights as the morning carer had called us and told us that the husband had collapsed.
He was beyond 'collapsed', he was lying on his back in the living room, his trousers around his ankles and his entire body was shaking. When I tried talking to him all I could get out of him was incomprehensible grunts and groans. When I tried to touch him he would become combative and try to push me away.
I looked around, the carer had vanished. Unfortunately this isn't unusual and to be honest they often aren't missed.
My first thought was that he had a low blood sugar – a nice easy job, give him some sugar and wait for his gratitude as we 'cure' him.
His blood sugar was within normal limits. This wasn't going to be as simple a job as I'd hoped for.
I did a full examination and there was nothing that would suggest the reason for his collapse or for his confusion. Every time I tried to do something to him whether trying to examine or dress him he would try to strike me, so my examination wasn't perhaps the best.
His wife was alternating between pacing and sitting talking about shoes – thankfully she wasn't distressed. Actually she was quite cheery, I guess that she is used to us folk, dressed all in green, coming into her house and making things better. There was no way that we could leave her at home while we took her husband to hospital, she would have to come as well.
We made the decision that we wouldn't be able to look after both of them, I would have my hands full with my patient and there was no way that I could also keep her out of trouble. My crewmate called up Control and asked for another ambulance to take our patient's wife into hospital.
The second crew soon arrived and took control of the wife while I and my crewmate got our patient onto the trolley. Once we got him onto the back of the ambulance he immediately settled down, it was as if someone had flipped a switch in his brain. We went from wanting to 'blue light' him into hospital with me holding him down to being able to drive normally into hospital while I had a friendly chat with him.
So once more we left the patient at the hospital – the nurses there would also have to look after his wife while they investigated why he had become confused and collapsed. At the end of my shift the hospital's theory was that he had suffered a 'Transient Ischaemic Attack' or 'mini-stroke' which had resolved on it's own.
And they did take good care of his wife.
My knee still aches but I'm not as reliant on the cane, hopefully it'll soon be good enough to return to work.
I recently attended a TIA, and it took me by complete suprise. Let alone the Patient.
Funny that in a society that promotes the pushing back of medical frontiers which makes people generally live longer, but that same society could not seem to give a toss about the care or the quality of life of this aging population.People are already charity fatigued so where does the money come from unless they allow all the longer living population (that they have enabled to live longer), to die off from neglect.
PS
Glad the knee is feeling better.
Thanks, Liz. Would you happen to know what percentage of TIAs and CVAs are asymptomatic ? I know that in some patients they can present with little or no physical symptoms. Also, what evaluation technique do you use in the UK for stroke ? Here in the US we use the Cincinnati Stroke Scale (Facial Droop/Arm Drift/Speech Deficit).
I'm a aux nurse/care assistant for a nursing agency & it's always embarrassing to hear about carers running off for no apparent reason. We would normally wait until the paramedics are leaving the scene before we leave. The only time Ive left before you guys was about 4 months ago, I trained as a St Andrews medic, so we were going to a clients house to cover for his regular homecare, we arrived & hed gotten up, tripped & clocked his head on the radiator, split his scalp from about an inch above his eye, kod himself, and was fitting, we cleaned him up & our supervisor phoned for an ambo. He came to, gcsd him as an 11, EMTs arrived, he was alert & improving, wed dressed his head, started to do a handover, just going into what had happened, what wed done & he told me to f**k off & stop pretending I knew what I was doing. So it works both ways, proper training & a little respect goes a long way. :)Keep up the good work, and congrats with the knee, just had mine reconstructed.
Strange you should post that, I had a “funny turn” just over a week ago and Mr Man thought I had had a mini stroke.The conclusion was that I had suffered some kind of “fit” but that it was nothing to worry about. I don't know, I never seem to get clear answers, but as long as it's followed by “it's nothing to worry about” then I suppose that's ok.
Without doing tests, how can a medical professional tell if you have had a TIA or a fit? And is the latter really nothing to worry about?
