What the Heck is a General Impression?

I’m tired of all the mumbo-jumbo.

Here’s my beef. Every medical provider, particularly those who work in the acute setting (such as prehospital medicine, critical care, or the emergency department), talks about a concept familiar to us all: the overall, gut sense of how ill a patient appears. In EMS training this is often described as the “general impression,” the “view from the door,” “big sick vs. little sick,” or other euphemisms. It’s your basic opinion of whether a patient is doing okay or not, and it’s formed within the first moments of contact.

Whatever you call it, it’s important. In fact, this one factor is often what really drives your management decisions. If a patient looks truly sick, it may not matter what the vital signs show or how the history sounds; they’re getting zipped over to the hospital with bells on. Conversely, if they look really well, it’s hard to get excited even if they complain of “12 out of 10 pain” and their pulse is 100.

Here’s the rub: everybody acts like this quality is completely impossible to describe. If you tell me the patient “looked sick” and I ask what you mean, you’ll probably wave your hands and reply that it’s ineffable; that you “had to be there”; that you know it when you see it, but that it can’t be quantified and can’t be analyzed.

If true, that would mean it can’t be taught, either. New providers would have to learn to recognize this mystical patient presentation by dint of long, hard-earned experience.

And perhaps this is true. Certainly there are other aspects of patient evaluation and management that actually are too complex to reduce to simplicities. Indeed, one of the central skills of medicine, and one that humans are uniquely equipped to perform (hence the last one that computers will take from us), is our ability to extract a diagnosis from a large number of variables by recognizing subtle patterns.

But I doubt that’s true here. Why? Because you form your general impression within the first moments you meet a patient. There just aren’t very many factors that can come into play, because you haven’t obtained much information yet. The view from the door isn’t going to include ECG findings or subtleties of the OPQRST.

So I have a theory, and here it is. The entire mythical gestalt of your general impression actually involves only three things: the patient’s behavior, their breathing, and the appearance of their skin.

Behavior

The first thing you notice when you meet a person is their behavior. This mostly means two things: their mental status and their level of distress.

A sick patient may be unconscious, or visibly lethargic; healthy people are awake and alert, because the brain is one of the last things the body allows to shut down. They’re also not obviously loopy, such as profoundly confused or combative, unless they have a chronic condition such as dementia.

And if sick people aren’t so sick they can’t complain at all, then their complaints reflect their acuity. They scream, they moan, they are visibly distressed by pain or fear. They say things like they’re dying or can’t breathe or can’t see or can’t move.

Some interpretation is needed here, because appropriate behavior can depend on the circumstances. Malingerers may say they can’t breathe when they clearly can. Panic attacks may present with greater distress than the physiology warrants. A child is most reassuring when grabbing at your stethoscope and stealing your gauze. And an infant may be normal when he cries vigorously and sick when he sits in silence. But it all comes down to how the patient is behaving.

Breathing

The patient’s breathing can be evaluated from across a parking lot. You can’t auscultate or measure their oxygen saturation, but you can get a general idea.

Are they breathing at all? Are they laboring, wheezing, gasping agonally, gurgling through pulmonary edema? Are they chatting easily with the firefighters, or is sucking down air the sole focus of their attention?

Skin

Skin appearance is an idiot-proof and instantly recognizable finding.

The most common sick skins involve pallor and diaphoresis. Shocky or otherwise sympathetically-charged patients are starkly white and sweating like they’re in a sauna. It’s one of the most characteristic appearances of acute illness.

Cyanosis is next up. “Shortness of breath” in a patient who’s pink, warm, and dry is one thing, but it’s quite another when they’re turning blue.

Less common findings include the red-hot skin of fever, the yellow skin of severe jaundice, the dry skin of dehydration, and the dependent lividity of the very dead.

That’s all, folks

When you talk about a patient who looks sick, or “doesn’t feel right,” or has some other nebulous problem like being “toxic,” you’re not tapping into some vast, indescribable vault of clinical judgment. All you’re doing is using shorthand that refers to the patient’s behavior, breathing, and skin. (Notice how these factors are emphasized in our initial assessment.)

A gut belief that a patient has a big problem after a full work-up (including an H&P and diagnostics) is a different phenomenon, and suggests that your intuitive side is recognizing a larger pattern that your conscious self hasn’t yet been able to label. But that’s a distinct process from the instantaneous triage you perform when you first walk into a room.

There may be exceptional cases where something different sets off your alarm bells. But I bet most of the time, it can still be linked back to one of these three categories. (An example might be the frequent flier, well-known to you, who is usually stoic but today seems worried and wants transport. That’s a discrepancy in their behavior, ain’t it?)

Don’t believe me? Just think of how you tell the stories of your sick patients. I’ll bet you say things like, “I walk in, and he’s bent over gasping; his skin is completely soaked and looks whiter than copier paper.” Those are the factors that we recognize as important, and that’s why they’re so vividly evocative. They’re the colors we use to paint the picture of badness.

