Advanced Emergency Medical Dispatch: Stroke and Seizure Protocols

Communication and Reassurance in Medical Emergencies

Communication patterns vary in emergency patients; some can speak but not understand (receptive aphasia), some can understand but not speak (expressive aphasia), and some cannot do either.
Being awake and unable to speak does not equate to a lack of understanding. A patient may still pick up on the tone and reassurance in a voice even if they cannot process the literal meaning of the words.
In emergency dispatch situations, the caller should keep the patient on the phone and continue providing reassurance.
It is vital to maintain professional decorum; callers or bystanders should not engage in casual "chitchat" about personal topics (e.g., a hot date) in front of the patient, as the patient may still perceive the environment.
The patient may benefit simply from the contact and presence of another person communicated through the phone.

Stroke and Berry Aneurysms

Stroke is not limited by age; it has no specific age range. Infants, children, and young adults can all suffer from strokes.
A stroke is defined as any bleeding in the brain.
A "berry aneurysm" is a specific type of stroke risk characterized by a ballooning at the apex between arteries, often located deep in the center of the brain.
Many individuals are born with berry aneurysms and may never know they exist unless they undergo an MRI or CAT scan for other reasons.
These aneurysms can remain intact throughout a person's life (e.g., someone dying at $60$ years old from an unrelated cause like being hit by a bus, with the aneurysm found intact during an autopsy).
In some cases, a berry aneurysm can rupture in childhood.
An illustrative case involves a grade-school student who appeared healthy one day and died the next. Her symptoms included a severe headache, followed by a facial appearance described as "melting" (drooping), vomiting, and sudden death.

Protocol 28: Stroke Diagnosis and Hospital Coordination

Protocol 28 begins with two standard questions regarding the quality of alertness and the quality of breathing.
If the initial report is simply "stroke," the dispatcher must ask the caller why they believe it is a stroke to identify the most common clinical answers.
The Stroke Diagnostic Tool is a specific pullout or page used for second-party callers to assess the patient before EMS arrival.
Pre-alerting involves notifying a designated hospital that they are about to receive a stroke patient based on the $911$ call, potentially before EMS even arrives on the scene.
Most jurisdictions do not have a single designated hospital for all stroke patients, making general pre-alerting less common, but the information gathered remains critical for treatment decisions later.

The Stroke Diagnostic Tool (Second-Party Callers Only)

The tool is modeled after the Cincinnati Prehospital Stroke Scale and the FAST scale (Facial grimace, Arm drift, Speech, and Time).
Some regions use "B FAST," which adds Balance and Eyes to the assessment.
The American Heart Association incorporates FAST into citizen CPR training for laypeople.
Cultural sensitivity is a factor in international translations of the protocol. While the Cincinnati scale traditionally uses the phrase "You can't teach an old dog new tricks," this is often changed in dispatch protocols to "The early bird catches the worm" because some cultures take offense at being compared to a dog.
Other variations for speech tests include "The sky is blue," "The grass is green," or "It's always sunny in Philadelphia."

Administering the Tests and Scoring

The Smile Test

The caller asks the patient to smile.
$0$ : Normal smile, equal on both sides.
$1$ : Smile is different on both sides.
$3$ : Only one side of the face moves at all.
$2$ : Patient is unable to complete the request.
$0$ : Patient or caller refuses the test (move to the next test).

The Arm Test

The caller asks the patient to raise both arms straight out in front and hold them for a moment.
$0$ : Both arms raised and held equally.
$1$ : Both arms raised, but one is higher or they cannot be held up high.
$3$ : Only one arm can be held up; the other does not move.
$2$ : Patient is unable to follow the request.
$0$ : Patient or caller refuses the test.

The Speech Test

The caller asks the patient to say "The early bird catches the worm."
$0$ : Patient repeats it correctly.
$3$ : Speech is slurred, garbled, or not understandable.
$2$ : Patient is unable to follow the request.
$0$ : Patient or caller refuses the test.

Interpreting the Score

The three scores are added for a cumulative result.
A cumulative score of $3$ or more is considered clear evidence of a stroke.
A score of three zeros ( $0, 0, 0$ ) indicates no test evidence.
If a patient has a pre-existing deficit (e.g., one arm hasn't moved since a stroke the previous year), that specific test is scored as a $0$ because the diagnostic tool specifically looks for new onset symptoms.

Clinical Importance of the Baseline

Emergency dispatchers set the "baseline" by performing the first diagnostic test.
Subsequent tests by EMS and the hospital are compared to the dispatcher's baseline to look for trends.
Improvement may indicate a Transient Ischemic Attack (TIA).
Deterioration suggests a fresh, progressing stroke.
The more data points available for trending, the more confident doctors can be in treatment decisions.
Skipping the tool because "EMS will do it" loses a critical piece of early data; even a $10$ -minute window can show significant clinical changes.

