When it comes to vital clinical skills that simply aren’t taught in EMT class, it’s hard to think of one more important, more frequently called upon, and less formally instilled than this: the ability to determine a patient’s medical baseline.
What’s that even mean? Simple enough. People call us because they have problems — specifically, new problems, or at least new complications of old problems. They don’t call us because of the stroke they had five years ago, or their existing stable angina, or because they still have dandruff. (Okay, sometimes they do, but then we ask why they really called.) So when you’re presented with the patient who has all of those things, the question is: what’s new?
Usually, of course, they tell you. “What’s going on?” “Oh, my stomach hurts.” Most days their stomach doesn’t hurt, today it does, they want to know why. Fair enough. But then you continue through your history and physical — does this hurt too? can you feel that? look here, please — and you find various other abnormalities. Are those new? If so, they may be important. If not, nobody cares. Nobody will thank you for performing a masterful assessment, stroking your beard, and announcing to the world: “I believe the patient has… cancer!” when it was diagnosed a year ago and the patient is already undergoing a planned course of treatment.
This was all much easier in the textbook. They spent quite a while teaching us what healthy people are like — their vital signs, their anatomy, their physiology — so that we’d recognize when someone deviated from that, and we could figure out why. And of course, that method works. As long as your patients are healthy. Unfortunately, healthy people don’t call 911 nearly as often as sick people. Forty years ago, maybe the majority of our patients were generally well individuals with acute problems — broken legs, allergic reactions, unexpected heart attacks — but nowadays, the bread and butter of EMS consists of treating acute exacerbations of chronic disorders, or new complications in the setting of multiple comorbidities.
So how do you figure out which irregularities are worth remarking upon, and which are unremarkable for the patient? Here are some tips.
1. Ask the Patient
When they’re able to help out, the patient is one of the best sources of information. Do you know how your blood pressure usually runs? Is your pulse normally a little slow? When did you get this bruise?
Patients with adequate memory and cognition are generally pretty good historians about their own bodies. Not necessarily the details — sometimes the endless litany of acronyms, tests, and diagnoses can blur together — but the personal stuff. They are intimately aware of the fact that they’re usually nauseous in the mornings, they’re told about their high BP whenever they visit the doctor, and they notice their abnormal pupil every time they look in the mirror. Patients with some cognitive impairment may be less able to help you out here, but as a rule, they should still be your first source — you should simply view their input with the appropriate amount of weight based on their perceived reliability. Of course, you should try to corroborate, and the best way is to…
2. Ask Someone Else
Most sick people, particularly those who aren’t 100% capable of taking care of themselves, have other people closely involved in their care. For those who live at home, these people are often family members or occasionally an aide or visiting nurse; for those living in a facility, it’s the nursing staff. (And for a patient being discharged from the hospital, it’s the doctor or nurse responsible for them.)
These people have spent ample amounts of time with the patient, so they “know” them — but moreover, they’re medically trained (or in the case of family, often have a sort of on-the-job medical familiarity of the patient’s conditions), so they know them medically. They not only have a reliably story to tell, they can often answer questions about the kind of medical signs you may be puzzled by. Oh yes, he’s got A-fib, his pulse is always like that. No, normally he’s alert and oriented, conversational, I don’t know what’s wrong with him now. Even friends or bystanders can sometimes help you out here — oh yes, Jeff has epilepsy, he takes medication for it, but he hasn’t seized like this in years.
This is the kind of information to gather before you leave a scene, because not only can it be important, you may be the only person who can obtain it. Once you show up at the hospital, if relevant history is missing from the clinical picture, the ED staff may try to make some calls and ask questions, but it’s much more difficult than if you did your job right to begin with.
This is also why it’s highly advisable, whenever time permits, to perform a reasonably full assessment prior to leaving the scene. That way when you find something striking, you can simply ask someone — is this normal? Nothing’s worse than taking an initial set of vital signs ten seconds after you start transporting, finding a blood pressure of 86/40, and wishing you’d done it five minutes earlier so you could’ve asked the nurse. (In fact, if you did this before leaving the floor on a discharge, they might just decide not to send the patient after all.)