I may raise some ire by dismissing the voodoo surrounding the clinical gestalt, but here’s my challenge: if you believe there’s more behind your general impression of “sick or not sick,” then reply in the comments and tell me what it is. Maybe I’m missing or forgetting something. Maybe I’m doing it wrong and you’re doing it right. But if you can’t point to what’s missing, then I’m betting there’s nothing more to it after all.

The Long-term Care Ombudsman: Advocates on Call

Although we like to talk around here about exciting topics like shock and airway management, the reality is that for many EMS providers — particularly at the BLS level — a large part of this job isn’t stabilizing emergencies. It’s routine work like dialysis trips and stable transfers from nursing facilities. Some folks find this stuff dull, and it can be dull, but the best way to make it interesting is to approach it just like the exciting stuff and try to be excellent at both aspects of the job.

How can you excel at bringing Mr. Smith to his third doctor’s appointment this week? You can learn to be a really good patient advocate on his behalf, something that almost all residents of long-term care facilities need. We’re well-positioned to fill this role because we have a one-on-one relationship with our patients. Unfortunately, we often lack the know-how and leverage to resolve most of their problems.

Our feature in the August 2014 issue of EMS World talks about how to use the ubiquitous Long-Term Care Ombudsman program to help. It’s easy, it works, and even if you didn’t know about it, there’s one available in your area. Give it a read and think about bringing it to bear the next time the guy on your stretcher has something to say!

Murder by Checklist

Reader Steve Carroll passed along this recent case report from the Annals of Emergency Medicine.

It’s behind a paywall, so let’s summarize.

 

What happened

A young adult male was shot three times — right lower quadrant, left flank, and proximal right thigh. Both internal and external bleeding were severe. A physician bystander* tried to control it with direct pressure, to no avail.

With two hands and a lot of force, however (he weighed over 200 pounds), he was able to hold continuous, direct pressure to the upper abdomen, tamponading the aorta proximal to all three wounds.

 

Manual aortic pressure

 

Bleeding was arrested and the patient regained consciousness as long as compression was held. The bystander tried to pass the job off to another, smaller person, who was unable to provide adequate pressure.

When the scene was secured and paramedics arrived, they took over the task of aortic compression. But every time they interrupted pressure to move him to the stretcher or into the ambulance, the patient lost consciousness again. Finally en route, “it was abandoned to obtain vital signs, intravenous access, and a cervical collar.”

The result?

Within minutes, the patient again bled externally and became unresponsive. Four minutes into the 9-minute transfer, he had a pulseless electrical activity cardiac arrest, presumed a result of severe hypovolemia. Advanced cardiac life support resuscitation was initiated and continued for the remaining 5-minute transfer to the ED.

The patient did not survive.

 

When the cookbook goes bad

The idea of aortic compression is fascinating, but I don’t think it’s the most important lesson to this story.

Much has been said about the drawbacks of rigidly prescriptive protocol-based practice in EMS. But one could argue that our standard teachings allow for you to defer interventions like IV access if you’re caught up preventing hemorrhage. Like they say, sometimes you never get past the ABCs.

The problem here is not necessarily the protocols or the training. It’s the culture. And it’s not just us, because you see similar behavior in the hospital and in other domains.

It’s the idea that certain things just need to be done, regardless of their appropriateness for the patient. It’s the idea that certain patients come with a checklist of actions that need to be dealt with before you arrive at the ED. Doesn’t matter when. Doesn’t matter if they matter.

It’s this reasoning: “If I deliver a trauma patient without a collar, vital signs, and two large-bore IVs, the ER is going to tear me a new one.”

In other words, if you don’t get through the checklist, that’s your fault. But if the patient dies, that’s nobody’s fault.

From the outside, this doesn’t make much sense, because it has nothing to do with the patient’s pathology and what might help them. It has everything to do with the relationship between the paramedic and the ER, or the paramedic and the CQI staff, or the paramedic and the regional medical direction.

Because we work alone out there, without anybody directly overseeing our practice, the only time our actions are judged is when we drop off the patient. Which has led many of us to prioritize the appearance of “the package.” Not the care we deliver on scene or en route. Just the way things look when we arrive.

That’s why crews have idled in ED ambulance bays trying over and over to “get the tube” before unloading. That’s why we’ve had patients walk to the ambulance, climb inside, and sit down, only to be strapped down to a board.

And that’s why we’ve let people bleed to death while we record their blood pressure and needle a vein.

It’s okay to do our ritual checklist-driven dance for the routine patients, because that’s what checklists are for; all the little things that seem like a good idea when there’s time and resources to achieve them. But there’s something deeply wrong when you turn away from something critical — something lifesaving — something that actually helps — in order to achieve some bullshit that doesn’t matter one bit.

If you stop tamponading a wound to place a cervical collar, that cervical collar killed the patient. If you stop chest compressions to intubate, that tube killed the patient. If you delay transport in penetrating trauma to find an IV, that IV killed the patient.

No, let’s be honest. If you do those things, you killed the patient.

