Dizziness, ALS or not?

[PSYCtest040]

Dose a patients complaint of dizziness with out LOC automatically mean an ALS work up??? The reason I ask is I received a QA/QI gig for not asking for an ALS assessment.

Here is the back story

My partner (a paramedic) and I ran a priority 3 (BLS emergency in my system) for a check the welfare. Patient called 911, stated she needed an ambulance and then hung up. PD arrived on scene first and reports we are clear to enter on arrival.

When we get there we find a 60 YO old female A&Ox4 complaining of feeling dizzy x3 days with no loss of consciousness. Further assessment revels a long history of psychiatric issues, bi-polar and COPD. Vitals are fine (pulse 88 BP 134/90 RR 22 with no accessory muscle use) SpO2 92% on room air (which is normal for her), lung sounds are wheezy but she moving good air. Patient is able to speak in complete sentences and skin is pink warm and dry. Patient has no complaints of trouble breathing, chest pain, head ache or nausea. Patient states she has had a normal appetite and is drinking plenty fluids. She keeps stating over and over she feels dizzy.

Now based on what I am presented with, I felt no ALS interventions are warranted and tell my partner I can handle. I put her on 4 LPM O2 via nasal cannula and placed her in high fowlers position for transport. Patient has no further complaints during transport.

Now my question is what are the varying protocols in the nation? My QA/QI auditor stated I documented the call very well and had no issues with the care I provided. He stated that a chief complaint of dizziness (with or with out +LOC) should have at minimum an ALS assessment. Should I have had my partner add an addendum to my chart? Should I have turfed this patient to the paramedic? Any insight will be greatly appreciated.

[screaming pizza]

Dose a patients complaint of dizziness with out LOC automatically mean an ALS work up??? The reason I ask is I received a QA/QI gig for not asking for an ALS assessment.

Here is the back story

My partner (a paramedic) and I ran a priority 3 (BLS emergency in my system) for a check the welfare. Patient called 911, stated she needed an ambulance and then hung up. PD arrived on scene first and reports we are clear to enter on arrival.

When we get there we find a 60 YO old female A&Ox4 complaining of feeling dizzy x3 days with no loss of consciousness. Further assessment revels a long history of psychiatric issues, bi-polar and COPD. Vitals are fine (pulse 88 BP 134/90 RR 22 with no accessory muscle use) SpO2 92% on room air (which is normal for her), lung sounds are wheezy but she moving good air. Patient is able to speak in complete sentences and skin is pink warm and dry. Patient has no complaints of trouble breathing, chest pain, head ache or nausea. Patient states she has had a normal appetite and is drinking plenty fluids. She keeps stating over and over she feels dizzy.

Now based on what I am presented with, I felt no ALS interventions are warranted and tell my partner I can handle. I put her on 4 LPM O2 via nasal cannula and placed her in high fowlers position for transport. Patient has no further complaints during transport.

Now my question is what are the varying protocols in the nation? My QA/QI auditor stated I documented the call very well and had no issues with the care I provided. He stated that a chief complaint of dizziness (with or with out +LOC) should have at minimum an ALS assessment. Should I have had my partner add an addendum to my chart? Should I have turfed this patient to the paramedic? Any insight will be greatly appreciated.

I can see where they are coming from. I'm not familiar with how your system is run, is a tiered response or are you on an ALS rig? If you're on an ALS rig, I can see the patient being put on a monitor due to complaint plus age. If it's an intercept/tiered repsonse with a relatively short transport time I can see maybe being justified transporting BLS due to circumstances. I also might wonder about the breath sounds. Were wheezes WNL and not requiring of treatment or was the patient not complaining of any RR related conditions?
I know this probably isn't what you wanted to hear, but it's an honest opinion. If you were one of mine, I'd say something, but since everything else was on the up and up and it doesn't seem as if there was any harm done, I'd just tell you to review protocols and not do it again. I'd be hard-pressed to be OK with a patient in their 60's with idiopathic dizziness for three days being treated as BLS.

[PSYCtest040]

I can see where they are coming from. I'm not familiar with how your system is run, is a tiered response or are you on an ALS rig? If you're on an ALS rig, I can see the patient being put on a monitor due to complaint plus age. If it's an intercept/tiered response with a relatively short transport time I can see maybe being justified transporting BLS due to circumstances. I also might wonder about the breath sounds. Were wheezes WNL and not requiring of treatment or was the patient not complaining of any RR related conditions?
I know this probably isn't what you wanted to hear, but it's an honest opinion. If you were one of mine, I'd say something, but since everything else was on the up and up and it doesn't seem as if there was any harm done, I'd just tell you to review protocols and not do it again. I'd be hard-pressed to be OK with a patient in their 60's with idiopathic dizziness for three days being treated as BLS.

