When “Everything Hurts” is Where Your Call Starts

When you have asked the question, “So what’s going on tonight that made you call 9-1-1?” it’s important to understand that the words you hear next represent an almost endless array of possibilities.

Without question, depending on what those words are (the patient’s chief complaint), the call immediately becomes either more challenging or less challenging.

For example, if “crushing chest pain” are the words you hear, the patient care response will almost certainly follow the predictable path of the national guidelines for emergency care. On the other hand, when you hear, “I don’t know…I’m just not feeling right,” you’d best fetch your detective hat and bring your best game as you work to identify what is making your patient “not feel right.”

This month in BTB, we are going to take a look at some of the most unique of the many possible responses—those that deliver a simple message but a complex patient care challenge, such as: “It just hurts everywhere,” “I hurt all over” and “Everything hurts.” A few memorable calls I’ve worked which all kicked off with one of those magical responses include:

1. A 27-year-old male rappeller who’s top belay was improperly fixed, resulting in a 30-foot free fall, with an additional 100 feet of rolling/tumbling down a rocky/gravelly embankment.

2. A 19-year-old crack dealer who was pushed out the side door of a car doing roughly 35 mph.

3. Three boys aged 21, 20 and 18, all unbelted with varying alcohol levels, who corkscrewed their Pontiac no less than three times in a muddy ditch after leaving the road to avoid broadsiding a side of prime Angus beef parked in the middle of a two lane road.

When confronted with a complaint that comprises total body involvement, it may appear to be overwhelming when it’s really not. What needs to happen involves a rapid trek down the decision-making tree in order to expedite and deliver quality care. In the three cases above, you have first a significant free fall, followed by the impossible-to-predict-injury potential of a tumble down a long stretch of hostile surface embankment; then a crack dealer acting like tumbleweed over one lane of very abrasive asphalt at a pretty significant speed before hitting the curb; and finally the boys in the car who were just human ping pong balls, bouncing around a relatively hostile automotive interior (head rests, dashboard, seat backs and other tumbling human beings). The significance of the mechanisms in these cases alone dictates spinal motion restriction steps must be employed immediately.

The next step involves a wide-angle scan of your patient, looking for any life threats or significant structural defects. Open chest wounds must be sealed immediately. Significant bleeding must be controlled with a clotting agent or tourniquet. Misshapen or malpositioned extremities need to be quickly identified as dislocations, fractures or both. Open book pelvic fractures require extraordinary splinting and pain management skills to avoid a catastrophic outcome. Even with great care a bad outcome is common, as this particular pathophysiology is almost without fail the result of a very significant mechanism of injury that has produced additional collateral injuries which may be impossible to survive.

Once the find-and-fix life threat phase is complete it’s time to package and go, with wheels turning toward a trauma center, the goal being the reduction of time between significant traumatic event and the definitive problem-solving care provided in the surgical suite. In other words, stop the leaks and replace the blood.

When you are challenged with doing all subsequent assessments and management in a rolling rig, a focused and circular—rather than linear—approach to medicine is required. As the catecholamines and endorphins start to wear off, “new” aches and pains may manifest, pointing in a new direction (i.e., “You know, my neck is really starting to hurt.”).

Woven into the care process, you must know with absolute certainty that the airway remains patent, breathing adequate and circulation uncompromised, or you must take whatever steps are necessary to make them so. This equates into the practical requirements of having suction always at the ready; cycling through breath sound reassessments every few minutes, or sooner if a change in patient status occurs; monitoring capnography readings and waveforms, as well as oximetry readings; and remembering to look up and see what the last NIBP reading was to provide some insight into trending.

Use a logical, well thought out methodology to your medicine: finding and address the potential killers; limit scene time to the bare bones minimum, then go into a search-and-destroy mindset as you look to find and fix new complaints as they emerge en route, or address the lesser items which didn’t make your potential killer list in your primary assessment. Keep a close eye on your diagnostics so you don’t miss important items like progressive tachycardias, rising CO₂ levels/poor waveforms or falling oxygen saturations, all of which can be predictors of impending doom.

As I see it, the patient who comes to you with the “everything hurts” complaint works you hard in two specific areas. First, it is mentally challenging as you deal with the dynamic of being in a continuous/ongoing assessment process addressing so many possible causes. And second, it challenges your skills as you must manage multiple patient care needs, all in a moving vehicle. It’s definitely doable, if you can just keep all those assessment and management balls in the air.

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 the EMS World editorial advisory board.