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.

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.

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