Avoiding the trap of underestimating signs & symptoms

[VentMedic]

Yes, I am quoting an article from JEMS. While I may not agree with every statement in the article, it does make many valid points that should stimulate some thought.

http://www.jems.com/news_and_articles/articles/jems/3403/dont_be_a_minimizer.html

Don't Be A Minimizer

Avoiding the trap of underestimating signs & symptoms

• Rollin J. Fairbanks, MD, MS, EMT-P
• March 2009 JEMS Vol. 34 No. 3
• 2009 Mar 1

One of the worst things you can do in EMS is become a "minimizer." A minimizer is a provider who underestimates the signs and symptoms of a patient and hastily concludes they have the most benign condition possible. Conversely, the best thing we can do for our patients is initially assume the worst and work backward from there. Minimizers are typically those with "medium" experience on the street (not newbies, but not old dogs). Many of us go through a stage of being a minimizer and later recover. But chronic minimizers exist. Think about it. Are you one?

Almost all problems, whether benign or serious, have a differential diagnosis. Frequently, not all of the serious causes can be ruled out without an involved workup in the emergency department (ED). For example, take the 49-year-old chest pain patient with only one obvious risk factor—smoking. He has reproducible, sharp, right-sided chest pain. Non-cardiac, right? Wrong. If you were thinking,& Right, then you might be a minimizer. This patient was actually having a myocardial infarction (MI). You should have been thinking MI, dissection, pneumothorax or pulmonary embolism (PE) until proven otherwise.

Worse than being a minimizer is being a "myth-guided minimizer." It’s hard to break habits based on assessment myths. One of the most common is the belief that reproducible chest pain can’t be of cardiac origin. However, research shows that reproducible chest pain is nearly as likely to be cardiac in origin as non-reproducible chest pain. Because of this, some experts suggest that checking for reproducibility of atraumatic chest pain isn’t a useful part of the physical exam.

http://www.jems.com/news_and_articles/articles/jems/3403/dont_be_a_minimizer.html

Let’s consider a different patient presentation. An EMS unit is dispatched to an "anxiety attack" at a university residence hall. They find a 21-year-old college senior complaining of severe shortness of breath. It’s clear she’s hyperventilating. She tells them she feels very anxious but isn’t sure why. They ask if anything stressful is going on in her life, and they learn she’s having relationship problems and has been studying hard for finals. When taking her past medical history, they also learn she has a history of anxiety.

The paramedic on scene has it all figured out—a 21 year old, during finals week, with personal problems and a history of anxiety. He writes "anxiety attack" as the working diagnosis on his report and signs the patient off to a BLS unit. En route to the hospital, the patient becomes confused and hypotensive, and when the EMTs check the oxygen saturation, it’s found to be 86%. In the ED, the patient is treated urgently for a presumed PE. In follow-up, the EMS providers learn the patient was a smoker and on birth control. Both smoking and birth control pills increase one’s risk for developing a PE, but it’s still considered a low risk for patients under 30.

 

[HotelCo]

Good article, looks like I need to get on JEMS.

 

[JPINFV]

Well written column. My one big concern, though, is how do we prevent from tipping to the opposite end of the spectrum? If you look hard enough at most patients, you can find signs and symptoms that could be life threatening? Ignoring the ideal, 100% paramedic response to all calls by degreed paramedics, for a minute and working with reality, do we now expect basics to call paramedics for every call? Do we expect all transports to be emergent to the closest facility without care of the patients hospital preference (provided that the preferred hospital isn't some ungodly distance away)? I'd argue that swinging back to being an 'exaggerator' (the opposite of minimizer) is just as dangerous and just as bad for our patients.

 

[HotelCo]

Wouldn't you say that it's a little better to think the worst, than to just dismiss a sign/symptom as something minor?

 

[MSDeltaFlt]

I think you're missing the point. Your pt, regardless of chief complaint, needs to prove to you that they don't need something done. That requires a thorough pt assessment; not to ***/u/me.

 

[Aidey]

Wouldn't you say that it's a little better to think the worst, than to just dismiss a sign/symptom as something minor?

Theoretically yes, until you start over treating and giving the patient medications they did not need because you thought they were sicker than they really are.

 

[mycrofft]

Doen't anyone watch "House, MD"?

(If you do, do you have anyone else to dispatch to my emergency? Just kidding). By "patients lie", he really means "the diagnostic picture doesn't".

Rule one: many "diagnoses on dispatch" are errant. Don't rely on their specifics, but get yourself on scene to make your own pronto.

Rule two: if ABC's are going ok on arrival, slow down a little and get a good evaluation with repeated VS and observation. Don't dawdle, do them enroute if that's feasible and necessary.

Rule three: you aren't a human MRI and your van, no matter how big and even if it says it's a mobile ICU, is not a hospital. If you think a case is complicated and interesting, don't bogart it, share it with your colleagues in the emergency dept promptly.

Final rule: rules of thumb are not holy writ but often taught as though they are. THINK!B)

 

[willbeflight]

Wouldn't you say that it's a little better to think the worst, than to just dismiss a sign/symptom as something minor?

