Pre-Hospital Box of Chocolates

I struggled with the title of this post since it may cover more than just this or be a little off topic. At any rate, sorry for the confusion.

I've been in the EMS profession since 1988, a relative newcomer but old by other standards. I've practiced pre-hospital medicine all over the world on 5 continents. I've gotten to see a lot and do a lot but by no means everything. I've experienced a wide array of calls, had some really odd ones, had some confusing ones, had some that were textbook and some that were so far-fetched that the book seemingly needed to be rewritten.

But no matter where I've gone I always come across one group of providers that has always given me fits. Generalizing? Yes, I have to. I cannot and won't be specific but this particular group seems to give me more trouble and make me scratch my head more than any other.

I really want to go in to specifics but I'm letting my better judgement take hold here and reserving comments.

For some reason some people seem to make things, how should I say it, "difficult?" I realize that some people do not necessarily have pre-hospital experience or education, and that's understandable. But they should still have some of the basic things down pat, especially if they've been in the medical field for any length of time.

Just some of the "top of my head" things I've seen or been told (feel free to add your own);
1.) A nasal cannula @ 15 lpm
2.) A non-rebreather @ 2 lpm
3.) A patient who's talking, a & o x 4 with a pulse ox of 39%
4.) CPR being done on a patient bed that bounces up and down with every compression
5.) CBG (blood sugar) of <10 with no patient deficits
6.) Blood pressure of >300 with a normally functioning, no pain, no complaint patient
7.) Patient on the toilet, called for a cardiac arrest; arrived to simply lift the patient's head (to open the airway) and they began breathing again
8.) Numerous calls to 911 for transportation (as an emergency) to the local hospital for headaches, ear aches, a "tickle in their throat," and for one "runny nose"
9.) Patients stating they have one complaint and the staff stating the patient has a completely different set of complaints
10.) Patients who are normally in a vegetative state with no ability to communicate period somehow tell the staff they have a complaint of pain or problem

These are all calls I've had that I can easily remember for one reason or another at one place or another. There are more but this is a good start. It's not uncommon to get called for a cardiac arrest only to arrive and find the patient awake, alert, and talking. What happened? It's also not uncommon to get called for a simple transport only to find out the patient is in dire need of medical care immediately. It's one of those, "you never know what you're going to come across when you get there." Be prepared.

Assessing a patient, you'd think, can be a simple task. Go from head to toe, assess the simple ABCs and go on from there. Do a complete secondary survey and find the finer points. Be detailed. Find out all the smallish items that may indicate an underlying problem that may not be readily seen yet don't overreact if it's not anything of importance. Take note of it and go on.

But it still floors me how assessment skills can be so different from prehospital to anywhere else. Take this call for example that I did with a BLS crew. Patient with a CVA history among other things. Has had a cough recently, is febrile, I & O normal, everything else appears fine. Patient's GCS is a 15, Very alert, oriented, knows surroundings and is very pleasant to converse with. The Cincinnati Stroke scale was normal x 3, 3 hours prior per staff.

We were told the patient's pupils were unequal and non-reactive, was complaining of chest pain, was febrile, had unequal grips and could not use the right side (where old stroke was), very confused and disoriented. Their diagnosis was another stroke.

The patient's grips WERE normal bilaterally. NO chest pain, used right side (all of it) without a problem, knew exactly what was going on and recited family history and family members as well as local happenings along with time, date, day of the week. Pupils were BOTH reactive and responsive to light. All of this was done in front of the staff as we assessed this patient prior to transferring to our cot.

Huh??? Where did these observations come from? We were told all of this came on within the last 30 minutes prior to our arrival. The patient even told me that they (roommate also) were watching TV together and talking about the shows (roommate confirmed this).

One correct finding? She was febrile.

It is true that we never know what to expect on any call, no matter the background of the call or where it may be located. We are called to a sick person and it turns out to be an overdose. We get called for an MVA and it turns out to be a shooting. We get called for an injured in a fall and it turns out to be a cardiac arrest. Anything is possible. Our station used to have a plaque on the wall stating, "Expect the worst, hope for the best." True words by someone who knows and has experienced a lot. We always have to prepare and expect the worst possible scenario and hope that it's not, for the patient's sake.

Assess everyone no matter how routine a call it may be. Even the simple transfer from ECF to a doctor's office for a checkup needs a quick once over. Do a good head to toe. If nothing else, those are the patients who are good to practice basic assessment skills on. Listen to the lung sounds and different fields. Look at the diagnoses and see if you can see any of the stereotypical signs that come with what they have. Look and feel the extremity edema of a CHF patient. What does it look like? What does it feel like? Do you see any JVD? Can you find a good pedal pulse on someone who has gross pedal edema? Do you feel any masses or pulsating areas in their belly on palpation? Do you palpate bellies? Do you rock their pelvis or feel their neck? Do you look at their ears or nares to see if there's any exudate? What about their mouth? Any open areas or bleeding?

All of these things can be very helpful in determining what may or may not be wrong with a patient. True, not all of them will be pertinent to every patient, but some of them may very well help diagnose what's wrong with them and better lead us down the right path of treatment prior to our arrival at the hospital. As always, document what you see, felt, and heard (or were told) as well as the responses to the treatments given.