Don`t Get Lost in the Land of Linear Thought

   The case I was reviewing was oddly straightforward. The two paramedics who responded to the call for a "man acting strange" rolled into the private residence and did, indeed, find a man acting strange. The fellow, who was in his early 70s, was clearly agitated and having trouble communicating with the EMS team. One of the medics grabbed the patient's wrist to obtain a pulse and, after some doing, found a pulse of 38. They immediately attributed his altered mentation to the profound bradycardia, and, with no further assessment, made the jump to the "symptomatic bradycardia" protocol and applied the pacemaker. They quickly got capture and set the rate at 70. Just moments later, the patient seized, went into full arrest and could not be resuscitated. What happened?

   In a nutshell, the two EMS providers got lost in the land of linear thought. Both admitted they did no other assessment after the slow pulse was identified, and once they headed down the symptomatic bradycardia protocol, they never looked back. Had they done a more thorough assessment, they would have found that the patient had complained to his wife the night before of a pounding headache. He had a history of hypertension for over 40 years, with diabetes added to the mix a few years earlier. The reason the patient was struggling to communicate was not because of the bradycardia, but because he had expressive aphasia secondary to a stroke. Application of the pacemaker overrode the body's attempt to manage the elevated ICP and gave the patient a second, and this time fatal, stroke. The big question post-call was, could this outcome have been avoided? In truth, the patient might have died irrespective of the pacemaker; however, applying the pacemaker guaranteed that this patient would die.

Understanding Algorithms, Protocols & Standing Orders

   Algorithms, protocols and standing orders are the backbone of patient care in the field setting. It is essential to understand that these game plans are almost exclusively linear: do this, then that, and then that. Proper sequencing is essential in prehospital medicine, and all three of the formats described above lay out proper sequencing and other important patient care elements like recommended drugs, drug doses, etc. The all-important caveat here is that these guidelines lack any real dynamic capabilities. As long as the patient presents according to plan, they work well. When patients present atypically, it takes a thinking EMS provider to provide the care the patient needs and deserves. The reason for this is simple: Algorithms, protocols and standing orders use a bell-curve delivery model. For patients who are within the curve, the care is generally appropriate, but for those to the right or left of the curve, patient care is clearly lacking.

Get a Thorough History

   Making clinical decisions on incomplete clinical data, as evidenced by this call, can have catastrophic results. In this case, one singular piece of assessment data drove the providers' decision process. Amazingly, they both missed the clear facial asymmetry, never got a complete set of vital signs, and used none of the diagnostic capabilities at their disposal. Had they performed the Cincinnati stroke test, they almost certainly would have made the correct field diagnosis. Getting a blood pressure would have pinpointed the hypertension. To simply find a patient with a slow pulse and decide that a pacemaker is the solution shows huge missteps in logic.

Remain Flexible

   As you continue to assess and manage your patient, maintaining a kind of ongoing mental dialogue is essential to creating a system of checks and balances. If your patient complains of difficulty breathing, once you've applied oxygen you need to revisit that problem, i.e., "Is it getting any easier to breathe, sir?" If you are treating 9 over 10 chest pain with morphine given in 2 mg increments, after 4 mg, see where the patient is. Still at an 8? Give two more rounds of 2 mg and revisit the problem. We frequently get sucked into the flow of a call and forget to follow up on how our interventions are working or not working.

   Another important aspect of flexibility is being acutely sensitive to any change that is inconsistent with expectations. For example, you are working up a 62-year-old patient complaining of chest pain. He localizes it as substernal and tells you he was moving some landscaping rocks when the pain started. Given his age and the extent of his physical exertion, working this patient up as a "possible cardiac/rule out MI" is logical. At some point you ask, "Does anything make the pain better or worse?" to which the patient replies, "As long as I don't move my arm and shoulder, the pain goes away." That rules out the cardiac care protocol. No angina/unstable angina/AMI patient I have ever seen can make true cardiac pain come and go with simple extremity movement. Keeping a flexible mind-set helps you pick up on this and move instead to the musculoskeletal injury protocol, where the solution to this patient's problems lies.

   Using these simple guidelines can help you work around the performance limitations that algorithms, protocols and standing orders bring to the table and keep you from getting lost in the land of linear thought. Until next month…

   Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS World Magazine's editorial advisory board.