Best Practices: General Weakness

As an academic emergency physician and an EMS Medical Director who also functions as a field provider, I strive to deliver medical care that is based upon scientific evidence or at least what is considered "best practice" in the absence of clear-cut proof of efficacy. Contrastingly, over the years I have found many daily practices of out-of-hospital clinicians to be based largely on myth and/or non-evidence based medicine handed down from one generation to another in EMS. Furthermore, my observation has been that many prehospital providers allow peer interaction to drive such clinical decisions rather than proven and accepted concepts of emergency medicine and/or principles of health care law. In some cases, the care rendered to the public based upon "this is the way we do it" guidelines is inappropriate and in other cases it is downright dangerous. All jokes aside, there are numerous examples of hand-me-down out-of-hospital care tactics that constitute what may be titled EMS "worst practices." The goal of this column is to present what is often called "best practices" or a generally agreed upon method to approach a clinical condition.

Myth: General weakness is a low priority EMS dispatch which is most often a BLS call.

Best Practice: General weakness is a nonspecific term frequently used by both patients and EMS providers as a substitute to describe a variety of symptoms or physical complaints that do not obviously point to a particular organ system. Ironically, neither the patient nor the practitioner may have a proper understanding of what the term means. The vast majority of patients who complain or are perceived to complain of general weakness, especially the elderly and those with chronic medical conditions, require numerous diagnostic tests to determine the etiology of their ailment and, not infrequently, are admitted to the hospital to facilitate this process.

Joe Hayes III, NREMT-P, Deputy Chief for Administration and Chairman of our CQI Committee at Bucks County Rescue Squad in Bristol, Pennsylvania, is one of those experienced paramedics who spend the time between dispatches pondering the very myths we talk about in this column. Recently, he uncovered a trend among our paramedics to under treat patients who have general weakness listed as the primary impression or working diagnosis. An in-depth chart review revealed the following characteristics of these incidents: the patients were mostly elderly; most, if not all, had significant past medical histories that included cardiovascular and/or cerebrovascular disease, diabetes, hypertension and a variety of other organ-system illnesses; most patients took prescription medication; and heart rate or blood pressure were usually abnormal.

Joe also found a concerning trend that many of these patients were transported "BLS," i.e. no traditional advanced life support interventions (blood sugar determination, intravenous access, 12-lead ECG, etc.) were delivered. There are ethical, legal and financial repercussions from the so-called downgrade in care when a paramedic decides to hand-off responsibility for medical care to an EMT-Basic partner, but this is a complicated subject matter which will be featured in a future column. More concerning to us in the short term was the lack of documentation for these patients. While there was sufficient information in some charts for our committee to easily conclude that the crew should have recognized that the patient was a candidate for ALS skills, the majority of patients had less than satisfactory histories of present illness and accompanying documentation for what should have been considered a potentially ill patient.

We postulate that this lack of documentation is directly related to a failure to appreciate the spectrum of illness which masquerades in the EMS world as "general weakness." This lack of understanding of the medical implications is probably directly related to the all-too-common decision among uninformed EMS providers that general weakness is a BLS call, i.e. there is no prehospital care or evaluation necessary for this subset of patients. (Personally, I can't stand the antiquated terms ALS and BLS. These are all EMS calls, which mean that the patient requires evaluation and diagnosis by personnel trained in emergency medicine including EMS providers. Every patient seen by an ambulance crew that includes a paramedic deserves a paramedic-level history and physical exam and an opinion, hopefully evidence-based, about whether diagnostic and/or therapeutic interventions within the paramedic scope of practice are indicated.)

While there is extremely little prehospital research on this subject matter, we believe that general weakness is a serious complaint that merits not only paramedic-level evaluation and work-up, but also an in-depth search for occult critical illness. Here are five reasons or examples why general weakness may often be neglected by EMS providers. If you read about these five points carefully, we think you will come to the conclusion that Bucks County Rescue Squad is not much different than many other EMS agencies out there struggling to motivate its personnel and improve patient care in the harsh climate known as the real world.

ONE: The term weakness in most contexts is a symptom or patient complaint, but it is repeated by EMS providers and used as a primary impression or working diagnosis without a complete understanding of an accurate definition of the term.

