Talking Neuro with Steven Burke, Flight CCRN.

What's up guys? Joel here with the Shift Brief. Today I am joined by my colleague and good friend, Mr. Steven Murphy. Steve and I have been working together for approximately five years now. Steve's background, he is a registered nurse. He's a critical care nurse as well as working as a flight nurse in the same organization as me. Go ahead and introduce yourself, Stephen.

Well, that was a good one. I was born 8 pound 6. My name is Stephen Burke. I'm from Cape Breton. Grew up in Cape Breton. Did my nursing training in Cape Breton and then moved up to the big city Halifax where I started my nursing career. Been in neurosurgery for 17 years.

Neurosurgery. Yeah.

Different aspects.

That's awesome. And then yeah, been flying for the last eight.

Yeah.

So you are our neuro guy.

I am a neuro person. Worked in neurosurgery on the floor and I worked in the intermediate care unit and worked in ICUs in a neuro capacity.

That's awesome. The last long time which I didn't know what neurosurgery was before I came to Halifax. I had never worked a placement or anything in neuro ever. And then my first job was in neurosurgery where we take care of traumatic brain injuries, subarachnoid hemorrhages, closed head injuries, spinal cord fractures, spinal cord injuries. And then the weird and wonderfuls like neurology, endocrinology. So it's a big dumping ground for all that is neuro. A lot of the time when the sicker neurology patients would always come to us because they required a lot more care. So yeah, we do end up dealing a lot with endocrinology especially and you know, med-onc, rad-onc. We deal with all those services.

A mixed bag of everything.

Yeah.

Yeah. Wow. That's impressive. Yeah.

Pretty busy though.

It is.

Yeah.

Yeah. And a little bit crazy.

A little bit crazy, which is perfect for me.

Goes with neurology. Yeah. So today, this episode, I guess we can call them episodes now because we have things going on.

It's an episode.

It is an episode. This episode is going to be just discussing neurology with Stephen. We now have his background. We have introductions times two.

Yes. Yeah. Well introduced.

Yeah. So I'm just going to fire out some questions and we'll just discuss them. And really this, the Shift Brief is growing. It's coming from the ground up. So we're discussing everything from primary care paramedic student level up to critical care.

It's primarily paramedic based, but certainly nursing and paramed definitely overlap in many ways.

So some of the things that we find overlap obviously in patient care is neurology. We're talking about strokes, we're talking about seizures and things like that. So why don't we talk about strokes for a couple. Can you explain what a stroke is to people that might not be familiar with what it is? I know there's a couple different kinds.

Yeah. So I think the one that we deal with the most is the one that everybody's familiar with is an ischemic stroke. Those are our patients that are time sensitive, time dependent. And they're the ones that we're flying for to get them to a stroke center as fast as we can because just like the heart, time is muscle, time is brain as well. So the sooner we can get that ischemic clot or whatever debris is blocking the blood flow through to get the circulation to that part of the brain, the quicker we can get rid of that, the better chance the patient's going to have. So you can say an ischemic stroke is to the brain what a heart attack is to the heart. It's a clot affecting the blood supply and damaging that tissue beyond that clot.

Yep. In that instance for sure. Yeah. Okay. What about the other kinds?

And then the other kinds that we have are hemorrhagic strokes. The one that we see a lot of the time is going to be a hypertensive bleed. So patient has uncontrolled hypertension, patient has been weaned off of their hypertensive medications over the last couple days, hasn't had a follow-up appointment, doesn't realize that their blood pressure is through the roof. And then they tend to have what they call a hypertensive bleed or you could call it a hemorrhagic stroke. And that's basically the reason that they differentiate between an ischemic stroke and a hemorrhagic stroke is because it's not from a trauma. It's from a blood vessel that has burst under the pressure of the hypertension. There's certain areas of the brain that you'll see most frequently, like a lot of hypertensive bleeds within the basal ganglia, which kind of sits towards the back of the brain. The reason is because within that basal ganglia there's a triangle of vessels that are actually quite thin, a lot thinner than other vessels in the brain. So hypertensive bleeds tend to happen there. Not that they're all going to happen there, but most of the ones you'll see if you dig into it, which I'm a nerd so I like to dig into that stuff, it will be within that basal ganglia area. And those patients can all present differently. That's the crazy thing about strokes in the brain. Depending on what vessel you have occluded, you're going to see symptoms that are different. So when you start assessing patients and you see, oh, this guy is aphasic and his personality is off...

