EMS Recon

      In the early morning hours, you are dispatched for an "asthmatic" on North 10th Street. You arrive without incident, access the apartment without trouble and find a 74-year-old female in obvious respiratory distress. She's clutching an inhaler and sitting in front of a box fan turned on high. She can verbalize in partial sentences, and you note an audible expiratory wheeze.

   Reaching her first, you throw down your bag and start to assemble a nebulizer to address the obvious cause of her distress before proceeding further. From the apartment entrance, your partner tells you to hold off; she's not having an asthma attack, but is "in failure" and needs another course of treatment. Sure enough, when you evaluate her further, she has rales beneath the wheezing, is hypertensive, tachycardic and is actually in CHF. A regime of nitrates, diuretics and CPAP later, you arrive at the local ED with a patient who is resting comfortably, her symptoms markedly improved. So the question remains...how could your partner possibly have known that from the doorway of the apartment?

INTRODUCTION

   We have all worked with Carnac the Magnificent--the shaman who seems able to diagnose from a distance, predict an outcome with uncanny accuracy and determine the level of seriousness based solely on dispatch information. Are these prehospital prognosticators born, or are they made? Is it truly a measure of clairvoyance, or are they just relying on their training, experience and background to come up with an educated guess?

   Without casting aspersions on anyone's psychic abilities, in most cases, it's the latter. A comprehensive prehospital clinician is often little more than a good detective with some medical training thrown in for good measure. The ability to take in a large amount of diverse information, decipher it and organize it into plausible outcomes for which a response can be developed is a unique and enviable skill. Some people seem to have a knack for it; the rest of us have to slog through oversights and (often unpleasant) surprises before we begin to catch on. In days gone by, soothsayers called these omens and portents, but since we don't work in areas frequented by ravens or owls, and human sacrifice is frowned upon, we can't rely on bird signs or reading entrails. That leaves our power of observation, which fortunately is something we can improve upon with practice.

ASSESSMENT

   There are many different approaches to effective patient care, but none of them can begin without an assessment. Just because the skill is called "patient assessment" does not mean it needs to wait until you are in front of the patient. There are observations you can make well beforehand that can increase your efficacy as a clinician and assist you in providing the most comprehensive care possible. After all, the patient is actually nothing more than the sum total of the events that led up to your interaction. This includes their environment, socioeconomic status, genetics, personal practices, culture and a dozen other things that alone are incidental, but, when meshed together, result in illness or injury requiring your intervention. There's a reason it's called "HISTORY of present illness." It's not always a singular event, but rather a story that you've now entered and are playing a role in. How the chapter (or story) ends will depend on the actions you take, based on the information available and your investigation.

   Remember that no matter how seasoned you think you are, or how good a detective you believe yourself to be, assumptions and generalizations are never as good as rules. Keep them as guidelines, but be willing to veer off into the unknown and be ambushed by the unexpected. Assumptions can lead to potentially lethal errors. Be ready to roll with that left hook that can come out of nowhere and make your patient worse.

PRIOR TO ARRIVAL: KNOW YOUR DEMOGRAPHICS

   From the moment of dispatch, you are already formulating an opinion. Will it be critical, or a routine transport to a hospital? Will it be high-profile? Is trauma involved, and will you actually get to put your training to use? Have you been to that same address a dozen times in the last six months for the same complaint? Knowing the layout and demographics of your response areas goes a long way.

   Economically depressed areas feel the proverbial crunches in areas you might not always expect. Yes, there is a higher prevalence of violent crime (of all types), but even though they may be the most dramatic, the reality is that they represent the minority of calls you will respond to in these areas. One of the bigger hurdles is a lack of adequate primary healthcare coupled with an overall unhealthy environment. Poor diet, exposure to pollutants, minimal climate control and economic restrictions all can contribute to a chronic exacerbation of illness and disease processes. Misunderstanding medical instruction and lack of education lead to misjudgments and poor self-treatment. You should expect that people in these areas will just be sicker, will have a higher incidence of acute presentation and may be non-compliant for reasons outside their control. Expect the possibility that your call will be compounded by CDS or some type of trauma.

   Are you traveling into an area where race and culture may play a role? Emigrant populations tend to live in geographical clusters, especially in and around cities. Recent arrivals and visitors may involve exposures to unfamiliar infectious diseases or ailments. What might have been the flu could be malaria, or worse. If there is a language barrier, are you prepared to work around it? Will there be cultural differences that affect or impede your assessment? One good example is the monthlong religious observance known as Ramadan, when observant Muslims fast from sunrise to sunset. Very strict observers even eschew IV fluids during this period, citing that no intake is allowed. How will you address a call for a syncopal episode secondary to fasting? Is the demographic unique? Do you know what options and resources you have? Do you have access to a translator should you need one? There are a few multilingual handbooks available with key medical phrases that can be quite helpful, but for those to be used successfully, the person you are using it with must be able to read. If you respond frequently to a specific population, take time to learn a few key words or phrases in their language, such as "pain, medicine, breathe." Paying attention to these details can and will make future calls into the same area less stressful and frustrating for you, and ultimately for your patient as well.

