The Four-Part Patient

There is little question that part of the lure of prehospital medicine is the challenge that comes with it. You can go on 100 chest pain calls and no two are alike. You may find a 12-year-old kid with a racing heart and chest pain from smoking crack, or a 35-year-old with similar problems after drinking a triple espresso. The possible age and etiology combinations are endless; however, all patients share certain commonalities. In the interest of providing excellent people care, it's worth taking a few minutes to explore the things virtually all patients have in common.

All Patients Have Needs

At the most fundamental level, patients will either have a medical condition, a traumatic condition, or some combination of both, e.g., the forgetful diabetic who takes a second dose of insulin, which bottoms out his sugar causing him to drive off the road into a guardrail. In that situation, a medical emergency resulted in a traumatic event. Once we determine which of the possible combinations a patient has, we can begin to correct the situation.

Every patient also has emotional needs. While it is generally true that most people have a fascination with emergency equipment and the people who come with it, that fascination ends when the ambulance pulls up in front of their house. When the doorbell rings and four EMTs, each carrying two jump bags, pile into their living room, interest and fascination give way to something more akin to anxiety and outright fear. It is essential that we provide psychological support while addressing patients' medical or traumatic needs.

First and foremost, it is imperative to communicate to patients that we understand their problems and are in control of the situation. Keep patients continually informed about how things are going, e.g., "We are going to give you a treatment to help you breathe better." Try to be as positive and upbeat as the situation allows. Helping the patient maintain a positive attitude is a plus.

All Patients Have Expectations

Here's where things get sticky. For many patients, their expectations about what will happen when EMS shows up are largely shaped by television. Of course, on television, you rarely see the blend of extended assessment and interventions that occur with real-life calls. On TV, the EMS team arrives, puts the patient on a stretcher, loads the patient into the rig, slams the doors and slaps them, signaling to the driver that it is OK to drive off at high speed. Next scene: arrival at the hospital, where a smiling doctor greets the paramedics, and the patient's problems are solved. Right!

Far too frequently, the television cardiac arrest patient receives but a single shock, which then converts into a perfusing rhythm. He starts breathing, and in short order, returns to a normal life. In the real world, only about 5% of cardiac arrest patients are resuscitated, with many of the survivors having some form of neurological deficit. Of course, any television program where 95% of the patients died wouldn't last long. How would you get advertisers with a reality-based survival rate for cardiac arrest? "Tune in next week for another exciting edition of Medical Losers!"

In order to deal with patients' unrealistic expectations, use a lot of tact, answering their questions truthfully, while still orienting them to reality. When a patient asks, "Am I going to die?" there's one answer: "I certainly hope not! You are really sick, but we will do everything we can to take good care of you and keep that from happening."

All Patients Have Family and Friends

At most emergency scenes, family, friends or sometimes both are represented. These people are often as frightened or anxious as the patient, while they wait and wonder what the outcome will be. Although taking care of the patient is the primary concern, neglecting the patient's family and friends is not good medicine nor scene choreography.

I suggest sequestering as many of these folks as possible in one area like the kitchen, where they can sit and have access to food or beverage. This serves two purposes: It is easier to relate what is being done for the patient if everyone is in the same room, and it keeps the route of egress and access to the patient open, so equipment can be shuttled back and forth. And, when it's time to move the patient, the process is much smoother if additional people are not milling around.

All Patients Have Rights

Increasingly, the courts continue to rule in support of patients' rights, particularly their right to decide what is or is not done to them medically. As litigation events continue to increase, it makes good sense not to behave in any way that will anger the patient and encourage legal action.

During all phases of a call, it is essential to treat patients with dignity and respect. If an alert and oriented adult patient does not wish to go to the hospital, don't argue about it. If the patient is sick enough to require emergent transportation to the hospital, there is no problem with going over the situation once more, reemphasizing why you think ambulance transport is in order. Sometimes, the patient comes around to your way of thinking and agrees to go to the hospital. Sometimes, he just listens to you politely, then says, "NO, I'm not going to the hospital in the ambulance." Believe it or not, adults who are alert and oriented to person, place, time and the events around them actually have a right to choose. It may not be the decision you would make, but that really isn't the issue. The bottom line is, it's their call.

Recognizing and addressing the commonalities of all patients facilitates a more well-rounded approach to medicine, i.e., not just focusing on IVs, splints and bandages. Certainly, those are important, but good prehospital care isn't only about techniques and technology-it's much more holistic. Techniques and technology only address part of a patient's needs, and that just doesn't cut it unless they are used with a heaping, healthy dose of people care. Until next month…