359 Mystic St — hip pain

Location: Alpha post

Time: 9:03 Tuesday

Conditions: Cool and dry

Equipmentfully stocked

 

Dispatch

You picked up the overnight shift to make a few extra bucks, got righteously worked, and now your eyes keeps wanting to close. You’ve had a few minutes of downtime, and the rumble of the truck is starting to lull you away when the radio crackles… (click for audio)

[Ambulance 61, 359 Mystic St; the sidewalk in front of 3-5-9 Mystic for a conscious, breathing 36-year-old female with hip pain. 359 Mystic is between College Ave and Upland Rd. With Engine 2. Time out 9:03. A61?]

Click to expand

 

Response

Steve wordlessly steers you in that direction, a somewhat low-income area of town only a block or two away. You easily beat the engine.

359 is a brick warehouse which looks abandoned, but standing out front is a woman who waves you down. You park by the curb and step out, bringing only the radio.

 

Scene

There’s nobody around except the patient and yourselves, although there’s actually a payphone booth nearby, which teleports you back to the ’90s, and you see a bus stop down the street. An occasional car drives past. You approach the patient, smiling.

 

Initial Assessment

It’s a reasonably healthy-looking woman with no obvious injury, nice pink skin, and unlabored breathing. You extend a gloved hand and say, “Howdy! I’m Sam. What’s going on?”

She shakes with a warm and firm grasp. In a deadpan, she tells you, “It’s my pelvis. I need to go to St. Vincent’s.”

Taken slightly aback, you say, “Ah — okay. What’s going on with your pelvis?”

“I shattered it in a car crash. I got three surgeries.”

“When was this?”

“Five years ago.”

“Okay. So what’s going on now?”

“It hurts so bad. I can’t go to work. I need help.”

“So it’s hurting more now than usual?”

“Yes. It’s been hurting all week.”

 

 


 

“Okay, ah… where do you usually go? Which hospital?”

“Anywhere.”

“Where’d you go before, when you were hurt?”

“I was at St. Vincent’s.”

“Okay, we can go there.” She’s clearly standing and ambulating without pain. “Are you okay to walk into the ambulance here?”

“Sure.” You and Steve lead her to the back, and she steps inside. “Watch your head.”

“Can you get her situated on the stretcher?” you ask Steve. He opens the straps and starts settling her in. Other crews would’ve put her in the tech seat, but you prefer to keep most folks on the stretcher for safety and easier manhandling.

You pop back outside and flip your radio over to the fire channel. “Firecom, A61?”

“Go for Firecom.”

“You can cancel the engine for Mystic Street.”

“Okay on the message. Engine 2, you’ve been cancelled, cleared by the ambulance.”

“Engine 2 has the cancellation, returning.”

You hop up into the back, where Steve’s got the young miss buckled in, and is taking a blood pressure. “Okay, so rewinding a bit, what’s your name?”

“Janine.”

“Janine…”

“Swift.”

“And your date of birth?”

“November second, ’77.”

She really is 36. Looks about twice that.

“Okay, so, five years ago you had a car accident, you fractured your pelvis –”

“Shattered.”

“– you shattered your pelvis, they operated on it at St. Vincent’s –”

“Three operations.”

” — and since then it’s been mostly okay? Or does it often hurt?”

“It hurts a lot, but it’s been terrible this past week, I can’t go into work.”

“Do you usually drive?”

“I take the bus.”

You rub your temples. “Right. Does it hurt all the time? Just when you move it, or try to walk, or what?”

“All the time.”

“Did you see anybody about this? More recently than five years ago?”

“I saw my doctor… he gave me Tylenol.”

Steve hands you a card that says:

126/82

88

18

BS

You’re pretty sure the last refers to neither blood sugar nor bowel sounds.

Very briefly, you examine Ms. Swift’s hips and lower extremities, firmly compressing her pelvis from the sides and checking distal circulation. It is excitingly unremarkable. “What sort of pain are we talking about here?”

“It’s really sore.”

“Any numbness, tingling, weakness in either leg?”

“No.”

“No trouble urinating?”

“No.”

“Any other medical problems?”

“No.”

“What medications are you taking now?”

“Just Tylenol.”

“Right on.” You rub your temples again.

Steve has slipped around you and is standing at the rear footstep.

 


 

“Okey doke, let’s take it to St. V’s on a 3,” you tell him. He closes you in, and in a few moments you’re chugging down the road.

“Do you have any allergies?”

She shakes her head.

“What were you doing where we picked you up?” you ask. “Do you live there?”

“No, no,” she answers. “I was waiting for the bus.”

“The…” Forget it. “Okay, hang on one second.”

You plop over to the tech seat and grab the radio. You tone out St. Vincent’s, and when they acknowledge, announce… (click for audio)

[Hey there St. Vincent, Scenarioville Ambulance 61. We’re eight minutes out with a 36-year-old female, complaining of worsening pelvis pain over the past week, consistent with an old injury. Doing okay; any questions?]

“N… ooo, thank you 61. St. Vincent’s clear.”

You chat aimlessly for a bit, but have a hard time finding much common ground.

Before long, you’re backing into the bay, and Steve comes to retrieve you. As you roll the stretcher inside, an unshaven nurse raises an eyebrow from behind a computer. “Pelvis?”

“Yep.”

“Triage.”

You roll through the ED, out the rear doors, and into the walk-in waiting room. There you have Ms. Swift step off and into a wheelchair, which you roll into one of the triage nooks. You give the nurse the name and DOB, and then inform her… (click for audio)

[So, Ms. Swift had a car accident about five years ago, shattered her pelvis, had a few surgeries to repair that; since then she’s had some associated pain on and off, but this past week it’s been especially bad, just getting worse and worse, and she hasn’t been able to get into work or anything, so she called us. No other history, takes Tylenol, normal physical, no allergies.]

The nurse taps at her computer. “Pelvis? Like, where?”

“Everywhere,” Ms. Swift states drily.

She asks a couple of her screening questions (yes she feels safe at home, yes she smokes, no she doesn’t drink alcohol, and so forth), then intones, “Okay, we’ll call you back in a few minutes.” You park her wheelchair in the waiting room where she can see the TV.

“All right, they’ll come get you when there’s a bed. All set?”

She nods; “Thank you.”

You shake. “Good luck.”

Out in the bay, Steve is eating sunflower seeds. “Pelvis pain? You’re kidding me, right? Right?”

“Hey, she was very… very…” You pause. “Okay, I got nothing. Let’s go.”

 

Discussion

Diagnosis: malingering

The reality for most EMS systems today (particularly in urban areas), and in fact for most of modern medicine — including EM and primary care — is that a substantial number of the patients that present do not have the complaints they describe. Their motivations vary, but one of the most common is drug seeking behavior — asserting symptoms that prompt healthcare providers to administer or prescribe narcotics or other medication with recreational potential.

These patients are difficult because they create emotional dissonance. We want to help people, yet we hate to be tricked, and believing we’ve been “conned” can provoke from us a hostile response. Needlessly treating fictitious complaints burdens the system and encourages further abuse, yet trying to weed out such patients runs the risk of undertreating those with legitimate complaints, which we should consider one of the worst possible outcomes.

In general, although primary care providers and emergency physicians should probably see it as their job to make a reasonable effort to screen for such behavior, that is not the responsibility of EMS. Treat all patients professionally, and presume that they have the symptoms they describe, without regard for their possible motivations.

Remember that it’s not your job to judge. Regardless of medical legitimacy, everybody is fighting some battle.

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