Get a Clue

Do you recall the first time you treated a real patient? Not a classmate or a manikin, but a genuine consumer of emergency medical services?

I have vivid memories of my first alarm as a paramedic student. It was a “sick” call and shouldn’t have been an ALS job, but my preceptor thought he was doing me a favor by letting me play with the Lifepak 10. Perhaps he anticipated the entertainment value. I didn’t disappoint him.

Consumed by the notion that This Is Not A Drill, repeat, This Is Not A Drill, I approached my morbidly obese patient. Dutifully and with inordinate precision I placed the electrodes at the periphery of his doughy torso. Following a clockwise click of the monitor’s power switch, the tiny screen came to life, revealing slightly irregular emerald undulations that were much less distinctive than I’d expected. There were lots of little bumps, some of which were bigger than the other little bumps. I decided it was atrial fibrillation—an arrhythmia that occurs when the heart’s upper chambers don’t pump effectively. There was a whole section in our textbook about that. Feeling like the offspring of Christopher Columbus and Marie Curie, I announced my interpretation to my preceptor and our driver (also a medic).

My mentors were very kind—at first. One of them explained that the cause of those “little bumps” wasn’t defective atria, but a flabby patient who jiggled when he moved. Then they reminded me that even if the guy had presented in a-fib, his pulse was in the 80s, so he wouldn’t need that IV I was preparing. Oh, and the irregularity I saw was probably the patient’s fight-or-flight response to my awkwardness.

Things got worse during our next case, when the medics asked me if I’d found more atrial fibrillation. Uh…no, heh heh, pretty funny. They didn’t stop tormenting me until our fourth or fifth call. It was as if Johnny and Roy were being played by Don Rickles and Andrew Dice Clay. No mas! I’d learned valuable lessons about field-vs.-textbook tracings, hasty diagnoses and superficial assessments.

Some would say, invoking a tiresome medical maxim, that I’d heard hoofbeats and thought zebras instead of horses. Wrong. At that point in my training, I’d never treated a “horse,” much less a “zebra.” My biggest mistake wasn’t misinterpreting an EKG, but rather seeing what I wanted to see. If there’s an adage that addresses my behavior, it’s “to look within and adjust the mechanism of perception.” Even if Beat Generation poet Gary Snyder was stoned when he wrote that, his words remind us that prehospital assessment can be skewed by a bias to find a treatable malady.

It’s easy to understand how incorrect or incomplete assessments can lead to errors of commission. So much of our training centers on oral, practical and written games of Name That Disease. Occasionally, students are reminded not to overtreat—the National Registry’s static cardiology station comes to mind—but often we’re drilled to match signs and symptoms to pathology rarely diagnosed in prehospital settings. Combine that with most EMS curricula’s very limited pharmacology and physiology, and doing harm becomes a distinct possibility.

I think errors of omission in the field are even more common. If we assume it’s horses whenever we hear hoofbeats, but we abbreviate interviews and exams that confirm or refute such conclusions, then our complacency could become the most threatening presenting problem.

A 2008 New Mexico study examined a fundamental aspect of prehospital assessment—determining whether patients need ambulances—and concluded EMS providers make wrong decisions approximately 10% of the time.1 I find that troubling because it’s much less risky to err on the side of caution when responding to emergencies. Are we overestimating our expertise, or just being complacent?