Oh, and I'm glad that your knee is getting better by the way 🙂
I guess I was wondering if there was any research to provide any estimate of how many TIA/CVAs go undiagnosed out of the total (i.e. “Silent Strokes”)
Apparently the rate of occurence for TIA is much higher than statistics would indicate, since most of them go unreported as they 'resolve' themselves in a short period of time. The problem is that many patients don't realize that a larger CVA may be on the way. If nothing else it's good that your patient made it in to hospital so that his carers are aware of the potential in the future….
glad to hear you are on the ment Tom.I've started reading the same book as you,
which will upset my daughter, 'cos she can't wait
to get her hands on it.
best wishes
sarah
We attended an “acting strange” ? TIA. The patient had phoned 999 herself as she was feeling off, she'd suffered a TIA a few days earlier and attended A&E with hubby. Diagnosed as a TIA she was due further follow up after the Xmas break. On arrival she met us at the door and she looked ill. Sometimes you can see that they're not right, she was not right. Very disorientated, mumbling and shuffling. We heloped her back into the front room and sat her down when she said “can you have a look at my husband, he's acting odd too”. Hubby was sat in a chair looking vacant. My mate stayed with her and i went over to him. He looked round when i said hello and just didn't click that I was ambulance crew. He looked ill too. After a few mins of “who are you, how did you get in, who are you, whay are you here, who are you” etc from him it was obvious that something was VERY wrong.Then my mate says that he's feeling poorly.
*Click*. It's VERY windy outside and the heating's on full blast. Hmm, could it be Carbon Monoxide poisoning? With that thought in mind I opened the curtains and opened the windows, my mate opened the back door and the conservatory wiondows and found the central heating which he turned off.
Then I legged it out and got the chair, I also contacted control for a second vehicle. Back in the house we loaded the hubby on and got him out and into the vehicle, then it was back in for the wife. On getting her out the other vehicle arrived and we passed he onto them. Back in the house again and it's close all the windows and doors. Fair enough we've opened them but I'm sure they'd have gone ape if they'd been burgled whilst they were in A&E!!!
My mate attended the wife, I atteneded the hubby and the second crew split to drive both vehicles, we'd both been in and out the house and were feeling a bit off ourselves.
Off to A&E and the Op's Super is there, control had called him. He's a good lad, on the crew's side. Dropped off the patients and he's offering to contact control to get us back to station for a break. My mate's still feeling poorly but I'm not too bad and OK to drive. back to base and chill with a cuppa.
The next day i checked up and the patients HAD been suffering from Carbon monoxide poisoning. Blood tests proved it. The high winds had stopped the gas from venting properly and the house had filled up over a few hours. The wife's previous TIA was most likely the same poisoning!
Why did I type all that? Well, when the ops super rang control to get us back for a break the control room manager said, “they can't be ill, they were only in there five minutes”. It turned out they didn't even want to send a second vehicle and had called the ops super to try and get him to come down and tell us to take both!
So well done on getting a second vehicle!
good to hear about the knee, take care with it.
I had a patient with a NOF on my trolley the other day, and was able to jump the cue at A&E as she was excepted in minors. Just as I was about to slide her over to the hospital trolley, she had a TIA. I hastily explained to the nurse that she had been with me for 2 hours and had a GCS of 15 through out. The thought of going back to join the cue for majors was worrying me. But thankfully, the nurse took the patient anyway. So I got to go back out on the streets, only to join the cue for majors 45 mins later!!!
Before catalytic convertors rendered CO asphxia in motor cars unfashionable, there was a persistent belief that this, as a method of suicide, took some little time execute – possibly as long as half an hour. The truth, however, is that it takes rather less than three minutes; perhaps you should direct the attention of your EMDC Supervisors to the excellent Wikipedia entry on the subject of CO poisoning!I'd recommend it to you as well! I wasn't there, so I'm not qualified to comment, however, I think that (given similar circumstances involving me) I'd have gone to A&E myself, and taken myself off the road until given a clean bill of health.
