House Calls

In the late ’90s, EMS temporarily became a diagnosis-free zone. “Just document the signs and symptoms” was the prevailing wisdom. I think our industry’s concern was that we lacked the tools and training to play Name That Trauma. Broken bones were “painful deformities” or “angulated extremities,” requiring interpretation by clinicians who excelled at fracture…I mean deformity management. Or perhaps geometry. After one sarcastic attempt at compromise—my suggestion that we diagnose only on even-numbered days—I conceded the value of x-rays and the people who read them. After all, a crooked femur could foreshadow a rickets epidemic.

In 2004, after years of diagnosing only when no one was looking, I was drawn to Fox’s new series House, a hospital drama about a brilliant but boorish physician who elevated patient assessment to an art form. A card-carrying iconoclast, Dr. House delighted in tweaking the medical establishment by demonstrating a disconnect between productivity and protocol. But the neatest thing about House, played by the incomparable Hugh Laurie, is that he often saved lives by thinking zebras instead of horses when he heard hoofbeats—the opposite of the classic mantra. Exotic illnesses and occult trauma were no match for his right-brained resourcefulness. I felt empowered by his swagger, and couldn’t wait to amaze medical control with my first case of pheochromocytoma.

My infatuation with House lasted maybe six months—long enough for me to realize that medical practitioners aren’t performance artists. We have fairly rigid, autocratic ways of reacting to scenes, patients and bystanders. If I could temper such regimentation with House-like imagination, I thought, perhaps I’d do a better job of aligning my limited, prepackaged therapeutics with patients’ needs.

Before I had a chance to work on my own tunnel vision, I encountered the very same during a visit to our dog’s veterinarian. Suzi, our 8-year-old cocker spaniel, has COPD and CHF (her lungs sound just like those of a person with those diseases). Nebulizer treatments and nitroglycerin aren’t options, so we’re forced to manage her condition with Lasix, Vasotec and continuous observation. My wife and I had adjusted her Lasix dose because its therapeutic index is just as narrow for dogs with those two illnesses as it is for people—too much and her bronchospasm worsens, too little and her pulmonary edema fulminates.

When I mentioned to the vet that I had decreased Suzi’s diuretic to address that day’s wheezing, he got angry and said something about leaving those decisions up to him. I reminded him he had called me less than a month before to warn about the potential harm of Lasix—research I’d already read as a medic—and that I was no stranger to the drugs or diseases we were discussing. That didn’t seem to make him any happier. He commented about hearing mostly crackles in her lungs, reluctantly left the dosing alone, but cautioned us about the same dire consequences I usually quote when my human respiratory patients refuse care. Suzi got better anyway.

The way Suzi’s vet responded to my participation reminded me of some of my own tendencies:

• Ego-driven. I know, that sounds horrible. We’re taught egos are bad; that they need to be suppressed so we can get along with each other. The definition of ego, though, is much more clinical and benign than derogatory terms like egoist or egocentric imply. Egos help us define reality by making us aware of ourselves and our environments. To be driven by our egos is to act according to those perceptions, but we’re not always right. Ideally, we should delay committing ourselves until we hear and evaluate the “realities” sensed by patients—their views of presenting problems and best solutions. Such thoroughness isn’t always possible when time is short.

• Pattern-seeking. During assessment, we look for clues we’ve encountered before. Our bias is to conclude something familiar is happening—fluid in the lungs of a CHFer, for example. That preference for patterns can lead to premature or incomplete diagnoses, particularly if we minimize ambiguous signs and symptoms. Ideally, we’d augment experience with flexibility: Hear hoofbeats, think horses, but check for stripes.

• Desire for control. I think most of us like to feel we control patients and scenes. Perhaps that’s because there’s often so little we can do about the presenting illnesses and injuries. Occasionally our sense of control is compromised by customers who are merely trying to influence their own outcomes. If we react to that with bad-patient/stern-medic demeanor, we’re marketing resentment instead of results.

Almost every good paramedic I know fits the above template. Some of us show that before becoming medics, others not until after, but our training encourages all three traits. Understanding the limitations of ego, patterns and control encourages us to be better listeners, more open-minded and less authoritarian.

Paging Dr. House…

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.