I hope, at this point, you’ve all heard of the FAST acronym for identifying signs of a cerebrovascular accident (aka stroke). My in-laws even have a magnet on their fridge with a great comic strip describing the FAST acronym. I have run in to a couple different versions of it in the last few years, but I’ll give you the basic one so you know what I’m talking about. But, we will also go over some other tools you can have in your arsenal for emergency response screening and I’ll tell you where you can go find even more!
I’m not sure if calling 911 is a skill or not, but I’ve certainly done it enough times that I have the process pretty much figured out. We skip the pleasantries and get straight to the point: Where are you, what’s the situation, who is the caller. DON’T WASTE TIME saying “Hi.” Wait your turn to talk. Use speakerphone so you can follow whatever instructions they give you. And always prioritize symptoms: breathing is always MOST important! You are given a priority number (0 is highest priority – that’s for the not breathing folks). And you NEVER hang up until you are told to do so or EMS arrives. It’s fast. It’s nerve-racking the first few times, but you get used to it (that’s a bit weird to say). If you are in doubt, you have two options: Call the physician and request next steps OR
Emergency response is a basic skill for rehabilitation clinicians and Physical Therapists are skilled to provide first line triage in the case of an emergency. Our specialty is movement: to move someone or not to move someone, and how that movement should be done is a critical part of not only our interventions but also emergency response. Large scale emergencies or single patient emergencies both require this level of clinical decision-making. Thankfully, if you don’t feel like you’re ready to provide that knowledge or skill, there are lots of tools to help you in both small and large scale emergencies.
My best advice: Stay calm, trust your training, and trust your gut. If something feels wrong, it probably is.
Let’s look at the FAST tool we mentioned. This is what really got me started down this rabbit hole of exploring emergency response screening processes. What is fast, easy, and gives me the most information to make the determination of what my next step is? The FAST tool is easy and, well… fast. I don’t have to do much other than look at someone and I know they need emergency help. I also know I need to get that help as fast as I can.
Pretty self-explanatory. I’ve had a few significant events in my practice (and outside of my practice!) where I have had to utilize this tool and other tools to assess my patients. I’ll tell you a little about these events so you know when and how to use these tools. I hope you can’t implement them quickly and easily so that, no matter what setting you are in, you can determine the best course of action for your patients, family, friends, or random strangers at your friend’s wedding…
The Stroke Diagnostic Tool
One of my patients in an AFC had a history of middle cerebral artery stroke which is what landed him in an AFC to begin with. One day, I showed up for his visit and he had fallen in the bathroom. The door was locked so couldn’t let me in to help him. His staff was unaware this had happened. As I was talking to him through the door, he told me he was uninjured but couldn’t seem to get up. He was confused and his speech was slurring harder than normal. I knew this because I had established a neurological baseline at my first visit with him.
After the AFC staff assisted me in opening the bathroom door, his symptoms persisted, so I took a set of vitals while calling 911. Although his heart rate was a bit high (he did just fall in the bathroom, after all…), his blood pressure was normal and he did have a slight fever. Upon answering and receiving the required information, the Emergency Dispatcher had me preform a stroke screening. In case you’ve never done this or heard of it, it’s three simple questions:
- Can he smile? (this checks for facial droop)
- Can he raise both arms equally overhead? (this checks for unilateral paresis/paralysis)
- Can he say, “The early bird gets the worm?” (this checks for slurring or other speech deficits)
This is called the Medical Priority Dispatch System (MPDS) Stroke Diagnostic Tool (SDxT), and it is based on research of the FAST acronym for stroke screening. The SDxT has a high specificity (0.96) and a not so impressive sensitivity (0.41). Therefore, this tool is great for ruling in a NEW stroke, but, because my patient already had a stroke with residual deficits, it gave false results. I had to repeatedly interpret the results in comparison to his baseline. I’m sure the dispatcher was really annoyed with me saying, “No more than his baseline,” as an answer to her first two questions. Thankfully, it was only a new UTI and he turned out fine after some antibiotics and inpatient rehab. Because this tool has a specificity of 0.96, though, it is great for ruling in new stroke if your patient presents with these clinical symptoms in any setting.
PT Clinical Decision-Making:
Is this an emergency? Yes, single-patient – needs evaluation s/p fall and for neurological changes, FAST criteria met, SDxT inconclusive
Does this patient need to move? Yes
How should this patient move? Lift assist team from the floor, track-chair up the stairs and out of the house (a chair on tracks that can climb stairs), and by ambulance to hospital
Other Clinical Tools
Another piece of the puzzle needs to be blood pressure. However, like I’ve mentioned many times before, taking a single blood pressure measurement (although better than doing nothing) doesn’t give you much information. You need to have a baseline measurement. The rate of noncompliance with hypertension medication can be anywhere from 40-60% depending on the article you read. So, even if you KNOW your patient has hypertension, that doesn’t mean they’ve been managing it properly. Those medications can have some side effects that people just don’t like (like going to the bathroom too often or symptoms of orthostasis), so people tend to not take them for different reasons. And that’s just the people you KNOW about! We’ve talked about exercise induced hypertension which may be present in just about anyone, and we don’t even really know how best to manage that yet. And then there is the basic fact that you can’t just look at someone and know they have hypertension. Clinical symptoms don’t always present in people who are young and healthy otherwise, and they often are missed. Please take a read in the article about blood pressure basics and dig in to some of the items regarding blood pressure management. We, as Physical Therapists, should be playing a crucial role in this arena. This is my soapbox and I will die on it. Vitals are vital.
