SickNotSick

This is probably part one of who knows how many because it is an important topic. But nobody wants to read a multi-hour dissertation all at once.  So enjoy the smaller bolus.

A few shifts ago, I had a good friend and long time medic as my partner. He has been a medic long enough that I don’t mind watching him work, so I happened to be driving that day. One of the first calls on the shift was to a dyspneic patient. We arrived to a small bungalow on the south side of town to find a 20-something woman lying on the couch moaning. She was supine, with her feet elevated on the arm of the sofa and her right arm thrown across her face. I relaxed and settled in to doing my job as the driver on the call – finding demographic information, seeking medications, and getting bystander stories; generally doing the necessary tasks that would make it easier for my partner to focus on the patient. I knew I wasn’t in a rush. After several minutes of questions and examinations, my partner assisted the patient to her feet and out the front door to the ambulance. I followed, leaned against the side door of the ambulance, and waited for my partner to buckle the patient onto the pram and set himself up for the transport. Eventually I let him know the information I had found out, handed him a piece of paper with the patient’s demographics on it, and walked around to the driver’s seat to head to the hospital.

The next call was also a patient experiencing shortness of breath. We arrived to an apartment building to find the patient on the front porch. She was sitting on a rickety aluminum chair, leaned forward with her hands on her knees. Her head was pushed forward and she gasped out a few syllables to explain that her asthma was bad that morning. I didn’t hear that, though. As soon as I caught sight of her on my way up the front walk, I turned around to get the bed. I pushed it toward a waiting firefighter, asked him to hustle it to my partner, and remounted the ambulance to spike an IV bag and set up a nebulizer treatment. I even planned to get the drug kit out to set out some epinephrine for my partner, but he arrived back to the ambulance before I could do that. We both got to work once the pram clicked into the bracket. My partner got to work getting a blood pressure while I put the neb into the patient’s mouth and explained how I wanted her to breathe through it. I put a pulse ox probe onto her finger and my partner grabbed the drug box to find some epi. I quickly wrapped a rubber tourniquet around the patient’s arm and stabbed a 16 gauge catheter into her large antecubital vein. Rather than finish the line, however, I attached the vacutainer hub to the catheter and taped it down lightly. My partner saw that and nodded: “I will finish that. Saint Elsewhere, please.” I hopped out of the ambulance and hurried around to the driver’s seat.

What is the difference between these two calls? 

The difference is in the answer to one of the first questions providers ask themselves: Is this patient sick or not sick? SickNotSick?

When you walk into a scene and catch sight of the patient, ask yourself, “Sick or not sick?” Start with your general gestalt, the same way a layperson would. There is no need to work through a bunch of questions; just think about whether the patient makes you worried (or a little frightened) from across the room. It involves skin color and moisture, but also the patient’s position, the work of breathing, and how frightened the patient appears. Next, if it is a trauma call, the mechanism comes into play. Is the car crash a terrible one, or was paint exchanged between bumpers?  Someone shot in the groin is probably sick and someone shot in the foot is less likely to be sick. And so on. When you are incredulous and ask for clarification, it often makes you lean toward the patient being sick: “Wait, this dude fell from where?” 

As you get closer to the patient and ask a few simple questions, you can tell a lot about the patient’s mental status. More than mental status, you can tell where they fall on the alertness AVPU scale. Finally, vital signs are an important part of deciding whether a patient is sick or not. Hypotension is bad. Extremes of tachycardia and bradycardia are too. Respiratory patterns matter more than we credit them. How many syllables can the patient say before gasping? Does the inhalation match the exhalation, or is the patient working harder to accomplish one or the other? What do the pulse oximetry, capnography, and ECG tell me?

Twisted all through the decision regarding sicknotsick is the provider’s experience level and personal history. If a respiratory patient has ever crumped on you and died without warning, you have a higher level of respect for respiratory signs like tachypnea. After a patient died shortly after a firefighter told me, “She is getting hard to bag,” the way to get my full and undivided attention is to say that to me. After overreacting to hyperventilating dramatic patients a few times, you recognize what carpopedal spasms look like. Some of the best lessons I have ever received were from making the wrong sicknotsick choice and paying for it.* 

The foundational test of sick-or-not-sick, however, is the janitor test. The janitor test holds that if a janitor walks past your patient and thinks, “Wow, that dude looks like he is dying!” then he usually is. I try to remind myself to balance the medical knowledge I have been given with good, solid common sense. I don’t want to miss the forest for the trees. I don’t want my own prejudices to steer me wrong. As an EMT or medic improves in his or her skills, they start to pick up on sick patients who have more subtle presentations. That is the mark of a Jedi medic. 

Start asking yourself whether you think the patient is sick or not sick after being on scene with the patient for about a minute. You can always change your mind later. Work more quickly on the sick patients. Reevaluate. Make sure you are on the correct path. Reevaluate again. Don’t be afraid to back down from sick to not sick if it is clearly warranted. Then reevaluate. Be ready to upgrade to sick from not sick and reevaluate again. Even more fun: Ask trainees and paramedic students whether they think the patient is sick or not after a minute or two on a call. Then help the learner to align their impression with yours.

*Hopefully I pay for my own mistake with a little embarrassment, rather than the patient paying for my overreaction or underreaction with their health and wellbeing.