What do you mean by aphasic? What's aphasic for those who may not be familiar with it?

Yeah. When you talk about neuro assessment, we talk about some core things that we're assessing because really what we're trying to do is figure out the basic neurological function that's happening. You have to put everybody on the same scale. There's a lot of different assessment tools, especially for stroke. Cincinnati is one of them that we don't really use a lot, but it's definitely used throughout Canada. GCS is kind of what we really use for neurological assessment.

Sure. And we're going to jump into those in a couple minutes for sure. Yeah. So creating a baseline through those assessments, you start to make connections like patient A had A, B, and C symptoms and that's what kind of bleed it was. And patient B had A, B, and C and that's what kind of bleed that was. So you can kind of group them together.

Yeah, you kind of start as you see these patients and assess them and hopefully find out what happens to them after. It's definitely a challenge sometimes, the hard part about paramedic medicine for sure. You start to group these things together and these symptoms into certain areas of the brain that are actually affected.

Yeah, that makes a lot of sense. We certainly know there's different areas of the brain control different parts of our body. So if you're immersed in it all the time, you would develop a natural habit to be able to group those things together.

Yeah. Alcoholism is one of those things. I'm pretty sure it's called Korsakoff syndrome, which is because people that have alcoholism or suffer with alcoholism have natural brain atrophy. When your brain atrophies, it shrinks. So what ends up happening is that our brain is all along our skull and it's held onto our skull, but when the brain starts to shrink, it starts to tear away from the dura and then what we end up getting is a subdural hematoma. So a lot of patients that suffer with alcoholism can end up with spontaneous subdural hematomas. We would deal with subdural, subarachnoid hemorrhages, all different kinds of bleeds that can happen within the brain. Basically all the word is trying to tell you is what layer it is located in.

Okay. Yeah. So people that suffer with alcoholism do tend to get spontaneous subdural hematomas that need to be... We're going to come back to a few things you touched on. Cincinnati stroke scale, GCS. We'll just talk about those for a minute and kind of break them down for people. Cincinnati stroke scale as we know: speech, facial droop, and arm drift. Talk about those for a couple minutes and what they mean to you. I know one out of three findings versus three out of three, the significance. What does that speak to you if somebody has maybe one finding, just a garbled speech but they have no arm drift, no facial droop? So a positive Cincinnati with that one finding, how sensitive do you think that is?

I mean, GCS and Cincinnati stroke scale and a lot of things in medicine are operator dependent and assessor dependent. We don't really use the Cincinnati stroke scale a lot in the hospital, but it is an excellent tool because at least it brings in some of the cranial nerves. GCS is kind of like we're just trying to look at basic function. So we're looking at eye opening, verbal response, motor response. Being able to do that really well and understand how it works is actually really important. Even if we stop there and we get a good GCS and it's a reliable number, that tells us so much. I've been through this with nurses a billion times before. You need to know what classifies as a localizing response in your motor response, what classifies as incomprehensible sounds. You have to look into each one of those little things. Patients can be oriented but still have a GCS of 11T because they're intubated or trached. So there's a lot of variations on a GCS scale, which is why we say it's not super reliable, but it is still an important number that we use every day because it gives us at least an idea of what we're dealing with.

