Lord Jim: Everything Under Control (Except You)

"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.

The woman on the couch in front of you appears to be in her 30s. She's a tad on the pudgy side, maybe 200 lbs or so, but her skin is unwrinkled, and she can't be much older than 35. She's complaining of profound light-headedness and a fluttering sensation in her chest. Her demeanor is docile and quiet, and you almost have to strain to hear her answers to your questions. While you squat in front of her, you lose your balance and find it necessary to shift your weight. Her instant response is to flinch, and you find yourself thinking that the movement seemed exaggerated. But it was quick, conditioned and automatic—definitely not faked. Just for a second, you get a hunch that she might have been crying in the last few minutes.

She's clearly avoiding your gaze, and it becomes apparent that she's checking the reactions of her male companion to your questions before she responds. You change your stance so you can see both of them at the same time, and, as you do, you notice there are three kids who appear to be between the ages of three to eight sitting on the couch opposite you. They weren't there when you arrived, but they strike you as being exceptionally well disciplined—silent and seated with their hands in front of them. They seem focused on the man.

He is also in his mid-30s. His arms are folded horizontally across his chest and he is standing with his feet about 16 inches apart. He doesn't move even when the fire crew is trying to work around him. He is watching and listening to everything you do, while also remaining focused on the woman. But he doesn't speak or acknowledge her discomfort. He's wearing a mechanic's shirt that says "Jim's Auto Repair" over the right pocket, and "Jim" in an embroidered white oval over the left pocket.

When you run the ECG, you find a narrow sinus tach with a rate of 156, no ectopy and no S-T changes. You question the lady about the possibility of key historical events —heart, lung, diabetes, high or low blood pressure, seizures, fainting spells, meds and allergies—but everything comes up negative. Almost every time she answers you, she looks at Jim first.

Q. What's going on with this lady?

A. More than her physical complaint, and that's for sure. Lots of things about this call point to the influence of a fella named Jim. Kids in this age group don't silently enter a room full of EMSers examining their mom, and they don't sit rigidly in neat little rows under any circumstances except one: fear. You know that hunch you got that this lady had been crying? Well, EMS hunches are as good as they get. Count on it, unless you learn otherwise. And finally, Jim's supervisory body language seems all wrong. Even the likelihood that he runs his own business suggests control. (Most control freaks don't do well in environments where they have to answer to a boss.)

If this lady says she doesn't take any meds, it's a good idea to ask her about herbal substances. But if you want the real answer, don't do that in front of Jim. Get the patient in your ambulance, where things are a little more under her own control. Of course, she may not tell you the truth there, either. If Jim is what he appears to be, his sphere of control could reach far beyond his physical presence. Sure enough, he has arranged for a neighbor to care for the kids. And sure enough, he does want to accompany you to the hospital—in the patient compartment. Duh! (Don't you do it.)

Once you get underway, you ask the lady if she has been taking any herbal substances like teas or "power drinks." She tells you she has been drinking some oriental tea she bought a few days ago in an effort to lose weight. She doesn't remember the name of it, and she doesn't want Jim to know about it. You're thinking ephedra.

Last, but not least, one of the greatest payoff questions in the history of emergency medicine is: "Have you been upset about something recently?" It goes straight to the heart of more medical mysteries than a CAT scan. But if you open Pandora's box here and now, you may prompt this patient to start crying again. Lord Jim would be sure to pick up on that when you get to the ED, so you decide to postpone it in favor of tipping off the ED physician. Your major goal here is to help this patient. Not just solve another riddle.

Resources

Domestic violence is a crime in every state. Dozens of helpful resources related to this subject can be found online, but it appears the two most valuable nonprofit organizations are the National Center for Victims of Crime at www.ncvc.org and the National Coalition Against Domestic Violence at www.ncadv.com.