Tuesday, March 29, 2011

Pay attention...it's in the little details!



I don’t normally cite recent calls in my blogs, but, well, this one’s important. If you think you were with me, you weren’t. If you think you were the patient, you weren’t. If you think you know when this call took place, you don’t. So now that the disclaimer is out of the way…

A while back my unit was dispatched to a local assisted living facility for an ‘abdominal pain’, downgraded to an ‘alpha’ response (1A1) just after dispatch. Now, typically, when that comes over the MDT and the announcement comes from dispatch, you can sometimes hear the groans in the ambulance. Just sayin’.

So the patient presents as an elderly person complaining of lower abdominal pain. The patient is walking the halls of the facility because ‘it hurts to sit down’. The pain has been going on since early afternoon (it is now early evening, five hours after onset. A quick assessment showed a conscious and alert patient, oriented to person, place, time, and event. Vital signs were unremarkable (BP 132/84, HR 74, RR16, SPO2 99% room air, FSBG 126, ECG sinus rhythm). Skin was warm and dry with good color. There was a little lower abdominal distension and tenderness, and no history of nausea, vomiting, and diarrhea.

We determined hospital destination, placed the patient on the stretcher, gathered our paperwork, and began our 15-20 minute transport. During the transport, my preceptee (I’ll call him Jeffro) initiated an IV and got an ECG and 12-lead.

Now, I know a lot of paramedics that right about now would have sat down in the ‘captain seat’ and started on their report. Jeffro couldn’t because I was sitting there. Besides, I push my preceptees to maintain a rapport with the patient and since this one was C&A&O, it was easy to do.

Part of the way during transport Jeffro noticed that the patient’s speech started slurring. He went ahead and performed a stroke screen and sure enough determined right sided weakness, right facial droop, and the already noted slurring. We notified the ED of the original complaint and our latest findings, along with out less than five minute ETA. After a quick exam backed up our en-route findings, a ‘Code Stroke’ was called.

So how did it turn out? Turns out the patient had a prior history of CVA (the facility’s paperwork conveniently neglected to tell us that, as did the staff) and was subject to transient episodes of the slurred speech and right sided weakness two or three times a day. This was confirmed by the family and the patient’s primary care physician (of course, the facility did not tell us about that, either).

Anyway, my point is that this patient’s condition changed in a way unrelated to the original complaint. And until the information was obtained a while later, there was no way we could have known that this was not in fact a stroke.

So what would have happened had my preceptee/partner taken the route of least resistance and plopped his a** in the captain chair and typed away? I know of at least one instance in my system where this happened, except the patient had ARRESTED and the medic did not know it. That is, not until they got to the ED and saw that sort of ‘dead look’ on the patient’s face.

I know, it is the path of least resistance. And I know the supervisors are always wanting us to clear the hospital in a hurry (some services and systems around these parts have a stopwatch running as soon as they get to the ED). And sometimes it is hard to carry on a conversation with someone in their 70s or 80s when you are in your 20s. But that is one of those things that is a part of your job. And I bet they did not tell you that in EMT school, did they?

Pay attention to little details. Just because the call started out as an abdominal pain doesn’t mean it is going to stay that way. Just like it is important to get more than one 12-lead, complete more than one stroke screen, and keep reassessing vital signs.

Because things change.

And if you don’t want to be the subject of blog fodder (merciless they are sometimes) or even the six o’clock news, you need to be on top of those changes.