Neurology can be confusing yet very enlightening at the same time. A general assessment that we teach our EMTs usually consists of a B.E. F.A.S.T. exam, a Los Angeles Motor Scale (LAMS) Score evaluation and generalized questions for checking the patient’s mental status (i.e., alert and oriented). Is this enough, though? How deep down the rabbit hole of neurological assessment should we go as EMS providers? We aren’t neurologists nor do we possess the appropriate protocols or treatment modalities for thrombolytic therapy or intracranial decompression. What we can do is find what’s noteworthy and relay that information to the professionals. That said, what is noteworthy?
Neurological emergencies primarily are strokes and seizures in the realm of EMS. However, we also can see altered mental status from diabetes, sepsis or hypoxia, to name a few more.
Every time that you have a patient who has a neurological-backed complaint, go at it with the same approach that you would with any other specific ailment, including trauma. I start my assessments with the general impression: Does the patient acknowledge me when I walk through the door? Do that person’s responses make sense?
Moving forward, you can get down to nitty-gritty details. Asking for a clear and concise history of the patient’s medical problems will be eye-opening, and start to rule out some stuff. Check the patient’s blood sugar. (It’s extremely easy, fast and definitive in ruling out hypo/hyperglycemia.) Has the patient had any recent infections? (A urinary tract infection can cause neurological abnormalities.) Any recent trauma? Is the patient hypoxic?
Next, start to really evaluate the brain. By evaluating cognition, you can start to identify what portion of the brain is being affected or, at least, have specifics to relay to an ER physician or neurologist.
I don’t expect you to memorize cranial nerves or anything like that. However, document patient responses to your questions and have the patient do a small task to assess cognition and motor skills. I have a patient tell me every number in a series of seven (i.e., 7, 14, 21, 28, 35, etc.). You can use any number but keep it simplistic enough, so anyone can do it, but also complex enough that there must be some thought that’s put into it. This is highly effective in general problem-solving, and it assesses speech.
Have a patient read from whatever you can get your hands on. Some who have stroke history have difficulty reading. This also assists in judging receptive/expressive aphasia.
A basic memory task really helps. Give your patient a few things to remember. My usual go-to is “blue, pineapple, nine.” Throughout your time with your patient, you can go back and use this as a control line of improved or worsening symptoms.
With just about all of the patients who I encounter, I inform them of my name when I arrive and then ask them throughout the transport whether they remember it.
Admittedly, this is a small list for evaluating a neurological emergency. If you really want to get deep into assessment, you can dive further into cerebellar strokes, National Institutes of Health Stroke Scale testing, ruling out Bell’s palsy and/or physical evaluations regarding motor/sensory. Schedule a clinical rotation with a stroke center and complete rounds with the team. See what they do and how you can implement their evaluations into your everyday neurological exam.
In the end, find the weird things, the signs that just don’t seem right, such as the patients who can’t read, can’t smell, can’t express their thoughts. In the acute state, all of those are abnormal signs. Get them to the hospital quickly and have a detailed report ready for the receiving team.
Remember, the worst-case scenario is a stroke/head bleed, so don’t be afraid to call a “code neuro” if you aren’t 100 percent sure. There is nothing wrong with being overly cautious in your approach/treatment.
