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.