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Hemi-Inattention

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Many medics do not realize that the Cincinnati Stroke Scale or Los Angeles Prehospital Stroke Screen are only reliable at identifying a hemispheric stroke. They can usually identify paralysis or weakness on one side of the body or another, but aren’t really geared towards identifying stroke of the brainstem, cerebellum, or intracranial hemorrhage.

To do that, you have to check for limb ataxia, visual field deficits, and deficits in extraocular movements.

But one phenomenon that never ceases to amaze me is non-dominant hemisphere syndrome. For around 85% of the population, the left hemisphere of your brain is the dominant one. Southpaws have a dominant right hemisphere.

And when a right-hander strokes out the right, non-dominant hemisphere of their brain, often the left-sided paralysis is accompanied by a total lack of awareness that anything is wrong.

Weird, that.

I’ve had a couple of patients over the years that I had to force to go to the hospital, so deep was their denial. One sweet little old lady was so certain that nothing was wrong with her that she insisted that the frail, flaccid black arm I was holding up before her eyes was my arm.

The guy I ran just a little while ago wasn’t quite that bad, but it still never fails to weird me out when I have to point out to someone that one entire side of their body has stopped working.

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Posted by on August 9, 2010 • Filed under: EMS Topics, Patient Management

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  • Matt G

    You see it in other things, too. The man who is clearly deaf as a post, but insists that his hearing is fine, although every question that you've asked has been shouted at him three times each. The woman who insists that she can see perfectly, though a license plate 20 feet away requires squinting and guessing to decipher. The older man who drags his foot but refuses to notice it, even after occasionally taking some falls.

  • #1 Dinosaur

    Don't be silly. How do you know there's a stroke if you haven't done an MRI?

  • Ambulance_Driver

    Wenckebach discovered his phenomenon several years before Einthoven ever hooked somebody up to electrode and stuck their feet in brine solution.

    So how did he figure it out without an EKG?

    The better our technology becomes, the dumber we get.

  • http://injennifershead.com Jennifer

    The delusion is strong with this one.
    So very strange.

  • Jdmedic

    Kelly – Great points! A few months ago I did a QA on a chart where the elderly Pt had a sudden onset of headache and vision change. I pointed out that the medic probably should have asked for a “Stroke Alert” since he was going to a stoke center anyway. I was told (by a supervisor) that since the Pt did not have R or L side weakness and “only” vision changes there was no indication of a stroke.

  • Christopher

    Has your service switched to the MEND exam? It covers visual fields et al. I recently discovered this gem during an ASLS class and highly recommend it.

  • Ambulance_Driver

    I use the MEND exam, but relatively few of our medics have been trained in it.

    I've been an ASLS instructor for about 5 years.

  • markmedic

    There is a word for this. Anosognosia is the condition in which the person who suffered disability seems unaware of or denies the existence of his or her disability.

  • Zing!

    Zing!

  • mdfps

    System I work in just updated pre-hospital stroke scale to be very in depth. MD decided that Cincinnati stroke scale was not sufficient and added Miami scale in conjunction. Together they test all mentioned above, visual fields, limb ataxia, etc.

  • Guest

    or the good old chest pain that isn't a pain only a discomfort (or indigestion) or tightness or (insert word of choice here)

  • NCEMT

    Had a patient like this not too long ago. An elderly gentleman who was at his doctors office for a routine check up. I did a stroke scale and noted slight pronator drift to the right side, and slight confusion and slurred speech. His wife and doctor both said he had been increasingly more weak and confused over the past weeks. Still, something told me that this man needed attention, fast, and if he didn’t go to the closest stroke center right then, he would die before the sun rose over the Great Wall of China. We ended up transporting him emergency traffic to the closest stroke center, which was 50 miles away. We called in a code stroke to get the stroke team ready, and arrived with 15 minutes to spare before his window for thrombolytic therapy closed. He left the hospital three days later with no pronator drift, no weakness, and no confusion. His doctor said that he is back to the man she treated 10 years ago.

  • NCEMT

    Also, I am McNellie926 on twitter, and Mac Sauls on facebook.

  • NeedleNerd

    so what about the old lady that says “its always like that”?

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