Do what actually matters for the patient in front of you. Nobody will ever criticize you for it, and if they do, they are not someone whose criticism should bother you. The only thing that should bother you is killing people while you finish your checklist.

 

* Correction: the bystander who intervened was not a physician, but “MD” (Matthew Douma), the lead author, who is an RN. — Editor, 7/22/14

Toastmasters for Trauma Patients

Almost everybody in healthcare has to occasionally deliver verbal reports to their colleagues or counterparts, and almost everybody starts out bad at it. It’s a weird skill and one that takes practice, even though all you’re doing is describing what the deal is with a certain sick person.

Here’s a little walk-through discussing one important aspect of a good verbal report — a clear, coherent structure of tone, cadence, and body language that gives your words “shape.” You shouldn’t sound like a robot, because robots are hard to understand. Be Martin Luther King Jr; that’s a man who knew how to make himself heard.

We’ll be practicing with the hand-off report Sam gave to University Hospital on the Mystic St and Beverly Rd call.

A Saving People Thing

This isn’t a criticism, Harry! But you do… sort of… I mean — don’t you think you’ve got a bit of a — a — saving people thing?

Harry Potter and the Order of the Phoenix, JK Rowling

 

In a few weeks, I will be leaving the ambulance indefinitely.

I’m moving a couple states away to return to school, a Physician Assistant program that begins in June. And while I hope to try and work an occasional shift with a more local service, it remains to be seen whether that will be possible. So I’m now approaching a crossroads where, after approximately four years of wearing a patch on my shoulder (many different patches, to be sure), I might soon be giving it up forever.

It’s a strange sensation. It’s been pointed out that, unlike other professions — butcher and baker and candle-stick maker — EMS has a unique ability to dominate the lives of its men and women. How many doctors and nurses do you see with bumper stickers, tattoos, and T-shirts proudly advertising their trade? For many of us, you don’t work as an EMT or a paramedic, you are one; it’s part of our identity. (That’s why it can be so devastating when, through life or injury or the whimsy of employment, we suddenly find ourselves without a uniform to wear — many of us don’t know what to replace it with.) There are prominent physicians of many years who still include “NREMT-P” among their credentials. That’s like an attorney listing his high school oyster-shucking job on his CV.

There are probably many reasons for this. Buckman has observed that becoming an EMT is one of the fastest and easiest routes to “feeling important” — one quick class, and you can break traffic laws and tell everyone you’re a lifesaver. We like that, I’m sure. There’s a lot of ego in this business.

But I suspect that it also attracts people who embrace its fundamental nature. At the bottom, this job is about going to people in distress and helping them. And there is something in us — I think in everyone, although stronger in some — that wants to do that. It resonates with us as humans. (Of course, many other things resonate with humans, including sex and bacon and a great parking spot. But that’s all right. We’re complex creatures.)

The point is, this business allows us to play that role in a unique way. I believe that someday I may enjoy sitting in an office and treating patients who walk in the door, or waiting in an emergency department, or roaming a hospital floor. But that’s different; you are the all-knowing Man on the Mountain, and your patients come and form a line to beg for your wisdom. On the ambulance, people call for help, and we go to them. We take the trouble; we’re the humble servant. Yes, they have to ask, but once they do, we bring the noise, we say: “There, there. We’re here now. Everything’s going to be all right.” In the simplest, most fundamental template of this job, people have problems and they call us; we hear the call and we drive toward them; we walk into their home or business or any of the places that people go; we see a human being in distress; and we kneel beside them and ask, “How can I help?”

By coming to people in their time of need, we get closer to the heart of it all. By our willingness to kneel, we open ourselves for the dying eight-year-old to ask: “Mrs. Nurse, will you hold my hand? I’ve never died before and I’m scared.” And that’s special, and it’s not such a bad thing to elevate it, even though — as Thom Dick reminds us — no matter how much we love it, it won’t love us back.

No matter where I go from here, for me, EMS will always be about that feeling of kneeling beside someone. Or the experience of sitting on the ambulance bench, alone, just my own thoughts and a trusting and vulnerable patient.

That moment when I walk into the room, and all eyes turn to me.

The mental perk-up as the radio crackles, and the extra acuity that dials in as I recognize my call sign and my gears start turning.

Opening my mouth to give a report to a trauma bay filled with nameless people wearing scrubs.

Holding an old lady’s hand as we bounce down the road.

Touching a shoulder as I say good-bye.

Iced coffee from Dunkin’ Donuts, titrated to my tiredness.

The smell, sound, and non-stop rumbling of a diesel engine.

Black shoe polish.

Sitting beside a partner and feeling like it’s the two of us against the world.

There’s a lot that’s wrong with this job. But there’s something that’s right about it, too, and it’s something important. And that’s why we keep coming back.

I’ll be busy soon, and this site will have to take a back burner. Updates will come less frequently, and I can’t guarantee new scenarios or new posts or new Library material on any reliable schedule. But wherever I end up, I don’t plan to turn my back on it. Because even if you leave the ambulance, I’m not sure if you ever stop being an EMT.