So just to break it down for the people that don't know what a GCS is. GCS is a Glasgow Coma Scale and it is a widely utilized tool to essentially evaluate a person's level of consciousness and responsiveness, their ability to follow commands, look at you, talk to you, move all their limbs. It's based out of a score of 15 in those three categories. If you get the worst in each category, you get a score of three. So a GCS of three is the absolute worst you can have, and a GCS of 15 being the best you can have. We'll put the prompt up right here. You're welcome to look at that and break it down on your own. I do encourage you in your practice, if you're a paramedic or healthcare provider, when you provide a GCS, provide a breakdown of what that GCS is so whoever you're giving a handoff to understands where they're losing points and what that means.

Yeah. Especially prior to an intubation. Because once a patient is intubated, we don't have the ability to assess them as well. So it is really important that if we come on scene, my first question is, what was your best GCS prior to the intubation? Because that can predict a lot of morbidity and mortality as the patient goes through their course.

Shifting gears a little bit. Still talking about strokes and GCS and Cincinnati. We know not everything that looks like a stroke is a stroke. One of the first ones that comes to mind for me is a patient experiencing a diabetic emergency, hypoglycemia. Their sugars are low, they're altered, they have slurred speech. What are some other stroke mimics you can think of?

Intoxication for sure. Not all strokes are going to appear the same. We look at face, limb movement, the stereotypical presentation of a stroke: paralyzed on one side, can't talk, facial droop. You might not be able to assess a facial droop on some patients because their anatomy is off. Sometimes they're not going to obey the command.

Why do you keep pointing at me?

Because you're stubborn. That's why. But mimickers can be a head injury, intoxication. That's usually what we end up seeing on scene. We see a lot of Bell's palsy.

That's another good one. Yeah. Some of the weird and wonderfuls. Bell's palsy would probably be in one of your weird and wonderfuls.

Yeah. If you were to take the average paramedic and think about their neuro assessment, they should be well versed in the Cincinnati stroke scale and assessing a patient's level of mentation, their GCS, their gait, checking pupils. If you had one thing in your background as a neurosurgery nurse that you would suggest to add to a paramedic's toolbox for assessment, what would you say?

That's a really good question. And if you can't think of one, maybe just jump into how you would do a neurological assessment and people could pick up some pointers from that. So if you receive a neuro patient or CVA patient, how would you proceed with a neuro exam on them?

For me, a neuro assessment starts at the door. It isn't necessarily me with my hands on the patient. A lot of the time when I start to assess somebody's neuro status, I'm just watching them for a little while. I want to see how they're interacting with the world. That can tell you a lot about what you think you're going to find in your GCS. Neuro is usually not a quick assessment. You're constantly watching people and thinking about a neuro assessment. For example, we picked up a patient with a reported low GCS of 7, need to be intubated. But when you walk in, sure, he's not speaking and not obeying commands, but his eyes are wide open and he's looking around the room, shifting from right to left. You think, okay, this isn't a GCS of 7. We'd intubate less than 8, but you get there and you look at him and think, oh no, wait, he's looking around, interacting, tracking. Something's not adding up. That tells you more information. You might not know what's happening and you don't need to know. Your job is to be able to communicate what you saw to the people you're bringing them to. I would say there's no one thing. Just always be looking at your patient and observing what they're doing neurologically and how that applies to them.

Yeah. And you already talked about limb assessment and pupils and watching for nystagmus, do they turn their head all the way to the right or only to the left? Is this a neglect that we're not picking up because everybody's approaching them from the left side? Then you discover he will not turn his head to the right at all and you've just discovered a right side neglect. What's causing that?

Yeah, that's a good point. We all tend to approach patients from the same side. Paramedics are notorious for saying we're going to come at you from all angles, but oftentimes it's still the same angle. So making sure you're going left and right.