Weakness implies altered physical strength. General implies nonspecific. Put these two concepts together and general weakness becomes a vague description of ten thousand patients we have all seen who are not having a stroke but just don't appear healthy. Rosen and Barkin's Five Minute Emergency Medicine Consult has this to say about the term. It is a lack of physical strength or energy and an inability to carry out a desired movement with normal force because of a reduction in strength of the muscles. It can also be a subjective sensation caused by neuromuscular disorders, systemic disorders and psychiatric illness.

Weakness is frequently a complaint or symptom espoused by a patient. The term should only be used as a physical finding when musculoskeletal and neurologic exams are performed which demonstrate decreased power in one or more muscles or muscle groups. Examination includes assessment of strength, changes in muscle tone, assessment of deep tendon reflexes, comparison of symmetry in muscle groups on opposite sides of the body and assessment of visual changes.

Placement of the word "general" in front of weakness implies that there is no decisive deficit in any part of the body. Rather, the individual feels a lack of strength. Commonly substituted symptoms by the patient are fatigue, dizziness, paresthesias, flu-like illness, etc.

While human beings all lose muscle mass beginning in the third to fourth decades of life, it is a myth that all elderly persons are weak or that weakness is an expected part of growing old. When patients at any age state that they do not perceive that their energy level is normal, this complaint must be taken at face value until illness is found or disavowed which, of course, requires an investigation of some sort.

TWO: The evaluation and interpretation of findings in patients with a chief complaint of general weakness is poorly taught in initial EMS education.

Res ipsa loquitur is a Latin phrase which translates to "the thing speaks for itself." Point two speaks for itself. EMS education is focused on eliciting and identifying select patient symptoms and discrete medical conditions for which a defined intervention can be performed to stabilize or correct the condition. The exact cause of weakness can be quite difficult to identify even in the emergency department. Thus, unless the patient presents with objective findings that prompt the EMS provider to react automatically, such as hypotension, there may be little that the average out-of-hospital clinician recognizes to prompt this response. Consequently, the patient with general weakness is not usually a situation in which the thing speaks for itself.

However, the differential diagnosis of illnesses which include diffuse muscle weakness is significant. Although many of these conditions cannot be adequately evaluated in the out-of-hospital setting if one's goal is to reach a conclusion, the group can be considered as a whole to mandate the standard "ALS work-up" of intravenous line, blood sugar check, cardiac monitoring and, increasingly, 12-lead ECG. In fact, the Five Minute Emergency Medicine Consult, which is designed to be used as a quick reference guide, lists 27 medical conditions and/or diseases in the differential for weakness. This far from complete list includes sepsis, myocardial ischemia, dehydration, endocrine disorders, poisoning, lupus, occult malignancy, botulism, neurologic disorders and many more. Thus, blood glucose monitoring for hypo or hyperglycemia, administration of prehospital stroke screens and acquisition of 12 lead EKG to rule out ACS are clearly indicated as soon as they can be properly performed.

A modified tilt test can also be performed to detect potential volume deficit. This can be done in the field quickly by hooking the patient up to the monitor, and then having them sit or stand. A positive tilt test is defined as an increase of 20 beats per minute within one minute from laying to standing. If the patient shows any clinical symptoms such as dizziness, increased weakness etc. which precludes them from standing for one minute, this should be considered tentatively positive regardless of the pulse rate increase or how long the patient has been able to stand.

It is much easier to teach basic concepts of organ-system illness and symptom identification rather than specific diagnoses, which is why initial EMS education including the national standard paramedic curricula is designed this way. It is also easier to train EMS providers to follow specific protocols rather than to think through the problem. However, the standard EMS education philosophy requires that the EMS provider work backwards in many instances to identify the problem prior to determining which medical care standards to implement.

Additionally, since general weakness is not considered to be a disease and the symptom can represent a variety of illnesses, there are few EMS systems which have a specific protocol to cover this entity. This phenomenon leads to two further problems. First, EMS providers frequently equate lack of protocols with unimportant medical issues. Second, continuing medical education in EMS is often targeted towards high profile or well-defined medical conditions for which there is either medical evidence that out-of-hospital care makes a difference in outcome or there are accepted principles of management which can be easily taught. General weakness does not fit either of these categories so it comes as no surprise that it is not a hot topic on the lecture circuit.

THREE: The tendency to minimize the complaint of general weakness begins at dispatch since most medical priority dispatch templates place general weakness in the BLS category. Nonemergent equates with "no ambulance required" in the minds of many EMS providers and the patients may not be afforded the close scrutiny that they deserve.

