Airway & Respiratory, Cardiac & Resuscitation, Columns, Patient Care

Say a Prayer for the Pretender

As the practice of medicine has advanced, so have the capabilities of prehospital care. Less than 20 years ago, we based the diagnosis of appendicitis upon the findings of right lower quadrant pain on physical examination, an elevated white blood cell count and the presence of fever. We determined screening for intra-abdominal hemorrhage due to trauma by performing a peritoneal lavage. CT scans were rarely available as a diagnostic tool.

The majority of patients did well in those days. However, I’m certain more patients with abdominal pain due to gastroenteritis underwent surgery to have a normal appendix removed. Likewise, we discharged patients with acute appendicitis exhibiting less-than-traditional clinical presentations. Every case of missed appendicitis that returned to an emergency department (ED) with sepsis from a perforation was evidence that, with the help of technology, the diagnostic process needed improvement. In the management of trauma, many blunt traumatic injuries diagnosed by CT scans are treated with simple observation and supportive care. It’s now rare to see the performance of open laparotomy, peritoneal lavage for diagnostic purposes, or drilling burr holes for head injuries based solely on signs and symptoms.

The advancement of patient assessment and acute therapeutic interventions in the prehospital setting is wonderful for our patients and profession. Although transport would be the primary action taken in select cases, we have more diagnostic and patient assessment tools that permit EMS providers to utilize specialized protocols to initiate definitive care. Many of these protocols involve time-sensitive interventions, such as our three-hour window for stroke protocols and our door-to-balloon goals of less than two hours from acquisition of an ECG-diagnostic of an ST-segment elevation myocardial infarction (STEMI) to performance of an interventional cardiac catheterization. Especially in these, EMS plays a more crucial role in achieving these goals than ever before now that we have these time-sensitive clinical standards.

Beware of wolves in sheep’s clothing
In our haste to beat the clock, we must still be cognizant of other pathologic processes that can be wolves disguised in sheep’s clothing. There have been many cases of an inexperienced intern ordering a plethora of expensive diagnostic tests only to discover — after all of the patient’s money has been spent on these studies — that the patient was exhibiting stroke-like symptoms due to hypoglycemia. Blood glucometers and dextrose are cheap and can save a lot of money if you’re willing to use them.

Likewise, a patient with a history of migraines or partial seizures may present with a focal neurological deficit known as Todd’s paralysis. I cringe at the thought of how many patients are emergently transported by healthcare providers who suffer from Dr. Bryan Bledsoe‘s dreaded condition of rotoriasis (the overzealous utilization of aeromedical services). These are solely due to the lack of obtaining an adequate medical history and performing primary and secondary patient assessments prior to transfer. A stroke victim doesn’t meet the criteria for thrombolytic intervention if they have symptoms that are isolated to confusion without motor deficits, have significant symptomatic improvement, or if the victim awakened from a night’s sleep with symptoms for which the onset can’t be clearly determined.

In addition, chest pain can be the presenting symptom for many disease processes. An MI results when the oxygen supply to the heart is reduced or disrupted due to coronary arterial occlusion, typically from an atheromatous plaque or a thrombus. A patient’s symptom of chest pain can arise from cardiac, pulmonary, gastrointestinal or other sources, and a 12-lead ECG is just one of many diagnostic tools to evaluate chest pain.

However, a 12-lead ECG may display evidence of a STEMI during an aortic dissection where the occlusion of the coronary arteries is secondary to the separating intima of the aorta physically blocking the lumen of these arteries. If this diagnosis is considered in the ED, a chest X-ray may reveal a widened aortic arch and a chest CT-scan can confirm the diagnosis. An aortic dissection is a difficult, if not impossible, diagnosis to make in the field. Yet the astute EMS provider may suspect it if a significant difference exists in the blood pressure measurement or the pulsatile quality between the right and left arms. A pattern of ST-segment elevation can occasionally be seen on an ECG in patients with a large pneumothorax. An X-ray machine might not be available in the squad, but you certainly may note a patient’s decreased breath sounds if you take a moment to look away from the ECG and carefully auscultate the patient’s chest.

Patients with recent MIs can develop Dressler’s syndrome, a post-MI pericardial effusion. Even in the best scenario, there is no such thing as perfection and some of these unusual cases will fool even the most experienced and skilled medical professional. I once had a patient who presented complaining of chest pain and had S-T segment elevation on his ECG. He was a heavy smoker and had a history of hypertension, hyperlipidemia and a strong family history of heart disease. His lung fields were clear, and he had no visible evidence of trauma. I spoke further with him while acquiring his medical history and asked him about past traumatic events. He recalled he had fallen off of his jet ski a few days before the onset of his chest pain and that it may have struck him in the chest. I deferred administration of anticoagulants or thrombolytics momentarily to obtain a bedside ultrasound of his chest, which revealed a traumatic pericardial effusion. Whew! A moment of pause and patience granted this patient a dose of good luck.

In all these cases, the administration of anticoagulants is clearly contraindicated and would have left you and your colleagues united in chorus singing “Swing Low, Sweet Chariot” at the bedside with potential malpractice litigants hovering above your heads like vultures loitering over road kill.

Deliver definitive (and thorough) care
I fully support prehospital protocols that facilitate the delivery of definitive care to our patients. An EMS system must create protocols that coincide with available resources. Some emergency care facilities, especially in rural areas, do not have CT scans, cardiac catheterization labs, or neurosurgical or cardiothoracic surgical capabilities. In these regions, a greater onus is placed upon the shoulders of EMS providers to utilize avenues within their protocols, including telemedicine and aeromedical support, to assist the appropriate triage and transport of patients in need of these services to tertiary care centers.

Medicine is an art and not a perfect science. One of the mantras within the Hippocratic Oath, “Above all else, do no harm” realistically applies to all members of the healthcare team. Regardless of the growing number of diagnostic toys in our toy boxes, we’ll never have a substitute for obtaining a detailed history and performing a through physical examination. The more we repeat questions during each stage in the chain of the emergency care process, the more information the patient or their loved ones may remember and add to our data bank. Your hands-on examination may add more to the equation than the information from a machine. We must all take the time to talk to and examine our patients regardless of the message our initial diagnostic data sends, and beware of the pretenders. If your cardiac monitor is displaying asystole and your patient has a pulse and is smiling at you, guess what? The patient’s always right.