Truth or Consequences

Of the many skill sets within prehospital medicine, arguably the most important is that of patient assessment. Without an organized, systematic and thorough assessment, patient care becomes little more than a matter of chance. A weak assessment may mean your patient gets the care he needs or he doesn't. Kind of a roll of the dice. Would you like that type of care for you or a loved one?

Under the umbrella of patient assessment is another key element of prehospital medicine: your ability to determine if your patient is sick or not sick. Time and practice polish that skill as you become increasingly proficient in your abilities.

Unknown to many, however, behind the curtain of patient assessment lies a simple matter that can potentially derail even your best efforts: knowing whether your patient is telling the truth.

Spend any amount of time in EMS, and you'll find that you're lied to every now and then. In and of itself, that is understandable. Who wants to admit that he drank aftershave because he is so addicted to alcohol? That she hates her life so much she resorts to smoking crack or meth to change her perspective? Or that he beats his wife or kids? The list of why someone lies to you is both long and varied. This month, I want to look at another facet of patient assessment that is potentially even more insidious and problematic.

Just as determining whether your patient is sick or not sick is an "either/or" choice, so is your initial belief about whether or not the patient is telling the truth. More specifically, what happens if you start every assessment believing that every patient is lying to you?

There is no question that there are patients who intentionally mislead you, such as those with drug-seeking behavior. This is typically the patient with a complaint that really can't be pinned down: "I have terrible back pain!" But, within just a minute or so, he offers a cure: "When it gets this bad, it usually takes morphine to clear it up. You do have morphine, don't you?"

That being said, my experience has been that patients who lie to us are the exception rather than the rule. Most people tell the truth about their crushing chest pain, the throbbing headache or whatever prompted the call to 9-1-1.

As such, it's my belief that it is better medicine to start each call believing that your patient is telling the truth. There are several serious pitfalls if you take the position that every patient is lying:

The assessment goes slower
When you either don't believe or don't want to believe your patient's history, the assessment becomes like a game show. Continually making your patient "prove" the validity of each statement breaks your assessment into a start-and-stop event. With that approach comes a more tedious, time-consuming assessment, which leads to another problem.

The assessment is less efficient and less productive
Every day on every call you are asked to deliver quality medicine while working with limited resources in an uncontrolled environment. When you put on your detective hat to try and solve the mystery confronting you, every clue you leave on the table potentially represents the clue that may have led you to the right working field diagnosis, which, in turn, would have led you to the correct care plan for your patient. If you are assuming that every answer is a lie, your thoughts dwell on that, diverting you from efficiently processing information and continuing to probe for clues to help you pin down what is behind your patient's problem. And that leads to a still bigger problem.

Patient care is compromised
Combine the two above-mentioned issues and you get to the real meat and potatoes of the matter: Patient care gets compromised. Even worse, you may not consciously realize what you are doing. Consider the patient with honest-to-goodness 10 over 10 chest pain. He's hurting big time, which scares him and elevates his heart rate, increasing his myocardial workload and oxygen consumption, and possibly worsening his evolving myocardial infarction. The whopping 2 mg of morphine you gave during the 30 minutes he was in your care did NOTHING to alleviate his pain, and he gets to the emergency department still stressed, with his heart working far harder than necessary and his AMI maybe just a bit larger because of it.

In conclusion
Please don't misconstrue. I understand and accept that patients do mislead us. I'll be the first to admit that I have been scammed more than once over the years. That is not satisfying, to be sure; however, I was willing to accept an occasional scam as a trade-off. By starting with the belief that I was hearing the truth, I simply made my assessment, gathered and processed information and did my best to provide quality care. Make no mistake, if and when my BS meter tripped and I came to the conclusion that I was hearing a story, I processed information and made decisions differently. However, I remain convinced that it is better to begin with "I'm hearing the truth" and accept the risk of an occasional scam, rather than starting with "I'm hearing a pack of lies" and potentially compromising the care of the overwhelming majority of patients who are truly sick and hurting by making them prove their story. Why should many pay the price for a few? It's either truth or consequences.

Until next month...