Blood pressure screening isn’t just useful to identify cerebrovascular accidents! If you take that baseline blood pressure and you know they typically run high, maybe 160/94, you may not be as concerned when you see a 166/94 pop up at your visit today. However, if you have established a baseline 160/94 blood pressure and you see 200/106 show up, now you can make a clinical decision regarding what you need to do next: do some further assessment because you know they run high, call the physician to determine next steps if they are exhibiting no symptoms, or call 911 if they are are in a hypertensive crisis with symptoms.
Unfortunately, if you see 164/90 show up, but you have no baseline to compare to, you may not know what to do. One of my very first patients as a PT student presented with a 164/100 blood pressure one day, but was having many symptoms of something else going on. She did not meet FAST criteria and I had no comparison blood pressure to go off of. I had clinical presentation of something so I called 911. She had a seizure in the Emergency Department shortly after arriving, but turns out she had a history of seizures. Hypertension was kind of like an aura for her. You just never know. If I had taken a baseline blood pressure, I may have had a better idea of what to do with her and not struggled to figure it out until the end of our visit.
PT Clinical Decision-Making
Is this an emergency? I didn’t know because I had no baseline to determine if this was a hypertensive crisis for her and I didn’t know her history of seizures. But, No, it was not an emergency due to her history.
Does patient need to move? Yes, but…
How does this patient need to move? …only to the floor if I would have known her seizure history. I would have called the physician for persistent symptoms and notified them of a seizure if it happened. She could have transferred to the hospital via private car with a driver if necessary depending on the outcome and length of the seizure.
To be very clear: DO NOT DELAY CALLING 911 to take a patient’s blood pressure. If they’ve met the FAST criteria, SDxT criteria, both, or ANY other emergency response criteria, and you haven’t taken their blood pressure yet, call for emergency medical assistance first! Time is literally brain cells. Don’t waste even a second. Like my patient above, even if it isn’t a stroke, they may still need medical attention for some reason. You can take their blood pressure while you wait for EMS to arrive or when the Dispatcher asks you to do it.
And then there is my friend’s wedding…
There I am in a gown at the head table during the reception and down goes someone in the crowd. The medical expertise at the reception included me, an NP student, and an ortho nurse. Not your best emergency response team, but better than nothing, right? I rush over to this mildly responsive man who cannot move and is slurring something and I’m immediately informed by a family member that he has a history of stroke somewhat recently. I observed pretty quickly that he met the FAST criteria so, I call for someone to call 911 because time is brain cells here.
Having no equipment other than my brain, I immediately started the SDxT assessment to save time, but again, because he has a history of CVA, lots of positives show up: heavily slurred speech, inability to raise the left arm, and obvious facial droop (I didn’t have to ask him to smile…). I started a detailed neuro assessment (think acute care-style) with his family member assisting for comparison to baseline and sure enough… exacerbation of symptoms. EMS arrived, I handed off the neuro evaluation outcomes, and off he went.
PT Clinical Decision-Making
Is this an emergency? Yes, single patient – needs evaluation of acute neurological changes, FAST criteria met, SDxT positive
Does patient need to move? Yes, immediately
How does this patient need to move? Yes, lift team transfer to stretcher from floor and by ambulance to hospital
Although these tools are specific to screening for cerebrovascular accidents, the Medical Priority Dispatch System utilizes an algorithm to screen for several emergency medical events. You can take a look at more tools here:
They have emergency protocols for tourniquet use, emergency child delivery, and even active shooter response! There is a section on nurse triage, fire, and many others!
Your clinical knowledge as a Physical Therapist (or other Rehab Clinician) goes a long way, even when other tools can’t give you clear answers. Overall, even though both of these patients were assessed with the same tools, both of them had history of strokes, and both of them gave confounding outcomes, they BOTH required urgent medical care for one reason or another. Having both tools in your pocket gives a higher percentage shot of remembering how to identify the need for emergency response and having a baseline comparison was key for both patients to identify the level of need. Eventually, it was clinical knowledge that determined the cause (not mine, but some very smart provider at a hospital), but it was the initial tools that got the patients the care they needed in time.
Have you used the SDxT or the FAST tool? I’d love to hear your story in the comments!
References:
Abegaz, T. M., Shehab, A., Gebreyohannes, E. A., Bhagavathula, A. S., & Elnour, A. A. (2017). Nonadherence to antihypertensive drugs: A systematic review and meta-analysis. Medicine, 96(4), e5641. https://doi.org/10.1097/MD.0000000000005641
Barron, T. (2013). MAKE IT FAST. The Journal of Emergency Dispatch. Retrieved from https://iaedjournal.org/make-it-fast/
Brice, J., et. al. STAT 911: Stroke Assessment Tool for 9-1-1 Dispatchers. https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.108.545574
Buck, B. H., Starkman, S., Eckstein, M., Kidwell, C. S., Haines, J., Huang, R., Colby, D., & Saver, J. L. (2009). Dispatcher recognition of stroke using the National Academy Medical Priority Dispatch System. Stroke, 40(6), 2027–2030. https://doi.org/10.1161/STROKEAHA.108.545574
Clawson, J. J., Scott, G., Gardett, I., Youngquist, S., Taillac, P., Fivaz, C., & Olola, C. (2016). Predictive Ability of an Emergency Medical Dispatch Stroke Diagnostic Tool in Identifying Hospital-Confirmed Strokes. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association, 25(8), 2031–2042. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.04.021
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