Airway & Respiratory, Patient Care

Beyond the Obvious

˙The only difference between a genius and one of common capacity is that the former anticipates and explores what the latter accidentally hits upon; but even the man of genius himself more frequently employs the advantages that chance presents him; it is the lapidary who gives value to the diamond which the peasant has dug up without knowing its value.Ó

ƒAbbe Guillaume Raynal

Now that a new paramedic class has started, I’m dealing with students and instructors on a regular basis. Treatment protocols are being memorized and hopefully understood, but I often reflect on the types of questions we ask students — multiple choice, fill in the blank and the occasional essay question.

Most of what my students and I will face in the field is routine; however, we occasionally get to truly help out some of our patients. When we do, it’s because we follow protocols. Other times, it’s because we choose to question and think beyond our protocols. Let’s look at this month’s case for an example.

It’s a cool winter day in the Northeast, and you and your partner are discussing everything but„EMS: politics, education and the state of the economy. You’ve just about resolved all of the world’s problems when the dispatcher sends you to an ˙elderly male, dizzy at Kent Family Dental Office,„401 Poker Pl., corner of Stillwagon Ave. Time out is 15:07.Ó

As you carefully respond to the scene, you review the possibilities. But in the dentist’s office, all bets are off. Dentists use multiple drugs and procedures that can often result in a patient becoming dizzy or passing out.

You arrive on the scene and find a 66-year-old man in a dental chair being given oxygen by the staff. The dentist tells you the patient came in complaining about pain in his lower jaw, and while he was being examined, he became light-headed. The patient is able to communicate and tells you the same story. He still has pain in the jaw and is a little sweaty and pale. While your partner gets vitals, you ask the dentist if he found any problems in the patient’s jaw. The dentist says no.

The patient has no history of medical problems and takes no medications. He’s alert and oriented times three. He denies any chest pain and shortness of breath, but complains of weakness. His vital signs are: pulse 60, BP 84/62, respiratory rate 14. You place your oxygen on the patient at 15 LPM via a non-rebreather mask and notice the patient has some jugular vein distention, but his lungs are clear bilaterally.

Your partner is obtaining IV access, and you hook the patient up to a 12-lead ECG.„Large ST segment elevation changes are observed in leads II, III, and AVF. You contact medical control and explain the situation to the doctor. He’s leaning toward MI (like you are) but believes that because the patient is elderly, the absence of chest pain is inconclusive.

The doc wants you to give nitroglycerin to this patient, but you state that you could give him nitro, understanding the orders, but would rather do a right-sided 12-lead ECG first. You say you remember a presenter at a recent conference noting that folks with signs of inferior wall infarct should have right-sided chest leads attached and evaluated to determine if they have right ventricular infarct (RVI). You note that it isn’t in the protocol, but the medical control doctor agrees.

The right-sided leads confirm an RVI. Instead of receiving nitro, the patient is placed in the Trendelenberg position and given fluid to aid in maintaining his blood pressure. The patient is transported to the emergency department (ED) without further incident.

The ED physician tells you the treatment was exactly what was needed, and that he’s been pressing the local„EMS committee to change protocol to require right-sided chest leads in cases of inferior wall infarct. He tells you that your case will shed much-needed light on the topic.

RVIs occur in 30Ï40% of all inferior wall infarct and are caused by occlusion of the same artery (right coronary artery as the inferior wall infarct). The presence of RVI raises the mortality and morbidity of the inferior wall infarct by a factor of eight.

The patient demonstrated classic symptoms and signs; giving him fluid and being cautious with nitrates were good treatment options.

The success of this case demonstrates that multiple-choice questions may not always be best for educating students. In fact, patients are often the best ˙fill in the blankÓ questions that teach students to search beyond the obvious for answers. Although having your students answer questions is a solid educational tool, perhaps the best skill we can impart to them is to remain unafraid to actively question techniques in a polite, professional manner. The questions students will„ask as practitioners are often more important than the ones they’ll„answer as students.