We were an ALS/BLS rig and our transport time was, about 7 minutes. Patients respiratory effort was normal with no adventitious sounds. History revealed a 20 pack year smoking history and no cardiac issues. The only reason I ask is I trust this paramedic and if any ALS interventions were warrented he would have stepped in.

[shfd739fm]

I can also see the reviewer's point. In our system that would be the medic's to ride. I would have put her on the monitor and obtained a 12lead. She has the risk factors for MI and with females tending to have atypical and often vague complaints it is something you can help rule out. Here all dizziness, near-syncope and syncope get 12 leads.

[CornholioMedic]

I can also see the reviewer's point. In our system that would be the medic's to ride. I would have put her on the monitor and obtained a 12lead. She has the risk factors for MI and with females tending to have atypical and often vague complaints it is something you can help rule out. Here all dizziness, near-syncope and syncope get 12 leads.

Quite often, the elderly may be suffering (And this isn't all inclusive of the elderly with the complaint of dizzyness) from A-fib. Either old or new onset. My past experience working in a private practice has shown that many of these people with this type of complaint are having an issue with A-fib.

I have to agree with 12 lead and possible ALS if a positive 3 lead and 12 lead show cardiac issues.

[wvditchdoc]

Allright here goes..........

Based on everything I have read that PSYC posted, I don't see it. I QA over 400 PCR's a month. If I had read that, I would not have gigged him. Yes her chief complaint was dizziness, is that indicative of anything else? Hell yes, from A Fib to a damn inner ear infection.

She was hemodynamically stable, we can sit here and "what if" all day long. There was no mention of an irregular pulse in the Vitals or any other indication that this call required ALS.

Besides, if PSYC's ALS partner was worth a damn, their "This needs ALS" alarm should have went off. As for the ALS assessment, they were there on the same scene, same call. As PSYC was assessing the patient his partner should have been paying attention. If something hadn't been right, PSYC could have notified them to get on it.

If I was gigged for this, I would fight it. This falls back on treating what is in front of you for what it is worth. Not just doing a 12 lead because it is written down somewhere. If you vary outside of your protocols, just be able to justify it.

In my opinion, and my opinion only, PSYC did right by this call.

[FF/EMTP1317]

With dizziness x3days I probably would have let my EMT partner have the pt. Before turfing it to her I would have placed the pt on the monitor and checked glucose level. I don't think PSYC did anything wrong but from a CYA measure for his partner it probably wouldn't've hurt to do a quick 3-lead.

[Medic_QT]

The department I work for is all ALS. I would have popped her on the monitor for shits n grins.


When I worked private, most of the time it was a medic and an EMT. Our Captain was an asshole and would QA a stubbed toe and ask why we didn't provide an ice pack, so I would have taken the run and done the ALS workup. Even if he wasn't like that, I probably would have still taken it, just cuz she could have ectopy or something that isn't necessarily life threatning, but would be nice to know.

[Resqtoy]

That's kind of a gray area, per my county's protocols it calls for a 12lead, blood glucose etc. It could be vertigo, could be a-fib, could be a million other things. I would've taken it ALS just because there's a slight chance that there was a significant underlying issue.

[JenVTemt]

Allright here goes..........

Based on everything I have read that PSYC posted, I don't see it. I QA over 400 PCR's a month. If I had read that, I would not have gigged him. Yes her chief complaint was dizziness, is that indicative of anything else? Hell yes, from A Fib to a damn inner ear infection.

She was hemodynamically stable, we can sit here and "what if" all day long. There was no mention of an irregular pulse in the Vitals or any other indication that this call required ALS.

Besides, if PSYC's ALS partner was worth a damn, their "This needs ALS" alarm should have went off. As for the ALS assessment, they were there on the same scene, same call. As PSYC was assessing the patient his partner should have been paying attention. If something hadn't been right, PSYC could have notified them to get on it.

If I was gigged for this, I would fight it. This falls back on treating what is in front of you for what it is worth. Not just doing a 12 lead because it is written down somewhere. If you vary outside of your protocols, just be able to justify it.

In my opinion, and my opinion only, PSYC did right by this call.

I agree with DitchDoc. You can play the "what if" game all day long in EMS. You need to evaluate the patient and treat what you find. In this case you found a pt with vitals WNL and a complaint that has gone on for days without any other symptoms/complaints developing and ALS was already right there "if" something did happen. It seems to me there were no "alarm bells" on this call that would signal the need for ALS". If your partner was just standing around he may have considered putting the pt on the monitor, but its wasn't absolutely necessary.

Just my opinion.