Quality Corner: Do Your Due Diligence

In EMS, you don’t win points by guessing right. You win points by maintaining a high index of suspicion, finding problems that aren’t so obvious and always erring on the side of caution. That’s No. 6 of the 10 Commandments of Quality EMS

A term that most accurately describes this concept is due diligence. Due diligence is the expectation that every EMS professional will be attentive and conscientious in assessing their patient. This includes the critically important component of giving credence to the patient’s chief complaint or concern. 

As EMS professionals we are the front line of emergency medicine in the community. We are paid primarily for our due diligence. We are not paid to be eternal optimists or assume nothing is wrong.

Identifying critical and potentially critical patients isn’t always easy. A nonspecific complaint such as generalized weakness may be the only presenting symptom for a patient having a serious event like an MI. An event such as syncope or near-syncope that occurred prior to EMS arrival in a patient who now appears perfectly fine, with picture-perfect vital signs, may be the only warning sign of impending cardiovascular collapse. Blow it off because you didn’t see it yourself, and you run the risk of missing the only opportunity to help one of those rare patients who needs it most. 

Failure to Communicate

Sometimes it may be difficult for a patient to express exactly what’s wrong. Some complaints are easy to describe, like pain or a cough. Other symptoms never experienced by the patient before may be more difficult to articulate, such as weakness, light-headedness or general malaise. The most you might get out of some of these patients is, “I just don’t feel right.” While vague and not always indicative of something life-threatening, such nonspecific complaints should be cues to assess further.

Communicating what’s wrong may also be difficult if the patient’s cognition is affected, either chronically, by something like Alzheimer’s, or acutely, as a result of whatever is presently happening. That can include hypoglycemia, hypoxia or derangement of any of a long list of body chemistry, much of which we are not familiar with and don’t measure in EMS (e.g., serotonin, thiamine, ammonia levels). While we all may be able to fill books with what we know, we could fill libraries with what we don’t.

Disease is a dynamic process. Patients can crash hard and fast—they’re usually pretty easy to pick out. They can crash slowly and gradually—they’re also not too difficult to identify. Then there’s the patient who alternates between stable and unstable as the body fights to maintain homeostasis. Depending on how sick this patient is, one episode of decompensation may be the only warning sign of looming catastrophe we get. Ignore it at your patient’s peril.

Denial Is a Killer

No one wants to believe they could be in the process of a fatal event. People frequently try to joke away their symptoms of serious illness or explain them with more benign possibilities. The most common example of this is for a patient to blame their chest pain, shortness of breath and feeling of impending doom on the last thing they ate. I wish I had a dollar for every critical cardiac patient I’ve had who attributed the massive MI they were having to the hot dog they just consumed.

Once the patient or their family or friend calls 9-1-1, they did their job. The burden then falls to us. We can never afford to buy in to the patient’s denial. As much as we might think the patient’s indigestion is nothing more than indigestion, our job is to play the devil’s advocate. Cemeteries are filled with patients who died of what they thought was indigestion but turned out to be an MI.

The fact that something was concerning enough for someone to call 9-1-1 must always be taken seriously. We should therefore start with the proposition that all our patients are potentially critical, and scale back cautiously from critical to noncritical to stable as guided by the facts of our detailed assessment, keeping in mind the limitations of our assessment capabilities. If we’re diligent, we can identify critical and potentially critical patients, but in most cases we cannot definitively rule out that possibility. If we could, it wouldn’t take a team of physicians, a battery of diagnostics and days, weeks or months to make a diagnosis. Never make the mistake of assuming you’re smarter than you are.

As Seen on TV?

Most of us chose EMS as our career with the high drama of saving lives in mind. Then we finished EMT school, started the job and realized those visions of glory were the exception rather than the rule, and the job is not always as glamorous as it looks on television. Most of us in EMS are mature enough to accept this reality and commit ourselves to do the best we can for all our patients while we wait for that call of a career. Some EMS providers, however, never seem to get over their dreams of glory. They constantly downgrade patient care, blow off any patient events not seen for themselves, and never seem able to accept the possibility that any patient could be seriously ill unless they explode in front of them. And because the majority of our patients are not teetering on the edge of death, 95% of the time they get away with it. But luck is fleeting. Therefore, the best approach to assessing our patients remains due diligence.

Joe Hayes, NREMT-P, is deputy chief of the Bucks County Rescue Squad in Bristol, PA, and a staff medic at Central Bucks Ambulance in Doylestown. He is the quality improvement coordinator for both of these midsize third-service agencies in northeastern Pennsylvania. He has 30 years’ experience in EMS. Contact Joe at jhayes763@yahoo.com.