One trick I’ve tried when I wasn’t smart enough to assess on scene is to simply call back. You’re bringing someone from a facility, and on the way, you find something funny. You’d love to know if it’s new or existing. Crack open the paperwork (or ask your dispatch) and find the phone number for the sending facility, punch it into your phone, ask for the floor or wing you took the patient from, and request the nurse who covered your patient. Then you can identify yourself and just inquire: “Hey, this dude’s got a blown pupil. Is he always like that?” This probably won’t work with most scene calls, unless you have a number for an emergency contact, but I suppose you can try to track someone down.
When nobody’s available to answer your questions, your best bet is simply to…
3. Consider the Context
As we often talk about, clinical decisions and diagnoses aren’t made from isolated findings. You have to look at the whole picture.
I love dialysis patients, because they’re like case studies in exercising clinical judgment. I have had regular dialysis patients who were at baseline non-verbal, marginally responsive, routinely hypo- or hypertensive, routinely tachy- or bradycardic, dyspneic, hemiparetic… pretty much anything you can imagine. Obviously if you know them you might have a better idea of their baseline, but again, with some of these people, I would not bat an eyelash to find them with a blood pressure of 80/70 on one day and 176/100 the next. Was either one an emergency? Not necessarily. It was probably something the dialysis staff and potentially their nephrologist would like to know about, but once again, it’s not helpful to anyone if you throw up your hands and announce that the person with kidney failure is sick. They know.
In any case, how do you figure out when their derangement is significant? Look elsewhere. Big problems have a big footprint. If the patient is communicative and reliable, how do they feel? Lousy? Fine? Weak, dizzy, nauseous? Pain in their chest, their head? Consider their history, look elsewhere in the body, and examine their medications. Assemble all the data you can, so that your findings are no longer a lonely, isolated result, but just one of many meaningful indicators.
To suggest that something might be important yet has no effects is to invite the question: if it’s not affecting anything, who cares? For instance, I once discharged a patient whose pulse was in the low 40s. No notation of this was found in her documentation, nor any obvious reason why she should be bradycardic. I eventually called back to her floor and her nurse confirmed that it was typical for her. But even if this hadn’t been possible, I would still have known the rest of her presentation: she was alert, oriented, mentating well, pleasantly conversational, and had a reasonable blood pressure and normal skin signs. She was experiencing no distress or acute complaints, and she was reliable enough that if she had been, she’d have been able to communicate her symptoms. So what were the chances that her bradycardia was something new, alarming, and indicative of a dangerous situation? Not very high.
The biggest challenge here is the patient with so many other comorbidities that they become difficult to clinically assess. If they can’t communicate well (or can’t communicate in your language), and at their baseline they have a wide variety of derangements, it can become difficult to wade through everything and isolate new badness from the tangle of typical badness. Use your noggin and do your best.
Finally, your fallback is always…
4. Get to the Right Hospital
Barring anything else, even in the most baffling of situations, most clinical mazes can be untangled if you transport the patient to their usual hospital.
By this I mean wherever they’re typically followed. It may or may not be their requested destination, although it usually is; in any case it’s where they get most of their care (often a nearby community hospital, although sometimes it may be more distant). Some providers give little consideration to these requests, preferring to push for transport to the closest facility or specialized points of entry, but this isn’t just a matter of where the patient likes the meatloaf and the nurses. If you show up with the non-communicative patient with a bizarre presentation and minimal available history, at a hospital that’s never seen them before, they are going to be just as baffled as you are. Eventually they may be able to sort most of it out, but only after substantial time and potentially invasive and unnecessary testing — not exactly the most timely and appropriate care. Remember that although one hospital can usually request records from another, it’s often a cumbersome process involving phone calls and faxed charts, and will never be as comprehensive as what the original facility has access to. (The exception may be hospitals that share an affiliation, which may use the same computer system and hence can mutually access shared records.)
Extremely complex medical histories should go to their customary hospital whenever possible. In some cases, the situation may be so unique that an outside facility won’t even want to touch it — your patient will simply be stabilized and transferred to their normal hospital. This is particularly true when there’s been a recent procedure, devices like an LVAD are in place, or the patient has a rare medical disorder; these patients really may need to be attended to by the specific physician who knows their case, and that kind of familiarity can’t be transmitted by fax.
Long story short, this whole process can be challenging, but managing it is one of the basic skills we need to hone if we’re working in the field. Any monkey can point to the ways that someone differs from textbook normality; it takes a discerning eye to pick out the changes that are relevant to our business of emergency medicine.
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