The EMS Detective

Using critical thinking with a prioritization, situation and analysis formula can help you avoid serious errors in judgment when assessing and treating patients. EMS providers must act as detectives, especially when basing judgment on information obtained from other personnel or bystanders at a scene. That information may be useful, but you must do your own assessments and evaluations if you want to do your job well.

First, prioritize. While doing your ABCs, think about the situation in general. Next, collect data: vital signs, history of present illness and past medical history, then analyze the data and make connections. Finally, take action, if you haven't already, and gather more data or reassess, reanalyze and evaluate the outcome of the actions already taken while en route to the ED. The following case review illustrates all these points.

Case Review

A skilled nursing facility calls dispatch to request an ambulance for a 61-year-old woman complaining of severe knee pain. Upon your arrival at the facility, the nurse sitting behind the desk nonchalantly informs you that the patient had a portable/mobile x-ray of her right knee and it was negative. No fracture, no trauma was involved, and she seems sorry about having to call. She continues to chat with your partner from behind the desk, as if nothing is wrong.

Upon entering the room, you find the patient supine in bed, alert and oriented, skin warm and dry, complaining of severe pain in her right knee. As she tells you what's wrong, you can see there is edema just above her knee and deformity at the patellar area. You check vital signs, which are: BP 140/80, HR 68, respirations 20 and pulse ox on room air is 92%. After you administer oxygen, her pulse ox improves to 99%. Pedal pulses are present but unequal, with the right bounding and the left barely palpable. She says she has no other symptoms and no trauma has occurred. When questioned further, she tells you she may have injured herself three days earlier when getting in and out of her daughter's car ":about three times." You can see from the paperwork that she has a history of recent tumor surgery and osteoporosis, and she tells you she had carpal tunnel surgery in the past. She is obese, with no cardiac history. The monitor shows an irregular rhythm from 68 to 108, and is in bigeminy. Having already placed her on oxygen, you decide to transport with full leg immobilization, request med control for an order of morphine for pain (which was 10 on a 1--10 pain scale) and hope the ED takes your patient's obvious fracture and what you suspect is a pulmonary embolus a little more seriously than the nurse back at the nursing home. Even though the patient had no chest pain and her lung sounds were clear, these were the diagnoses upon her admission to the hospital.

Let's analyze what might have happened in this case. If you are going to be a good detective, you must be continually thinking and analyzing. Use all of the information at your disposal. Don't take things at face value, and don't stop thinking just because the nurse or doc is unimpressed. Don't automatically think, "The x-ray showed no fracture, so there must not be one," or "Maybe there's something to this knee pain, but there can't be anything else wrong." In fact, there can be more than one thing at a time going on, and many times there will be. Just because the patient is not complaining of chest pain does not necessarily mean no cardiac problem exists. She says she is only slightly short of breath and she is sure it's due to the pain, but is it? Assess the patient. Does she have shallow, irregular respirations, or is she breathing normally? Does her story fit what you see? Use other people's clues in your analysis and decision-making if they work, but don't automatically use those clues as the basis for what you are going to do when you treat your patients.