The "Why" List

I was recently running a patient assessment/clinical simulation for my paramedic class in preparation for their upcoming skills testing during finals week. It was a reenactment of the following particularly unusual call that I'd run a few years ago:

EMS is dispatched to a “possible fall” at a private residence. As the crew pulls up, they see a young man sitting on his porch in a T-shirt, even though it is a cool day and is drizzling. The patient is leaning up against a wrought iron fence that surrounds the porch. A six-foot stepladder is lying nearby in the grass.

As the story went, responding to his wife’s nagging about the overflowing gutters, when the rain let up, the man got out the stepladder to clean them. Rather than actually set the ladder up properly, however, he leaned it against the wrought iron. As he started to climb, the ladder moved and dropped him across the top rail of the fence, leaving a foot-long, one-inch-wide bruise across both upper abdominal quadrants.

The initial assessment found this young man complaining of belly pain, although he did not appear to be in acute distress. If anything, he seemed unusually relaxed. His airway was open, but his breathing was slow and shallow at a rate of 8. His pulse was fast and regular, producing a BP of 96/60. Breath sounds were clear, and he had almost nonexistent pinpoint pupils. His skin was pale and wet.

For this simulation, I was working with Lt./Paramedic John Payne from the Bremerton Fire Department. When it comes to role-playing, there are few who get into the patient role with as much enthusiasm and attention to detail as John. Thanks to his outstanding work, students experience a far more realistic simulation with greater learning potential.

There a number of unique elements about this call, and John shared his own assessment tool called the “why” list. Like many EMSers, John writes notes on the back of his glove, e.g., vitals, chief complaint, allergies, etc., but he also leaves a section for his “why” list, made up of any oddities or unusual elements of the call, which in turn serves as a reminder to find out why these anomalies are present and what, if anything, they mean.

For this call, John told the students there were four items that would make his “why” list:

1. Since it was lightly drizzling and the EMS team was wearing coats, why is this guy sitting up against a fence in the rain wearing a T-shirt?

2. Why would a person complaining of pain appear to be comfortable and quite at ease?

3. While it is a relatively dark, cloudy day, why are the patient’s pupils little more than dots?

4. Why is the patient only breathing 8 times a minute?

As a general rule, medicine has a certain logic: Most patients present with signs/symptoms that are common to their given condition. Of course, there are always a small percentage of outliers with atypical presentations, but when it’s all said and done, if it looks like a duck, walks like a duck and goes "quack, quack," think duck and you will be right seven days in a row.

That being said, it’s important to pick up on things that are out of the ordinary, or inconsistent with what you would normally expect. As John told my students, the why list on his glove was a permanent reminder to follow up in case he forgot about them as the call evolved.

The story behind the story relative to this case:

The wife admitted giving her husband a ration of grief about the water pouring down their picture window from the overflowing gutter. Both husband and wife were junkies who had recently scored some heroin and had just fired up. In his dreamlike state, laying an aluminum ladder at a 45-degree angle against an iron fence seemed like a good idea, until it kicked out and dropped him like a sack of sand over the top of the fence rail.

In this case, it’s getting the answers to the why questions that really flushes things out. The why behind the pinpoint pupils and slow, shallow breathing pointed toward narcotics, which pointed toward "Why is this guy sitting in the rain in a T-shirt?" Because he is indifferent, thanks to the heroin. "Why is he complaining of pain, but looking relaxed and pain free?" Yep, heroin is again the correct answer.

Without those answers, the entire patient care approach would have been to manage the suspected liver laceration, which was obviously the top priority. Recognizing that heroin abuse was intertwined gave much more insight into the patient presentation and impacted his care, as he was given titrated small doses of Narcan to keep his respiratory rate in the 10 to 12 range and help maintain good sats.

Whether you write it on your glove, a note pad or a piece of adhesive tape on your jump pants, a why list can be invaluable. Answering those whys can clearly improve your medicine, which means better patient care. What’s not to like about that?

Until next month…

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.