Real Talk: Lessons Learned in EMS

Check out the latest submissions to EMS World’s newest series, “Real Talk,” where providers share their lessons learned in patient care. What would you have wished someone advised you on earlier in your career? Tell us in an email to editor@emsworld.com. Stories will be made anonymous. 

1. "87 YOM patient called 911 at 10pm stating he began to feel weak with an unsteady gait around 6pm. He is normally not weak and is ambulatory. He has a history of AF, DM, HTN, TIAs, LBBB and PTCA with stent placement. He takes commensurate medications and has no allergies. A Cincinnati Score was performed and was determined to be negative. His BP was 179/96, HR 80, RR 18 and his BGL 240. Patient was monitored and transported to the hospital w/o any event or change. The patient turned out to have a hemorrhagic stroke, but because he did not present with the tell-tale signs (identified through a stroke score like slurred speech, arm drift and weakness) no stroke notification was made, nor was he transported specifically to a stroke center. Patient history (in this case specifically AF and TIAs) is very important to be combined with the current clinical presentation to come to a rule out diagnosis."
    
2. “One of my biggest EMS mistakes was cardioverting someone in rapid atrial fibrillation. What I missed was that the patient had a fever of 104.1°F. I was a new medic and got tunnel vision BIG TIME. I was not thinking sepsis/fever. It was summer time and the family stated that the patient had just become ‘suddenly altered.’ I asked about previous medical problems and was told the patient was ‘healthy.’ The patient’s heart rate was 190-220 and the patient had a weak brachial pulse. The patient did not respond to the cardioversion and it was not until I reached the ER that I realized the patient had a fever which caused the rapid atrial fibrillation. It was also at the ER that the family then stated that the patient had ‘cardiac problems.’ I use this example today when teaching new medics.”
    

3. "Always check all vital signs. This is a lesson learned from missing one, and as Murphy’s Law has it, the missing vital sign happened to be the one that explained the patient’s symptoms.

   We were dispatched to a 24-year-old female reported to be “feeling anxious.” The dispatch notes stated that the patient had a history of anxiety and depression and was prescribed medication for depression. I chatted with my partner on the way to the call, saying, “Probably a panic attack. Let’s get her calmed down and sorted out.” Diagnosing her on the way to the call was my first mistake.

   My partner flashed a thumbs up and we parked, entering an apartment complex to find the patient sitting in the lobby. She was visibly shaking, her hands especially. From a distance, I could see that her skin looked a bit pale, she was perspiring, and that her respiratory rate was increased. She smiled nervously as I approached, and I introduced myself and began asking her how she was doing. She replied that she was having a tough time recently, that life and work were difficult, and she was having trouble coping. I ruled out any life threats, she denied any other medical problems, and I continued reassuring her that we were going to take care of her. I asked those uncomfortable questions about depression, and she indicated that she was having suicidal thoughts recently. She said she had a history of panic attacks, but felt that this episode was different.  

   “I just want to go to the hospital to talk with someone,” she said.  “I’m pretty healthy, but I feel really bad right now.”

   “No problem,” I replied.  We walked to the ambulance and she sat in the captain’s chair. I asked my partner to wait a few minutes while I obtained vital signs: she had an elevated blood pressure, was tachycardic, not hypoxic, and was breathing at a rate of about 28. Her lungs were clear and equal, and I quickly applied a 12-lead EKG. Then, we were on the way.

   During transport, my patient spoke softly and was hesitant to answer many questions. She seemed embarrassed about her circumstances. I did my best to make her feel comfortable, but her shaky hands, increased respiratory rate and pale skin were worrisome to me. I asked her again if she thought she was having a panic attack, but she said it didn’t feel like the ones she had had before.

   My partner made the last turn into the hospital’s ambulance bay, the tell-tale bump from the curb signaling our arrival. I was noting her information for my patient care report, and I asked her the name of her medication. She told me it was Zoloft, then shared that her doctor wanted her to take something else, but she couldn’t remember the name of it.

   “Was it another medication for depression?” I asked.

   “No,” she replied. “He says he’s worried about my blood sugar.”

   “Oh,” I said, hairs on the back of my neck instantly standing up. “Um, are you diabetic?” 

   “No! Not at all! I’m not diabetic,” she said. “But I think my doctor said I could be someday.”

   My partner opened the side door to the stair well of the unit.  “Ready?” she asked.

   “Hey, not just yet. Can you come up for a sec?” I said, my face probably beet red.

   “Ma’am,” I said to my patient. “I’m just going to check your blood sugar real quick, okay?”
   
   My partner grabbed the glucometer kit and handed it to me. I steadied my patient’s hands and pricked her finger, silently hoping during the meter countdown that the number would be normal. Of course it wasn’t. It was 320.

   I flashed the screen to my partner, who wordlessly grabbed a bag of NS and spiked it while I opened the IV start kit and explained to the patient why she was probably feeling this way. Starting an IV with my patient on the captain’s chair was just silly; I asked her to sit on the cot and then inserted a 20-gauge catheter and hooked her up to the IV fluids, wide open.

   “Let’s get you inside,” I said. “The doctor will be able to help you manage your blood sugar so you don’t feel like this again, okay?”

   She smiled nervously at me, and I smiled nervously back, kicking myself for failing to get a complete set of vital signs as I had been trained to do.

   Yes, I got tunnel vision, I was anchored on the anxiety diagnosis, and I should have listened to the voice inside my head telling me that something didn’t add up. More importantly, I should have stuck to my well-established system and obtained all the vital signs, not just the ones I thought were relevant to my patient’s current condition.

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