The Tree of Knowledge

In Christian theology, the tree of knowledge bore the fruit eaten by Adam and Eve in the Garden of Eden – eating the fruit was the original sin.  In EMS, the tree of knowledge is different, but still involves original sin (but not theologically).

Think of an EMS call as a tree.  At the beginning, when I am assigned the call, I’m not even sure if there is a tree there, let alone if it is an oak or pine tree.  Is it old, or a sapling?  Has it been hit by lightning in its life?  Is the bark smooth or craggy?  Are there leaves on the tree, or is it winter? 

(Courtesy CopyrightFreePhotos: http://www.copyrightfreephotos.hq101.com/main.php)

Patient contact usually begins with a question: “What’s the matter?”  Think of this piece of information as the EMS tree’s trunk.  The actual wording of the question is not important.  “What can I do for you?”  “What seems to be the problem?”  “Are you hurt?”  All of these beginning questions start the call and give us an idea of what we are doing on that scene.  If there is no problem, there is no tree.

Every call begins with dispatch information; what the caller thinks is going on, third party caller statements, a guess as to the nature of the problem, and that kind of information.  Dispatch information comprises the roots of our tree – we may not be able to see the roots, but there is information there if we were inclined to dig it up.  How much digging will be required depends on how well that knowledge is passed on to responders.

Separating off from the “trunk” are the main branches of our tree.  In general, I use the OPQRSTA mnemonic: onset, provoking, quality, radiation, severity, timing, and associated symptoms.  The mnemonic you use, or even if you use one, is not important.  But most calls require some information about each of those points.

Each “OPQRSTA-branch” has sub-branches of questions.  So for onset, the main branch question is “Really.  I’m sorry to hear that.  How long has that been going on?”  Forking off of that question are the sub-branches: “What were you doing then?”  “Oh, yeah?  How long had you been doing that?”  “Has this ever happened before when you were doing that?”  “How was that time similar?”  The main “onset branch” thus separates out into smaller and smaller branches all the way out to little twig questions.  That pattern of questioning is repeated for each of the main OPQRSTA branches.

In most cases (where time isn’t a factor), it is not important whether you skip from branch to branch, or to pick one branch and follow it to its end before switching to another.  Start with onset or start with associated symptoms (“What else is wrong with how you feel?”).  Ask all of the main branch questions before asking detailed twig questions or skip from branch to branch as the conversation leads you.  It doesn’t matter.  What matters is that, no matter the order, each branch is thoroughly examined out to its end.

Physical exams are important too.  I think of this as fleshing out my tree – the equivalent of looking at the bark, leaves, and animals that live in the tree.  The more information I have, the more accurate the picture of my tree.  Find out if the texture of the bark.  Is there a bird’s nest in the tree?  Are the leaves green and healthy, changing colors, or fallen off?  How thick are the branches?  There is a difference between a centuries-old craggy-assed oak tree and a sapling that was just planted.  They’re both oak trees, but it is the specifics that make each tree unique.  Think of the physical exam as showing you those differences.

Is that a spruce or a pine? Better ask more questions.
(Photo courtesy Anthantor, CC3.0 license)

Original sin comes into our model because, in many cases, most bad decisions on an EMS call come from not having an accurate picture of your tree.  You think you have a pine tree, so you talk the patient into staying home.  But it isn’t a pine tree – it is a cedar tree you’re dealing with.  Cedar trees should go to the hospital.  Whoops. 

That is kind of written in jest, but it is a serious point that decisions made without accurate information are only good decisions by accident.  Most incorrect decisions come from inaccurate or incomplete information.  We all know how to treat an MI, for example, but missing the fact that we’re dealing with a subtle presentation of an MI makes it almost impossible to make purposefully correct MI treatment decisions.  Tracing back poor decisions usually leads to incomplete exams and inaccurate histories. 

So mistreating the patient is a sin, but doing it because of an incomplete history and physical is the original sin.