Every once in a while, you’ll run across a patient care report that causes your blood pressure to spike, your pulse to double and your “I’m going to fire someone” trigger finger to get itchy. We were reviewing some charts last week when one launched my sympathetic nervous system into overdrive. A 34-year-old woman was awakened in the middle of the night with a fast heartbeat and “anxiety.” Her vitals were pulse 112, respirations 24, and bp 134/90.

The paramedic crew was kind, compassionate, reassuring and clinically incompetent. It was clear from the patient care report that they heard the word “anxiety” and decided that she did not have a significant medical problem. When we hear the word “anxiety” in a chief complaint, pulmonary embolism is the first thing that pops into our minds along with a host of other serious or potentially life-threatening conditions. We’ve been around long enough to know that some people who complain of anxiety need nothing more than to attend a Tony Robbins seminar, but there are others—more than many paramedics realize—who will die quickly without proper diagnosis and intervention.


The problem is that the tools to make that differential diagnosis have yet to make it to the prehospital world. Heck, even in the hospital one-third of pulmonary embolisms are misdiagnosed or missed completely. Most of the people who die from pulmonary embolism were never treated for it.


One of the first considerations in both quality management and the Just Culture framework is, “How much influence did system issues have on the situation you’re investigating?” During the interview with the paramedics involved in this case, they made it clear that they were kind and compassionate with the patient as they talked her down, but that they did not believe that she might have a serious medical issue. Their anxietybased report to the receiving hospital set the triage nurse up to place the patient in the waiting room rather than a bed in a monitored room.


After some coaching by our medical director, the crew came to the realization that they can be kind while they do a full work up. During our conversation with them, they indicated that everyone treats these patients this way. We checked with a several other medics in our operation who confirmed that we may have a culture of underappreciating the full spectrum of serious medical conditions that a complaint of anxiety or hyperventilation should have.


Disciplining or providing individual employees with education will not solve system-level culture problems. The system and culture must be changed. To be successful, a full performance improvement project needs to be chartered. In this case the medics involved are taking the lead by providing system-wide education on the appropriate differential diagnosis and treatment for complaints involving anxiety, panic attacks and hyperventilation. This will be followed up by creating a system-level performance indicator that measures the percentage of patients with an anxiety-like chief complaint who are fully worked up. Cases in which care was inadequate will be followed up with individual coaching until the overall percentage of patients receiving appropriate care is sustainably high.