I wanted to express an opinion to my EMS colleagues. This is not a policy statement or educational mandate, but simply one person’s opinion and an invitation to think about some types of brain pathology seen in the pre-hospital setting. Please recall that my career is concerning the diagnosis, treatment and work towards improving the outcomes of patients with stroke and traumatic brain injury. While I assure you there are new technologies coming to help diagnose these patients they are not ready yet.

Stroke and brain injured patients often are confused, agitated, “frontal” and / or sleepy. What becomes problematic is the patient who communicates apparently cogently but who may not be able to make appropriate decisions or refuse medical aid. The brain can compartmentalize functions fairly well sometimes and good verbal skills can mask severe pathology elsewhere in the brain.

Here is a scenario to consider. You have a possible stroke patient; the patient is hemiplegic, agitated and combative. While the more common scenario is a sleepy somnolent stroke patient this presentation is quite possible. If the patient is hemiplegic do they acknowledge the weakness on one side? There is the phenomenon of the alien hand where patients do not recognize their own plegic extremities. You can hold a person’s hand in front of their face and ask them, “whose hand is this?” and they will say yours or I don’t know. If this patient is trying to refuse medical aid, it may be in their best medical interest to transport them nonetheless. The patient has a real and potentially serious brain condition and needs urgent care. How you facilitate those next steps is a subject for medical control and agency policy. Options are to sedate and transport the patient because they are confused, agitated and a medical emergency because brain cells are dying. Communicate with medical control or the hospital and get a confirmation of your suspicions. Work harder to convince the patient to be transported. Or you could leave the patient where they are.

While alien hand is an extreme example, the difficulty comes in trying to assess when denial is part of a brain’s pathology. Please remember that there is NO consensus on procedures, but I would like to offer a suggestion for the EMS community. If you see a patient with two previously undiagnosed neurologic abnormalities along with denial, that patient may be unable to make appropriate decisions as to their medical care. For example, weakness and confusion in a suspected stroke patient is consistent with many kinds of stroke. The confused patient found at home may want to stay home in their comfort zone but that may not be in the best interest of the patient. Even if they can clearly state that they want to stay home and are fine, that denial may be an added symptom to the weakness and confusion process of a stroke patient. Do they acknowledge the problems they have and have a strategy for dealing with them?

Here is a brief list of physical symptoms that might be considered as neurologic in such situations: numbness, tingling, tremor, asymmetry (including facial expressions, pupils and strength), incontinence, diaphoresis, altered speech, disorientation, confusion, and fever.

So a patient sitting at home in their comfy chair stops talking to their family. The family calls 911 and you find the patient still in their chair, talking but not using their left arm and has a new facial twitch. The family confirms the patient is just not right and the above observations are new. However, the patient can clearly tell you they are fine, they know where they are and the minor inconveniences of being unable to use their left arm is no problem; denial. Even if they adamantly refuse transport, this person may be in the middle of a serious stroke.

The key to consider is that there are two interpretations here. One, is transporting a patient “against” their stated wishes, when you have a clinical impression that that person’s brain is not functioning correctly. Transporting may cause consternation but normally little harm when done correctly. The alternative is leaving a patient in the process of clinically deteriorating. While they may recover they could also have a devastating cognitive outcome as the brain is in the process of a managing a severe pathology. Some lawyers might start to call this abandonment.

I have had the personal experience of sitting with a bunch of armchair quarterbacks reviewing a situation where a stroke patient says that their “problem” will get better. Said patient was able to refuse care and caregivers complied with that refusal. By the time the seriousness of the stroke was realized the brain damage was permanent. It is all too common to see a suspected stroke patient in relatively little distress with numbness and or weakness on one side of their body say things will be fine; AND people believe them. They are believable because they calmly say, “I’m fine, and do not want to go to the hospital.” The armchair quarterbacks will counter; if you suddenly lost feeling in your arm would you think that fine? Not likely.

As with any call, document clearly what is seen. Have a great relationship with medical control so that they can be ready to back you should you decide that the patient in front of you is not capable of making a decision concerning transport at this time. This may have to occur even when the words the patient says could sound clear and cogent, if the patient denies or does not recognize other clinical manifestations of their brain disorder the denial is likely to be masking something serious happening in the brain.

To avoid confusion, I do not think that any of the above is assessing “competency” of a patient. I think this is more discussing risk of a brain type disorder that needs medical evaluation. Before you go out into the field again ask yourself one question; “What is your agency’s policy on this subject?”