Glad to hear the knee's feeling better. Make sure you don't go back to work too soon and do yourself long term damage – don't try to be a hero. (We already know you are)
Im an experienced nurse and my field of expertise is Stroke and TIA (Transient Ischaemic Attack). Toms patients episode does not sound like a TIA. Patients experiencing TIA very rarely loose consciousness or experience involuntary movements. TIA can be difficult to diagnose conclusively and is based upon the history i.e. the description of the episode that the patient and any observers give there are not any conclusive diagnostic tests for TIA although it is thought that the damage in the brain may show on some forms of sophisticated brain scans. TIA is characterised by a loss of specific neurological function that lasts for a short time. The text book definition says less than 24 hours but there is a fine line between TIA and stroke and there is increasing opinion to say that TIAs are small strokes. The loss of neurological function can manifest in many ways and is caused by a lack of blood supply to a specific area of the brain. Typically the patient will experience a loss of movement and/or sensation down one side of the body. This may affect face, arm or leg or 2 or 3 of these. Depending on the area of the brain affected other patients may experience difficulties with speech, normally word finding problems-dysphasia. Rather than slurred speech-dysarthria (this alone can have many causes). Some times there is a loss of visual field to one side. The people above who comment that TIA can be a warning sign for stroke are right and anyone experiencing TIA should be referred to a neurovascular clinic for more conclusive diagnosis and a plan to reduce their risk factors for stroke. Most patients are put on aspirin. It sounds as if Toms patient experienced some form of fit or seizure, these can often be one offs caused by some imbalance in their body. Epilepsy would only be diagnosed if the patient had several fits and had been thoroughly investigated.Sorry for the long post but Im off sick my self and very bored so its nice to be able to put my knowledge to some use.
cheers Kev, we were offered the A&E by the Op's Super. But by then i was feeling fine (i'd been in and out of the property to get the chair, contact control and twice with patients) and the fresh air cleared my head. My mate was still a bit off but declined as the queue was huge (it was New Year's Eve). We agreed that if we felt rough when we got back to base (30miles away in a smaller town) that we'd pop along to the minor injuries unit.Following the letter of the law we “should” have asked for 4 more ambulances! 1 for each of the patients and one for each of us!
In the UK I think some paramedics use the Face Arm Speech Test (FAST). But you would have to ask them what they use I only know this from journal articles. As for the question about how many strokes/TIAs are asymptomatic i'm not sure if i understand your question, if you didn't have any symptoms you wouldn't know you had had a stroke. i suppose if the TIA caused a pure dysphasia (word finding, language problem) and you didn't have to speak to anyone you wouldn't know.
Thanks Liz, your answer has been very helpful and informative.
That's a very difficult question to answer–the balancing of NHS budgets with population longevity and patient care. Not sure what the answer is in the UK because you already pay far higher income tax than we do here…and many us complain.
FAST, the face, arms, speech test is basically just that:Face – is there a weakness? If they smile is the smile equal on both sides? Often if you get them to put their teeth together and smile even the smallest droop becomes obvious.
Arms – Ask them to put their ams straight out in front of them and close their eyesand count to ten. If an arm drops there is a weakness in that side.
Speech – is the patient dysphasic or dysarthic? Is the speech slurred or are they unable to speak?
All of these only measure new deficit. I have found in my own practice that these are not infalliable, and good indicator is also grip strength, lean to one side etc. Obviously we tend to record and do FAST because it has its own section on the patient record form.
Hope this is of some help!
“Quantity not quality” would seem to be the defining phrase of our age – from food, to material goods, relationships, and extended lifespans without the support structure to make them enjoyable.
So if they are dysphasic, can they think the word but not say the word?
not exactly, they can think the concept but not be able to find the word to express themself.
It is known that many people who have TIAs do not seek advice, some studies have suggested around half of all TIAs go unreported.
Interesting – you really saved some lives there, nice one!
Thanks for that – I agree that TIAs typically have similar symptoms as CVAs, I have seen some weird and wacky things when parts of the brain stop functioning properly.The *extremely* rapid recovery would make me suspect that it wasn't a seizure.
At the end I think the hospital were a bit stumped, so TIA is a pretty god catch-all for 'weird neurological symptoms and everything else has been ruled out'.
Yep we use FAST, but most of us go a bit further in our assessments, partly because of the things that we learn from hospitals.
Indeed wot on earth dya think you're doing Tom, adding additional skills and practice to your armoury!!!???
Thanks LizThat must be a scary place to be, not being able to communicate;
It must make the patient feel very vulnerable