We've covered pretty well the different types of strokes: ischemic versus hemorrhagic. We've talked about some very basic ways to assess them, a bit about the pathophysiology. Let's talk about treatment for a couple minutes. Prehospital, specifically on the ground ambulance, when it comes to picking up a patient that you think is having a stroke, it's pretty basic care. Stroke team activations if your service offers such a service. At the tertiary care center, your stroke center, you can activate that stroke service, but prehospitally it's really ABCs. Certainly monitoring that airway is going to be one of the biggest issues for the ground paramedics because seizure, coma, death are real things. Have your suction handy, oxygen readily available. Make sure your tanks are full at shift start. Get IV access in case they need to use dye in the CT scanner. In my experience, for ischemic strokes, they're generally pretty stable on transport to the hospital. The ones that always gave me a bit of a pucker factor prehospital were the ones I thought were hemorrhagic strokes. They had a recent history of a fall or we're talking about that sudden thunderclap headache these patients experience, and all of a sudden we're starting to trend down that route of Cushing's triad: widening pulse pressure with hypertension, bradycardia, abnormal Cheyne-Stokes respirations. Those patients will notoriously projectile vomit, seize, clench, and go into cardiac arrest. So those are the ones that get me very worried prehospital.

So aside from monitoring and managing their ABCs, getting access, keeping a close eye on their airway, heart rate, checking the sugar to make sure they're not hypoglycemic, looking for those CVA mimics, anything you would offer for treatment prehospital or anything important to think about in those ischemic strokes specifically?

I mean, you've just covered it. The only thing I can really add is emotional support for the person if you're able to give it. They're having a terrifying experience. Everybody in the general public knows the signs and symptoms of a basic stroke. When it starts to happen to you, there's nothing you can do about it because you still know it. You've heard, you've seen the commercials, you've watched the podcast, you've watched the Shift Brief. You've learned how to evaluate. So emotional support is really important. You're always going to have to worry about all those medical things you just discussed. The difference between somebody that is good at it and somebody that is elite is that they're able to maintain those thought processes in their head while still providing emotionally supportive care to the family and the patient. Explain to them what is going to happen because we've taken them into emerge so many times. Prep them for what is about to happen to get them into the mindset that this is happening and they need to step up.

I think emotional intelligence could be its own chapter or category. Some people are really good at it and born with that kind of stuff. Some people have to work really hard. A lot of it comes from experience, from watching guys like you that have been doing it for so many years and how you interact with patients and families. If it works and provides emotional support, you just take that and put it in your little toolbox. That is the exact conversation I'm going to have with somebody when this starts happening when you're on your own. My entire nursing practice is based on things I've observed from people that have done it around me for 17 years.

Mentors. We're all fortunate to have some good ones. We've all had some bad ones.

Yeah. Absolutely.

Hopefully more good than bad.

Yeah. You learn a lot from the bad ones too.

It's true.

You get to decide what you want to add to your practice and what you want to throw away. Your practice is going to be yours, but it's going to be made up of a lot of the things you've observed over your years.

That's a good way of looking at it. It is going to be yours and at the end of the day, you're responsible for your demeanor and your treatment in that moment. You're certainly responsible for your license. But that person experiencing that emergency is relying on you to have ownership of the skill set you're bringing to them. They're not going to remember how much lead they were on, but they are going to remember if you shaved their nose or not. I only say it because that is exactly something that has happened to me. So those are the things that patients will remember. Anyway, what I'm saying is you've discussed perfectly all of the... Hypoglycemia is definitely one of them you have to watch for. It has been proven that people who are hypoglycemic and having strokes don't do as well. So you want to keep them normoglycemic and normothermic. And we're still talking about ischemic strokes.

Ischemic strokes. Yeah.

Yep. It's a little bit challenging here in this province to deal with hypoglycemia prehospital.

Absolutely. So fluids are appropriate for sure. Saline is what's carried on the ambulance, but hypoglycemia is certainly a good one to consider.

Just make sure you have a number. Make sure when you roll through that door, you're like, he's got a glucose of 16, so there you go. And then I go, thank you very much, and I grab the insulin syringe. That's the transfer of care. The more information you have for me coming in, the quicker I can do my job and get treatments on the way. I'm going to recheck the glucose anyway, but I'm probably going to be grabbing for the Humulin and bringing it in with me right before I check it because I know I need to get that down.

