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