Presumptuous Assumptions

You are dispatched to a local strip mall to see a “sick woman.” You arrive and find a 44-year-old lady complaining of a “racing heart.” A quick pulse check confirms an absent radial and weak carotid pulse at roughly 210 beats per minute.

The patient tells you this started suddenly about 15 minutes ago while she was reading the paper. She also claims this is a first-time event and nothing like it has ever happened before. Lastly the patient shares that she has prescriptions for an inhaler for her asthma and a beta-blocker. She denies using the inhaler but says she’s been compliant with her Inderal.

Let’s go ahead and put you in the role of the lead responder on this call. You have just obtained the history described above. If you look carefully at this brief history, there are multiple points where you may have to make assumptions based on what you’re being told.

Do you believe she is 44 years old?

A snapshot exam reveals a hard, weathered person currently vacillating between a homeless shelter, a couple of halfway houses and any friend with a couch. She looks 60 at best.

An accurate age would help you gauge the impact of a tachycardia over 200. An older heart is clearly more at risk to have a negative impact from a sustained tachycardia than a younger heart might be. Also, an older heart that has been exposed repeatedly to a drug like meth clearly has an increased likelihood of a catastrophic event. As such, you might be better prepared if you had that information readily available.

Do you believe her time frame for this event is accurate?

Time is often quite distorted when someone is in the middle of a crisis. Maybe it has only been five minutes since the onset of the “racing heart,” but then again, maybe it’s been 20. Does the time frame matter, and if so, how much? Given the patient’s age, this heart rate is not necessarily lethal, but the longer the heart has to maintain it, the more likely it will eventually take its toll, and the rate will need to be controlled either chemically or electrically.

Do you believe this a first-time event?

You go ahead and take this as a true statement, but in truth this woman continues to struggle with meth use. In truth she has had this same feeling in her chest multiple times, but her heart was beating so fast this time that it made her call 9-1-1. Knowing this is yet another in an ongoing series of tachycardia events might make you rethink the stability of this heart, along with whether there’s existing or evolving cardiac damage.

Do you believe she is compliant with her medicine?

Logic would dictate she is not compliant with her beta-blocker, because as a rate-control drug, it should not allow her heart to spin up over 200 bpm. Then again it may be that the meth is just overpowering the Inderal. One way or another, you will need to get the rate under control sooner rather than later.

Discussion

In this brief vignette, there are four pieces of information you must decide are either true or false. Once you have made your choices, then you must move forward with your care plan. In a more complicated scenario, there could easily be 8 to 10 pieces of information you will be forced to presume to be true or false. Clearly, as you increase the number of assumptions you have to make, you increase the likelihood of making poor choices secondary to getting fed poor-quality or even outright false information

To build a safety net under your assumptions, let logic serve as a buffer and drive your thought processes, since most medicine follows a logical pathway. However, if something you’ve been told just doesn’t seem to make sense, circle back around and revisit it with your patient. If there is clearly a disconnect—as in the case above, where the patient says she’s taking a rate-control medication and is compliant with dosing, yet presents with a heart rate of 200-plus—you may need to confront the patient to figure out if you’ve made an errant assumption or if the illicit drug is overpowering the Inderal.

Keeping your thought process “light,” wherein you buy in cautiously, rather than opting for a hook, line and sinker approach will help you make prudent choices in what you take as facts. Couple that to a model of a rolling assessment—i.e., evaluation/reevaluation, where you continuously rethink the story you’re hearing—will help you make better presumptuous assumptions.

Until next month…

Mike Smith, BS, MICP, is director of clinical education and lead instructor for the EMS program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.