So let's talk about hemorrhagic strokes and how their care would be a little bit different from an ischemic stroke. Prehospital, ground ambulance paramedics, ABCs are super important. We talked very briefly about seizure, coma, death. I've seen it countless times where those patients have that sudden herniation, raised intracranial pressure, they start to seize, vomit, you have an insanely difficult time managing their airway, and they have a cardiac arrest in the field because it's usually very fast.

Yeah, when they let go, they let go.

So timely transport for those guys. I would say to anybody doing this prehospital, make sure you're not delaying transport for anything that's not crucial. IV access on the way. I've always been a big proponent of that. The mentors I had coming up through my paramedic career have almost always told me, get really good at starting an IV going 80 kilometers an hour backwards because there's almost never a reason to stay there unless you're fixing hypoglycemia or your patient is seizing and you need to give them some benzos. 95% of the time you don't need to delay transport to start an IV. So get the big stuff that matters out of the way really quickly and then expedite transport to your stroke center.

The care for a hemorrhagic stroke then? How would that be different from an ischemic stroke or is it the same?

I think it's pretty similar. Blood pressure control is important in both. You don't want to... You want to get them there as fast as you can. That's the point. Do your ABCs, have a glucose when they get there. We don't want to overly lower their blood pressure because the brain is still going to need to use collateral circulation to get blood flow and oxygen to the parts of the brain that it can. It needs to overcome.

Right. So that's the whole cerebral perfusion pressure.

Exactly. If I go back to school days, it's mean arterial pressure minus ICP.

Yeah. And we'll never have... So it's your intracranial pressure that's going to be subtracted from your mean arterial pressure to give you your cerebral perfusion pressure. We don't have a way to measure intracranial pressure in the prehospital environment. We do in the hospital. We throw an ICP bolt or an EVD in the brain and we can get a pressure, transduce it, start to trend it, and push pressure to get proper perfusion. But to your point, making sure we don't drop the blood pressure too much, the reason is because you don't want to lower the cerebral perfusion pressure.

Yeah. Exactly. So we usually say we don't want to lower that blood pressure greater than 25% of the patient's baseline blood pressure. That's kind of where you draw the line. For a hemorrhagic one prehospital, you're still not going to really know. You gather your history, your vitals, how the patient presented, and try to get a really good case on what this is based on all that information.

So it kind of brings us back. We're talking critical care down to the primary care student level. You work in the neurosurgery unit, we work in a flight critical care environment. But if I were to summarize all the information we just put out there, what we're saying is be good at the basic stuff. It all comes down to having your assessment and the ability to gather information and present a patient. That is detrimental to how somebody you're giving that patient to is going to perceive what the diagnosis is. Gathering that information and a good med history, because you bring a patient in and we don't have a med history, how are we to assume that they're on blood thinners? Then they deteriorate in the emerge and we find they're anticoagulated and we could have reversed it if it was reversible to give them a little more time to get to intervention. But the whole thing is you have to be really good at the basics. You have to know anatomy, physiology, assessment, and be able to gather a history and a story quickly.

Yes. Because expedited, you got to go. Definitive care, right? We talk about stay and play or load and go. That's a phrase all paramedics, especially new ones, are familiar with. These are load and go situations where you are not going to fix that patient's problem in their living room. Unless you have to do something immediately life-saving, it's time to get out of there. It's not time to stay and chat and make jokes, which I love to do, but I've gotten a lot better at knowing when to place them appropriately.

Absolutely. I think we're going to wrap it up for the stroke conversation. That was pretty in-depth.

It was a lot.

Yeah, I think we were just going to go for five or six minutes, but as somebody who doesn't deal with a lot of strokes, that was a lot. Subarachnoid hemorrhages. Yeah, let's go. Anything else you would throw out there before closing or do you think that's suffice? Watch, follow, and subscribe to the Shift Brief.