   Have a working knowledge of the unique facilities in your response areas. What is just a numeric address could turn out to be anything from a low-security prison or labyrinth in the form of garden apartments to a biological agent research facility. Will any of those have unique needs, or should you take additional steps or precautions in your response?

   Being savvy about your response area can help fine-tune your expectations and give you an edge by preparing you in advance for something that's unusual and specific to where you're going.

   And we aren't even there yet...

ARRIVAL ON SCENE

   Safety is always paramount. You cannot help anyone if you or your partner are incapacitated. It may seem a simple thing to put the truck in park, inform the dispatcher that you're on scene and proceed into the location with your equipment. But take a minute to consider all the factors that go into that basic sequence.

   Assuming you arrived safely, where do you park? Are other apparatus involved blocking your access? Will stopping where you are block them in if they have to leave? Are other units/agencies responding that haven't arrived yet? This is especially important if you anticipate the need for rescue; rescue apparatus often have space and distance limitations. Are you using the most efficient access point to get to the patient, or did you park on the wrong side of the courtyard? Walking may seem like a good idea at the time, until you have to extricate a couple hundred kilograms of very sick patient or end up needing additional equipment to effectively treat your patient before moving him.

   What is the general layout of the location? Are the access and egress routes uncomplicated? Remember that hazards don't always have to be obvious. Is it an older house or building where "structural integrity" is more of a phrase than a reality? Lighting, exit points and angle of the stairs are things that most of us just process as we walk through a location. The rest have to work a little at it, or don't recognize them as necessary factors until they have to get out fast. Distance (both vertical and horizontal) from your vehicle always comes into play. The ambulance is our home base, our center of operations, our tiny controlled environment. When we travel away from it, there's that invisible umbilical cord—that lifeline back to our equipment in case we need it. When you are called to a scene where you have to travel any distance, imagine how you'd manage if that cord were cut. Do you have everything you need? If you think you might need something extra (suction, linen), bring it. Don't roll the dice. You're gambling with a life that doesn't belong to you. If all of us were that lucky, we'd have cashed out long ago and be enjoying a long vacation of our choice somewhere else.

   Yes, we'll get to the actual patient eventually...

ON THE SCENE

   The general living conditions can tell you a lot about the residents (keep in mind that your patient may just be visiting). Is the general environment organized or cluttered, clean or dirty? A well-kept house usually indicates good self-care, but that does not mean the patient is medication-compliant or knowledgeable about his or her medical condition. Meanwhile, "dirty" is often subjective. There are levels of neglect from acceptable and expected to horrific and incapable of sustaining their own ecosystems. Poor hygiene may be deliberate or a personal practice, but it can also indicate neglect or a simple inability to care for one's self any longer. If your response has taken you to a more upscale area of town, be wary. Affluent or very well-maintained locations can lead you to a false sense of security regarding the validity and accuracy of the care or information being provided. Remember, don't judge, just process.

   Look for evidence of medical history. Don't just rely on your interview for it. For some inexplicable reason, asking "Do you have any medical problems?" invites a range of answers, rather than one accurate one. Look around, taking a moment when possible to scan the bathroom and kitchen. Nightstands and medicine cabinets are where people often store their current and old prescriptions. Refrigerators can yield anything from insulin to "Vial of Life" paperwork including the patient's personal and medical information. They can also give you an indication of the person's ability to take care of him/herself. An empty refrigerator could be symptomatic of neglect, or indicate someone who could benefit from a referral to social services. Look for nebulizers in living areas, discarded lancets or sharps disposal containers. You may even find old hospital bands lying around, or still on the patient. One important trick is to keep up with current prescription medications. This is invaluable in deciphering a person's medical history, especially when they cannot tell you themselves. You don't need to know every drug's chemical structure, but you should learn what they're commonly prescribed for. If you don't recognize a medication, look it up, find a field guide, ask the patient what he takes it for or inquire about it at the hospital.

   In addition to medications, look for abuses and environmental factors. Smokers tend to be obvious, unless you're a smoker yourself and don't notice the odor. Look for evidence of alcohol, CDS use, or even what food happens to be out. Poor diet contributes to problems not only with diabetics but with other conditions as well. We don't see dialysis patients ON Thanksgiving—we see them two days after they've overindulged. Don't disregard supplements. Many commonly touted dietary supplements can interfere with a patient, depending on their medications and history. Ginseng, gingko biloba, St. John's wort and aspirin can all cause thinning of the blood and lead to serious problems. Energy drinks can trigger tachycardia and complicate patients with hypertension and cardiac history. OTC inhalers are potentially lethal in the hands of an elderly patient with the right medical history.