It's not uncommon for paramedics to be prejudiced by the scant information available from the initial dispatch or diagnosis over the phone. General weakness is a chief complaint that can easily lead a paramedic down the slippery slope of minimizing illness, and minimizing illness is one of the surefire ways to make mistakes in emergency medicine. The Clawson package makes a reasonable attempt to place those patients who call 911 with nonspecific complaints into an ALS category if they have a cardiac history, although it is well known that one of the weaknesses of the best medically directed dispatch software in the world (as with any emergency medical dispatch software) is that it can miss patients with sepsis. EMS providers must constantly be reminded to evaluate each patient objectively and to avoid infusing bias ("I've been here three times and the patient is never sick") into their differential diagnosis.

FOUR: Many patients who complain of general weakness are elderly. Other times a third party has made the 911 call. Neither group may be able to accurately describe symptoms of the patient other than their perception that the patient is weak.

The patient population that complains of general weakness is one that is prone to difficulty describing their symptoms by virtue of the fact that these patients are typically elderly, frail, have limited education or do not understand how to effectively communicate their condition. Thus, they cannot be relied on to be accurate assessors of their own condition. The most we can hope for is their recognition that something may be wrong. Again, we find ourselves coming perilously close to the slippery slope known as "missing the boat" due to under treatment if EMS providers mistake a lack of patient complaints for lack of illness. After all, if there were anything serious going on, wouldn't the patient mention it? How serious could it be if the patient is conscious and oriented and in no apparent distress upon our arrival? These questions may sound facetious, but, in fact, they are probably uttered several times per hour around the country when discussing patients with weakness who do not overtly present with life-threatening signs and symptoms.

FIVE: Paramedics often fail to think outside the drug box, as Joe Hayes puts it. If there is no drug to cure the symptom or complaint, the medical condition is minimized.

The end result of the evaluation of a patient with general weakness may be that they do not require any parenteral medications. However, this is not a justification for failure to initiate ALS diagnostics or therapeutics. Again, we face one of the weaknesses of EMS education which is that there is relatively little time spent teaching paramedics about medical conditions or situations for which it is not perceived that field care makes a difference in patient survival. While it is understandable that there is a finite amount of time to teach a large block of information, I truly believe that there is not enough emphasis placed upon the conservative approach to patient work-ups, i.e. that patients who are potentially ill should be given the benefit of the doubt which includes ALS assessment and treatment whenever possible. Finally, even if there is no protocol in your EMS system that addresses this subset of patients, I encourage you to follow the National Standard Curriculum and evaluate these patients completely. Often, one or more diagnoses will eventually be found. If they are not, the EMS efforts are still justified by the fact that as thorough a search as possible was initiated to get to the bottom of the patient's complaint. After all, this is exactly what will be done in the emergency department.

If you know of an EMS practice which is questionable, hotly debated amongst your fellow providers or downright dangerous, e-mail me at jaslowd@einstein.edu with your thoughts and what you think is the standard of care and we will discuss it in this open forum. Hopefully, we can improve care through education.

Dr. Jaslow is a board certified emergency medicine physician fellowship-trained in EMS and Disaster Medicine. He is the Chief of the Division of EMS, Operational Public Health and Disaster MEdicine and Co-Medical Director of the Center for Special Operations Training within the Department of Emergency Medicine at the Albert Einstein Medical Center in Philadelphia. Dr. Jaslow is also the Medical Director and Lead Physician for the Pennsylvania Task Force-1 Urban Search and Rescue Team and an active firefighter/paramedic and EMS Medical Director in suburban Philadelphia. He currently serves as the Medical Editorial Consultant for EMS Magazine and as a member of the editorial board for Advanced Rescue Technology. He can be reached at jaslowd@einstein.edu.

Joe Hayes, NREMT-P, is the Deputy Chief for Administration at Bucks County Rescue Squad in Bristol Township, Pennsylvania. Their claim to fame is that they were the EMS agency portrayed in the M. Night Shyamalan film Signs which starred Mel Gibson. Joe can trace his career in EMS back more than 25 years, but he still gets excited about improving quality and he still gets frustrated when he misses an intravenous line. Joe is also an amateur writer who always wanted to have his name associated with an EMS topic. Although Dr. Jaslow has modified some of the artistic license Joe used in his espousal on general weakness and EMS, all of the concepts above are his own. Joe would appreciate any feedback at jhayes763@yahoo.com.