OK, Prime example, I was on a ride a few months back when we get a call for intractable back pain. We get there. The patient is a male in his mid 50's. He is grey in color, sweating and can't sit still due to the pain in his back, right lower quandrant . It started about an hour before and nothing he has done helps. His vitals are stable. The Paramedic on duty gives Morphine in route. Pain does not subside at all. First thought, is kidney stones. Morphine does not help much with that pain. I found out later that the patient was given basic care for kidney stones once he arrived at the hospital. On his way to CT, patient crashes. They figure out that he has a tear in his aorta behind right kidney. They rush him into OR where the patient dies on the table. Never underestamate symptoms. That is a lesson learned early!

 

[Onceamedic]

Excellent post ventmedic (as usual). I am having an issue right now with a medic that works for another agency (think fire). This is a middle level experienced guy who is egotistic enough to think that he has seen it all. Suffice to say that his minimizing of symptoms cost my patient who was having an MI about 25 minutes worth of heart muscle.

I appreciate the information. As a green medic, I don't minimize but now I know to watch out for it in myself.

I was watching one of the trauma shows on TV the other night and the ED doc in charge made the statement - "Every trauma patient is treated the same way. That is the only way to make sure we don't miss anything." He was talking about a systemized assessment. We hear a lot about not being cookbook medics and thinking outside the box. I think some providers misinterpret this to mean that they can take shortcuts in the assessment algorithms. Big mistake.

Thanks again Vent.

 

[mycrofft]

Every pt is treated the same way. Not bloody likely.

You can lose pt's by wasting treatment time while diagnosing and waiting for labs. Every pt gets treated the same to a point, then their cares diverge soon as differentials are panned out.

The aortal aneurysm case was a good example, of more than one principle. First, happened months ago; there were no more recent examples because they are so dinging rare. Second, even if they occur in the ER, those pt's are very likely to die, the symptoms are so variable and the cases relatively rare, and the damage is like a huge GSW to the most lethal vasculature to injure. Third, reassess the pt; I have my doubts that treatment for renal calculii proceded without at least a cathererd urine tested for blood etc., followed swiftly by KUB xray and ultrasound, some of which can be done bedside at the ER.

You have to take the data provided by the originating party, weigh it against their impression, while getting your differentials going. Field folks need to make sure they have accurate adequate and current data, not universal data on everything nor data narrowed by presumptive thinking.

And, while you're doing that, do your trip papers, navigate back to the hospital, and hokk/unhook the pt from vehicle O2, suction, etc. And get me a tuna melt on rye. (Fourth, you aren't infinte, prioritize).

 

[drdique]

You can lose pt's by wasting treatment time while diagnosing and waiting for labs. Every pt gets treated the same to a point, then their cares diverge soon as differentials are panned out.

The aortal aneurysm case was a good example, of more than one principle. First, happened months ago; there were no more recent examples because they are so dinging rare. Second, even if they occur in the ER, those pt's are very likely to die, the symptoms are so variable and the cases relatively rare, and the damage is like a huge GSW to the most lethal vasculature to injure. Third, reassess the pt; I have my doubts that treatment for renal calculii proceded without at least a cathererd urine tested for blood etc., followed swiftly by KUB xray and ultrasound, some of which can be done bedside at the ER.

You have to take the data provided by the originating party, weigh it against their impression, while getting your differentials going. Field folks need to make sure they have accurate adequate and current data, not universal data on everything nor data narrowed by presumptive thinking.

And, while you're doing that, do your trip papers, navigate back to the hospital, and hokk/unhook the pt from vehicle O2, suction, etc. And get me a tuna melt on rye. (Fourth, you aren't infinte, prioritize).

I couldn't agree more. About the AAA, or the tuna on rye.
Had an obese pt 2 yrs back with low backpain, no trauma, pressure in the 80's. Pressure responded to fluids and came up to 120's and no obvious pulsating mass. We delivered to rural hospital with cardiac concern. Hospital dismissed as a possible stress#, and dehydration though x-rays couldnt dx a #. The next day she was sent to a major urban centre for further assessment. She passed-away enroute to her appointment. A simple U/S could have saved this woman.

The rules apply to those treating the patient both before and at the hospital. Now in this case, it was the hospital staff who made the assumptions. Imagine if the ambulance crew had dismissed this patient as "another fat old person whining about pain" and the impression the hospital would have had then. This first impression can be very detrimental to a pt's outcome due to a lack of urgency from healthcare providers. YOu're better off to say,I'm not sure, than to write-it-off.

"Listen to the sounds of the horses, and remember the zebras." (me, 2009)

 

[mycrofft]

My dad exsanguinated in a MRI machine status-post AA repair.

In the month postop he never fully recovered from anesthesia and sedation, developed rectal bleed in nursing home, sent to ER, and bled out due to develpement of an aortal-bowel fistula secondary to erosion by the stent and possibly (I surmise) an instraoperative nick or some such.
SUCH a long shot, presenting symptom was unlike anything they'd seen associatd with AA repair...not their fault. "Insh' Allah" as they say.

 

[mycrofft]

My dad exsanguinated in a MRI machine status-post AA repair.

In the month postop he never fully recovered from anesthesia and sedation, developed rectal bleed in nursing home, sent to ER, and bled out due to development of an aortal-bowel fistula secondary to erosion by the stent and possibly (I surmise) an instraoperative nick or some such.
SUCH a long shot, presenting symptom was unlike anything they'd seen associatd with AA repair...not their fault. "Insh' Allah" as they say. But he wasn't treated just like everyone else, and it would still ahve not helped him