   If history has taught us one thing, it is that one of the most effective ways to win a battle is to divide and conquer. When it will not interfere with patient care, have one person interview the family/spouse/bystanders, preferably out of earshot of the patient. The patient will just not always tell you everything, and the tidbits offered by an additional interview can radically change the seriousness of what you may be dealing with. It will also help with the primary patient assessment, allowing the patient to focus on you and reducing outside interference. Take note of the dynamic: Is the patient well cared for, with a good support network? Are there undercurrents of anger, frustration or exhaustion? Is there something not being shared? Refusing treatment or transport isn't necessarily because the patient is trying to be difficult or doesn't want to cooperate. There may be underlying factors indicating domestic problems, neglect or need for additional intervention by other agencies.

   Above all, listening is crucial in a good investigation. This is especially true for patients with a long or complex medical history. In most cases, the patient knows himself better than anyone, with the family a close second. What's different or new? What was going on earlier in the day? Ask about their history and medications above and beyond the immediate needs, when necessary. Especially in the case of a complex medical history, caregivers are often all too willing to vent to a willing ear, and you will walk away with pieces of pertinent information you can file for later use (or look up yourself when you have time).

AT THE HOSPITAL

   Wait! Aren't we going to do an actual patient assessment? Aren't we here to solve the mystery and actually treat someone? Well of course we are, but the point here is not the actual patient--it's everything that influences that sliver of time where you've been called to intervene. If you want to treat the actual patient, wait for an article on patient assessment.

   Transfer of care is like a game of "Telephone," where important points often get lost. Make sure the receiving facility gets the correct information and staff don't have any questions, even if you have to be persistent to get across the things you feel need to be reinforced. EDs are busy places, and the staff may only listen to the high points. Your report may be the only opportunity to bring your patient's condition to someone's attention, so don't waste it. Make sure your documentation reflects everything you've discovered and what you've done. Even a small point you think is not important at the time can become the factor an inquiry hinges on later, and your report may be the only thing that corroborates your actions and discoveries down the road. If your investigation leads you to believe you have a case of abuse or neglect, be sure to report it. Sometimes, you may be the only advocate for a patient during a critical period, and the information you've collected may make you the best voice for him when he has none.

   Get your answers anywhere you can. If you have unresolved questions, find an experienced RN or ED doctor and ask. Most of them will appreciate your efforts to expand your knowledge base, or will at least point you toward valuable resources where you can look them up yourself. It will also increase your credibility for taking a proactive role in your overall patient care.

REVISITING THE PATIENT ON NORTH 10TH ST.

   You are dispatched in the wee hours of the morning for an "asthmatic."

• Secure high-rise building, senior citizen housing.
• Even though the complaint is "asthma," statistically, the early morning hours are known for cardiac events, CHF, etc.

• Tenth floor, so be sure to bring adequate equipment and carrying device. Consider suction. You arrive without incident.

• Your partner mentions he's been there before, and after hours the best access is via the rear parking lot. This saves you from having to walk around the building.

• You find a 74-year-old female in obvious respiratory distress. She's clutching an inhaler and is sitting in front of a box fan turned on high. She can verbalize in partial sentences, and you note an audible expiratory wheeze.

• The apartment is tidy; she appears to live alone.
• The inhaler in her hand is an OTC brand; the box is on the table.
• Prescriptions on kitchen table are an anti-hypertensive and oral diabetic agent. There's no evidence of a prescription inhaler or nebulizer anywhere around her.
• The patient indicates a sudden onset that woke her from sleep.
• She's sitting in front of a fan. Patients in pulmonary edema typically feel air hunger very quickly and will take what they assume are logical steps toward getting more air. You will often find them in front of a blowing fan, perched in an open window or tripoding on their front porch. While this could certainly be in response to other respiratory ailments, the immediate suspicion is rales until proven otherwise.

   Thus, we suspect the patient of something other than asthma and can treat accordingly. Correct early intervention is her best opportunity for a good outcome.

CONCLUSION

   While this is a rudimentary example, it demonstrates how much information you can glean in a short amount of time with simple observation. Notice there wasn't a single vital sign taken or hands-on patient care factored in at this point. Yet, as a result of your observations you can be preparing an optimal treatment plan before even touching the patient. Instead of focusing all of your assessment skills solely on direct patient care, begin your observations from the moment you're brought into the story and see where the evidence takes you.

   Tracey A. Loscar, NREMT-P, is a training supervisor at University Hospital EMS in Newark, NJ. A practicing paramedic for 19 years (and counting), she is very active in multiple facets of prehospital education. At any given time she can be found in ambulances or classrooms throughout northern New Jersey, or you can reach her via e-mail at taloscar@gmail.com.