Suffixes and Time-Sensitive Treatment

Medical directors designate a specific time window for stroke treatment eligibility (e.g., $3$ , $4.5$ , $5$ , $10$ , $12$ , or $24$ hours).
A suffix is required for every Protocol 28 code to denote the type of evidence and the time since symptoms started:
- Symptoms started less than the designated time.
- Symptoms started greater than the designated time.
- Time frame is unknown.
A "wake-up stroke" occurs when a patient goes to bed normal and wakes up with symptoms. Depending on the agency's designated time (e.g., $24$ hours), a wake-up stroke may be coded as being "within time."
Fourth-party callers (e.g., a person across the country on the phone with their mother) cannot perform the diagnostic tool but can still provide critical time information for a suffix (e.g., Suffix L for less than the time limit).

Protocol 18: Headache

Protocol 18 is not an ECHO, shunt-from, or shunt-to protocol.
For a citizen to call $911$ for a headache, the pain is usually significant. Dispatchers assume there is something noteworthy about the headache.
Potential causes include migraines, meningitis (inflammation of the brain's outer covering), high fever, flu, COVID, wonky blood sugar, drug reactions, toxins (liver/kidney failure), or high blood pressure.
A stroke-related headache is often described as a "lightning strike" or searing pain occurring out of the blue.
Protocol 18 allows for stroke assessment if the patient presents with specific markers:
1. Inability to talk normally.
2. Sudden onset of severe pain.
3. Numbness or paralysis.
4. Recent change in behavior (within $3$ hours).
If any stroke symptoms are present, the dispatcher asks for the exact time symptoms started, codes a Charlie level response, and then performs the Stroke Diagnostic Tool while responders are en route to update the suffix.

Protocol 12: Convulsions and Seizures

This is the first protocol discussed where the patient does not have to be awake or breathing.
Common causes of seizures: scar tissue from head injury, hypoxia (lack of oxygen), hypo/hyperglycemia, toxins from organ failure, or reactions to medications and pharmaceuticals.
Epilepsy (or seizure disorder) is a condition where seizures are idiopathic (occurring without a known immediate external cause).

Generalized Seizures (Grand Mal)

These involve the entire body and the brain. They consist of three distinct phases:
1. Tonic Phase: The body stiffens.
2. Clonic Phase: The body jerks or flops.
3. Postictal Phase: The brain "reboots." This phase can last $5, 10, 20, 30$ minutes or longer. The patient is often unconscious and may make gurgling sounds because they cannot protect their airway.
Seizures have distinct sounds: flopping, soft grunting, and gurgling.
Rule 4 (Protocol 12) / Rule 13 (Case Entry): If a description strongly suggests a generalized seizure, go to Protocol 12 regardless of the "awake and breathing" status. This prevents unnecessary CPR on seizing patients.
If the seizure stops and the patient does not wake up, a Breathing Verification Diagnostic (BVD) is mandatory to ensure they are not in cardiac arrest.

Seizure Variants and Complications

Status Epilepticus (Multiple Seizures): Defined as two or more seizures without a "lucid interval" (waking up) in between. This is coded as 12-Delta-2.
Focal Seizure: Only part of the body jerks; it does not involve the entire brain, and the patient may remain conscious.
Absence Seizure (Petit Mal): A brief staring spell where the patient remains conscious (upright) but does not react. Frequently misidentified as daydreaming in children.
Atypical Seizure: A seizure that looks different from the patient's normal pattern; these are associated with poor patient outcomes as they may indicate a new underlying medical issue.
Eclampsia: Seizures resulting from a complication of pregnancy. It is preceded by pre-eclampsia (elevated blood pressure, fluid retention/swelling in ankles, and hyperproteinuria/protein in the urine).

Questions & Discussion

Question: Does anyone know if your EMS or your hospital use a different sentence for the speech test? Response: One paramedic shared that using the phrase "You can't teach an old dog new tricks" was so insulting to a patient's family that they nearly threw him out of the house. He is now working with the medical director to change the diagnostic sentence.

Question: Is Protocol 18 (Headache) an ECHO or shunt protocol? Response: No, it does not have the purple tab (ECHO), the white/yellow diving board (shunt from), or the narrow yellow tab (shunt to).

Question: Regarding seizures on a military base, do you see many of these calls? Response: While a military base may have a healthier-than-average population (skewed health population), if there is family housing on base, seizure calls will eventually occur. Any environment with children or diverse populations will experience these medical emergencies.