Situational Perceptiveness: Assess the Predicament—Not Just The Physiology!

EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right expert and share their advice with you. Send ideas c/o emseditor@aol.com.

When you first arrive at the home, it seems like a fairly routine call for chest pain. The time is about 1600. The little yard is neatly manicured, with a white picket fence in front of it. You see a bird feeder with a statue of St. Francis in the middle, and a small American flag flying from a staff over the front door. The fence is trimmed in dark red, and it follows the path of a fairly elaborate ramp with a mild slope in front of the house, as though someone with a wheelchair might live there. The house is about 50 years old, but it's very well kept.

A concerned neighbor lets you in the house. Once inside you notice the smell of meat cooking. The living room is dominated by a hospital bed with a trapeze rack above it and a triangular handle hanging from the rack. An elderly gentleman is in the bed, but it appears he's not the patient today. He points toward a woman in her 70s, seated on a couch and obviously in some distress. She's pale, weighs about 130 lbs., seems anxious, and is wiping her eyes with a handkerchief as though she has been crying. She seems to be consoling a little wire-haired dog, which is alternately jumping onto the couch with her and frantically running around the room, whining. An old grandfather clock is ticking away in the background. The room is festooned with European-looking artifacts of every description: statues, paintings, old photos and knickknacks. You can see a cat box in the adjoining kitchen and food cooking in a crockpot on the kitchen counter.

The lady's name is Clara Kraft. She's complaining of non-pleuritic infrasternal pain that came on three hours ago and seems to be worsening. She's becoming light-headed, and you notice she's mildly diaphoretic. She denies shortness of breath. Her pulse is 50, weak and irregular, and her respirations are 22, regular, full and effective. Her blood pressure is 110/66. The ECG reveals a sinus bradycardia with frequent PVCs and occasional bigeminy, and the S-T segments in her anterior leads are mildly depressed. Her axis is normal. Her neck veins are flat and her lung sounds are clear. Despite the dim lighting in her living room, her pupils seem a little small-maybe two millimeters bilaterally. There is no history of heart, lung, diabetes, high or low blood pressure, seizures or syncope, and there are no meds or allergies. She has both lungs and both kidneys.

Q. What's a normal pupil size in low lighting levels?

A. Depends on how low is low. But you brought several calibrators with you. Check the pupils of two or three members of your crew and engine company for comparison.

Q. What do you think is going on with this woman?

A. You'd certainly want to rule out an MI, although the ECG is not impressive in that regard. But something is depressing her heart rate, and maybe that's why her BP seems low. She's not tolerating her vitals, as evidenced by the light-headedness and the ectopy. She needs to lie down. She needs the usual O2 and IV, and maybe some atropine would bring up that heart rate and even out that rhythm.

Q. What ELSE do you think is going on with her?

A. This woman is apparently the sole caretaker for her husband and at least a couple of animals. In fact, from the look of things, she's a very good caretaker. If her husband is lying in a hospital bed at 4 in the afternoon, he's bedridden until proven otherwise. The fact that he pointed instead of talking when you came in suggests he doesn't speak, and the trapeze suggests he has some ability to move himself around-but not enough. Could be he's recovering from a CVA.

So, even if Mrs. Kraft is not having the Big One, her main concern today is going to be much bigger than her own medical status, and she needs to know you realize that. If she is having the Big One, her anxiety can still be a major issue. Either way, it warrants your prompt attention.

Q. What would be a good question to ask at this point?

A. It might be worth knowing if this woman has been working in the garden today, just because of those pupils, the bradycardia and the diaphoresis. If she has, she may have absorbed an organophosphate. Her appearance isn't dramatic in that regard, but it would be a good thing to rule out.

Q. Clearly Mrs. Kraft needs to go to the ED, even if the atropine brings up her heart rate and gets rid of the ectopy. How can you reassure her that her husband and her animals are going to receive the care they need?

A. Get her attention, look her right in the eye, and tell her you understand her predicament. Tell her it's important to you, and let her know that you're going to take care of things for her. Tell her what your observations indicate-that it doesn't look like she's had a heart attack, and that it's possible she may be coming right back home. But ask her for a telephone number of someone who can back her up-a family member or a neighbor, maybe. Ask her when her husband needs his next medications, and let her know that you're going to help him to the bathroom before you leave. Promise her that you will communicate her situation thoroughly to the ED physician. Turn off the crockpot. Finally, ask another crew member to make sure the dog and cat have water and food. Make all of those arrangements with her lying there in front of you. Then, if you're not going to be on duty the following day, tell her you will ask tomorrow's shift to stop by and check on things for her.

Remember, this woman has good reason to be scared. When you've loved someone and lived with them for many years, the prospect of being forever separated must be terrifying to live with. Speaking of whom, don't forget the guy in that hospital bed.

Not talking and not hearing are two very different things.