Live from Prospect St: Dizzy at Hillcrest (part 1)

Many moons ago, there was an enlightened discussion list run by Jeff Brosius and Valerie DeFrance called Live from Peachtree St. The format was this: Jeff would periodically present scenarios based on real-life calls, putting them out for debate on diagnosis and treatment; later he’d provide the outcomes, with a discussion of the relevant clinical issues. It was a great educational model, and I’ve always thought that scenario-based instruction was a fantastic way to learn to parse the details of a call, determine what matters, come up with a working diagnosis, and make your decisions. You can’t learn hands-on skills from scenarios, but you can exercise your noodle, and more noodle-exercise is what this business needs.

Sadly, Live from Peachtree St. closed its doors years ago, although its archives are available online and still a great read. In the same spirit, however, and with permission from the authors, I’d like to revive the tradition. With that in mind, and harkening from my own neck of the woods, I give you: Live from Prospect St!

To juggle the format a little, I’d like to break these cases up. Remember “Choose your Own Adventure” books? In a similar fashion, I’ll give you the first chunk of the call, let you analyze the facts and make some decisions, then go forward with another round of details, and finally present the outcome. Cases are either true to life (obviously edited for HIPAA) or closely based on reality with editorializing for educational purposes. Feel free to send in any cases of your own! We’re not only interested in intriguing or unusual calls, but also more run-of-the-mill cases that illustrate important fundamentals of assessment and care.

All levels are invited to play, but in keeping with our mission, we will assume a BLS scope of practice. Onward!


Dizzy at Hillcrest

You are the technician on A-8, a dual-EMT, transporting BLS ambulance. You are equipped with BLS epinephrine, aspirin, glucose, nebulized albuterol, pulse oximetry, and finger-stick glucometry. Intercepting ALS is available upon request. It is noon and the weather is fair.

The radio crackles: “Ambulance 8, respond cold to Hillcrest Manor, in the lobby, for the patient with dizziness.

Driving non-emergently, you arrive several minutes later at an assisted living facility. In the lobby, you are met by staff, who direct you toward an elderly woman in a chair. A nurse informs you she has been feeling somewhat unwell all day, and 30 minutes ago began complaining of dizziness. She also states that she failed a finger-to-nose neurological test. They request that you transport her to Mount Doom Hospital, a high-quality community hospital several towns away (20 minute transport routinely; 13 with lights and sirens); it is a cath lab and stroke center, although not the nearest facility for either, and is not a trauma center. The nearest facility is a community hospital of similar size and capabilities (10 minutes routinely; 5 with lights and sirens).

You kneel in front of the patient, noting that she is alert and appears generally well, in no obvious distress. She introduces herself as Ms. Smith, is 68 years old and fully oriented, and tells this story:

“This morning when I was getting out of bed, I fell and bumped my head. After I got back up, I was trying to do my writing assignment for our group, but I kept finding that I just couldn’t seem to think of the words — I’d stare at a sentence for ten minutes without knowing how to finish it. I’ve been feeling a little dizzy most of the day, and a little sick — I vomited a few times. And I feel like there’s a pressure behind my eyes.”

While you talk, your partner obtains these vitals:

Skin: dry; unremarkable at the core; cool and slightly pale in the extremities
Pulse: 90 [at the radial, strong and regular]
Respirations: 14 [regular, normal depth and unlabored]
Blood pressure: 164/98
Oxygen saturation: 96%

When asked, staff report that Ms. Smith’s medical history includes coronary artery disease, diabetes, mild dementia, and hypertension.

What is your current impression of the patient’s priority?

What are the leading possibilities in your differential?

What further assessments or information would you like to better inform your decisions?

What actions or interventions, if any, would you like to take at this time?

Post responses to the comments.


  1. Great idea! Just a couple weeks ago I was thinking about starting up a blog of cases like this and happened across ‘Live From Peachtree St.” while researching if anyone else had done it yet. Props on continuing a great educational series.

    (I’m late commenting, but haven’t looked at part II yet)
    At this point the crux of my decision-making would be based upon some sort of neurological exam searching for signs of an intracranial bleed (likely subdural). I’d also ask about the events surrounding her fall to see if she had any symptoms beforehand. I’m not impressed by a single failed finger-to-nose test by the assisted living staff, but it does tell me to definitely scrutinize her neuro exam. In our region we stick to the Cincinnati Stroke Scale as a standard and it certainly does the job, but for for the sake of curiosity and experience I usually add in a couple more maneuvers if it doesn’t delay or distract from care.

    She’ll also got a fingerstick BGL.

    As for interventions, there doesn’t seem to be much required prehospitall at this time. In my region we couldn’t get away with not administering oxygen, but I think an NC @ 2 Lpm would be perfectly reasonable.

    Now the tough part of this is the transport decision. If she has a positive neuro exam, I’d really want her at a trauma center. Since that isn’t listed as an option, I’m going to highly suggest the closer hospital simply because it theoretically saves a few minutes getting to the CT scanner. I’m not too interested in the stroke center designation since embolic stroke isn’t forefront in my differential and that title doesn’t indicate any neurosurg capabilities, but it is nice to know that either hospital will likely rush her off for a CT if she has any deficits. It would also be poor form to bring her in without ALS capabilites, so we’re also calling for an ALS assist who would likely get IV access and run a 12-lead.

    The final point of contention may be spinal precautions. With the information provided I do not see an indication for immobilization, but I’d definitiley palpate her spine and ask about pain. I could not disagree with anyone who decided that an older person falling was a high-risk mechanism on its own, though.

  2. note: I’m not advocating increasing scene time waiting for ALS; I intended that as an intercept if somehow possible. Their help is not going to change the patient’s care or clinical course, but bringing her in without them would garner some glances from the nursing staff at the hospitals in my area. If she has to go in BLS, so be it; they’ll be sticking her for labs when we get in anyway.

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