“Crocodiles are easy. They try to kill and eat you. People are harder. Sometimes they pretend to be your friend first.”
Not long ago I went to a house for a lift-assist call. The crew and I got the woman off the floor and safely onto her couch for an assessment.
Her initial stroke exam was negative. During the assessment she listed over to the right a little and made no attempt to catch herself. She had no complaint, her speech was clear, and she remained engaged in the conversation, as if her position never even occurred to her. I gently straightened her back up and kept talking to her. As soon as I let go, she tipped over to the right again.
I excused myself, stepped out of the room, and called a stroke alert. About halfway through the transport, she developed a pronounced droop, and her right side became flaccid. Later, during the debriefing, the (new) medic on the crew mentioned she’d “never seen a stroke in progress” before. We focused on the importance of obtaining baselines for mentation, motor, and speech and what the “listing” on the couch suggested.
There is a level of education that comes only with patient contact. Books cannot give it depth, lectures can only describe it, and even YouTube can only provide you with a two-dimensional experience. Simulation—and I mean good simulation—comes a tiny bit closer, but even then it will not physically immerse you the way firsthand experience does.
I can describe for you, in graphic, literary-quality detail, what burning human flesh or a lower GI bleed smells like…but you will never really appreciate that level of awful until you’ve had that sensory experience yourself. On reading that I’m certain many of you felt the ghosts of that sickly sweet and/or coppery fecal tang tickle the backs of your throats. For the rest of you, give it time—it will happen.
Like the late, great Crocodile Hunter, Steve Irwin, you need to be out there, in the swamp, with all your five senses, experiencing the human condition in humans’ natural habitat. It cannot be replaced. For the record, the ambulance doesn’t count as their habitat—it’s yours.
Go into every call with a level of scientific curiosity that goes beyond medicine and into the human. You know your protocols, but do you know what they sound like when they work? Do you know what it smells like when they don’t? You could be the best-read medic out there, and your patient is going to hit you with a curveball. On the plus side, it usually happens once, because once you’ve seen it/heard it/smelled it/touched it (ew), you’re likely to recognize it next time.
What follows is a compilation of odd signs and symptoms either from my experience or submitted to me by others. It is by no means a complete list, and while some are recognizable from textbooks, others are subtle or rare enough to bear mentioning. To steal a line from comedian Bill Engvall, “Here’s your sign.”
“If they are hanging out of their window or on their porch in their underwear, they officially cannot breathe.”
“Standing in front of an open freezer or directly in front of a box fan, they are using ghetto CPAP.”
“If they’re standing up, holding on to a dresser or table for dear life, do not move them until you have a handle on their breathing. Climb them like a jungle gym if you have to, but start your treatment while they are literally hanging on.”
“If they keep saying they can’t breathe but are bent over, be careful. Don’t write it off. Suspect PE.”
“If they tip over and that’s not their baseline, revisit your stroke scale or just toss it and find an onset time—there’s something neuro going on.”
“When the patient lets out a crescendo screech, randomly or in response to stimulus, suspect significant TBI.”
“Plucking at their clothes, straps, or ECG wires, suspect frontal lobe involvement, delirium. It’s even got a name: floccillation—picking at straws.”
“Neonates who keep making a fist with one hand are likely seizing.”
“If they make it a point to say they’re thirsty, they’re more than a quart low.”
“Every patient I’ve had who wanted to pull themselves up, reach the top rails, and pull themselves off the stretcher was having a dissecting AAA.”
“Pedestrian struck: one shoe, trauma two. Two shoes, trauma one.”
“The STEMI hue: The book calls it ashen, but it’s more of a cross between ‘get-me-to-a-PCI-center-stat’ white and ‘my-myocardium-is-choking-to-death’ blue.”
“Beads of sweat on the upper lip.”
“If they say, ‘Tell my [husband/wife/significant other] I love them,’ danger! They mean to die on you.”
These are subjective offerings, not science. By now you are probably coming up with your own. Feel free to send them to me for future, refined versions of this list.
Go on safari, people-watch, observe, and take note of what you’re physically experiencing. Take those precious seconds when you enter a home to take a sensory snapshot. Tie that to what you learn during your assessment and treatment to teach you not just how to treat patients, but people.
Tracey Loscar, BA, NRP, FP-C, is a battalion chief for Matanuska-Susitna (Mat-Su) Borough EMS in Wasilla, Alaska. She spent 27 years serving as a paramedic, educator, and supervisor in Newark, N.J. She is a member of the EMS World editorial advisory board.