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Patient Care

Your Captain Speaking: Symptoms and Their Order Can Be COVID Clues

An excellent EMS physician, David Tan, MD, taught me this long ago: “Look at your patient, ask good questions, and listen. Ninety-five percent of the time, they will tell you exactly what is wrong.” Many of us have had patients who seemed to follow a standard script for problems like cardiac arrest or shortness of breath, pointing us right to their problem. Perhaps we can apply this technique to COVID-19. Even with the vaccine now available, we will be dealing with COVID-19 for some time.

A recent study finds the signs and symptoms of COVID-19 often appear in a specific order.1 Every illness leaves us clues to its presence, and sometimes, if we look closely, we can find a gap in its armor. With COVID-19, both the order in which signs and symptoms present and which shows up first are significant.

What are commonly the first signals for symptomatic patients? Follow along on the picture of Samantha from her head down. It’s that easy to remember.

Fever—This one is superimportant. A fever or temperature increase, according to the study, was the first to show up. This is a massive advantage for us to know both personally and for others! This knowledge means we need to check our own temperatures daily. We all have a baseline. For me, with the thermometer I use every day, it’s always in the 97ºF range. Few thermometers measure exactly and consistently, but that is my general baseline, so if I saw a temperature of 98.6ºF, for me it could be the start of symptoms.

If you are not checking your temperature daily, please start. Use the same probe each time and at a consistent time of day. If you’re going above your baseline, perhaps self-isolate and be aware for other symptoms. As a standard, the CDC says a fever is 100.4ºF (38ºC) or greater.

When you show up to work, do they perform temperature checks as you come in the door? A check using a scanning-type thermometer (temporal or tympanic) could be just the weapon for early identification. Other than a lack of equipment, is there a reason why EMS organizations could not do this when their employees report for work? My experience with forehead temperature scans at airports is that the readings vary too widely to be effective, but as an airline, we provided every pilot and flight attendant with a thermometer and directions.

How about your patients? Clearly, temperature is one of the vital signs we all learned in basic EMT class. In the past this was not one of the readings we normally took, other than a feel of the skin through our gloves for normal, warm, or hot. Touching your patient is still a good thing to do. More than temperature can be conveyed. As an EMS organization, do your ALS and BLS units have the equipment to take temperatures of every patient? If you don’t, take steps to make this happen.

It’s not just about taking the spot temperature of a patient; temperature also should inform your history-taking. Ask your patient if they take their temperature regularly. Do they have a thermometer? Do they record it? They’ll likely say no, but you might get lucky. No kidding, I have recorded my temperature daily since March 2020, when my airline asked our pilots to do this.

Can temperature tell you the difference between the flu and COVID-19? It appears so! With COVID-19, the study found the fever came first, then the dry cough and muscle aches. With the flu, the cough comes before the fever. That could be an important lead to distinguish flu from COVID-19 (though keep in mind some unfortunate patients might have both). Ask good questions and listen to your patient.

Cough and muscle aches—After the spike in fever, the next likely manifestation is a dry, unproductive cough and muscle aches. A favorite spot for the SARS-CoV-2 virus is in the nasal/oropharyngeal area. This is why the tests swabs needed to perform a nasal sampling go so far in. Many dismiss this stage as allergies and don’t appreciate the warning sign. It was months into the pandemic before the loss of taste and smell was recognized as a symptom. It makes so much sense now, given where the virus likes to reside.

Gastrointestinal distress—With the flu, gastrointestinal problems are not that common, and nausea and vomiting do not commonly occur with it. They do with COVID-19! Diarrhea is also a feature of COVID-19 but not common with the flu.

There is nothing normal with this pandemic. A whole variety of signs and symptoms have been reported. These include:

  • Fever and chills
  • Cough
  • Difficulty breathing
  • Fatigue
  • Muscle/body aches
  • Headache
  • Loss of taste or smell
  • Sore throat
  • Congestion, runny nose
  • Nausea, vomiting
  • Diarrhea

Knowing the signs and symptoms of COVID-19 is important to protecting yourself, your patients, and other medical providers. The order in which they appear, and which ones do or don’t, is revealing. They are easy to remember—just work top to bottom.


1, Citoner G. COVID-19 Symptoms Usually Show Up in This Order, Healthline, 2020 Aug 19;

Dick Blanchet (ret)., BS, MBA, worked as a paramedic for Abbott EMS in St. Louis, Mo., and Illinois for more than 22 years. He was also a captain with Atlas Air for 22 years and an Air Force pilot for 22 years.

Samantha Greene has been a paramedic, field training officer, and operations supervisor for Abbott EMS of Illinois for the last 10 years and a lieutenant for the Madison, Ill., Fire Department for the last five.


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