My partners and I used to bet doughnuts that we could out-diagnose the docs back at the hospital. We often did. What we did wasn't a real diagnosis, of course. Only Doctors can diagnose. It was more of a good guess that was right a lot of the time. 

This may sound a little silly. Doctors are more educated. They have all kinds of tests and tools at their disposal. They have a controlled environment and many more protocols than we have, but we still out-guessed them when it came to root cause. We even got secondary conditions right (like Congestive Heart Failure (CHF) or Diabetes) that lead to whatever emergency we were called upon to deal with. How can I make this claim? 

The reason for this phenomenon is simple. We have context. In the field, we see patients, bystanders and the environment in their natural state. We see first hand what else (besides our patient) has been disturbed, how people are reacting, and we hear many versions of the same story - the story of the emergency. By paying close attention to the context from which we extract our patients, we get volumes of useful information. 

For example, my partner and I were once dispatched to a small community in North Charleston, South Carolina. The call came in as "A man fell off a roof from a ladder." This was not much to go on, but as usual, I reviewed my "Ectopic Brain" for trauma related protocols on the way to the scene. 

On the way, I noticed that we were entering a depressed area. Drug activity was pretty common. Violence was equally as common. Cars were older and looked beat up. Some were on blocks in the yards. I assumed the socio-economic status of residents from this side of town was low. 

When we pulled up to the address, we saw no evidence of a ladder. The grass was tall. The siding on the house was dirty and falling dow in spots. The chain link fence was open - as was the front door to the home. We called into the residence, engaged the first adult person we could see and were invited to come inside. 

Entering the residence, we found about a dozen kids sitting around the main living room TV. They were overweight and dressed poorly. Two women seemed to be keeping watch over them. One looked disinterested. The other lead us back through the house. 

On the way back, we asked the woman leading us about what happened. She said she didn't know. That the "other #$%@" (reference the disinterested looking woman in the main living area) probably knew more. She told us that she was "...just his F$#%@ wife..." and that she never knew anything. I probably raised an eyebrow.

The wife lead us to the master bedroom where we found a late 30 something black male patient lying face down on a bed. Leg's hanging off the side just below the knee. He was clearly alert, breathing, and in pain. He cursed. 

I engaged the patient, explained who we were, and asked about what happened. He said he fell of the roof a few days ago, was having pain, and could not move his legs. I probed a little more while I started my exam and he asked me to come closer. I leaned in and he told me to get rid of the woman standing watch over us. I asked her to step outside while we completed our exam. She complied. 

Once she was gone, he explained that he had severe pain in his lower back and that he was "pissing fire." He went on to describe what seemed more like a urinary tract infection than an injury from a fall. His explanation of the fall (that happened 3 days ago) did not fit his signs and symptoms. He said he'd been walking around, working etc since the fall and had no problems that would indicate an injury. His chief complaint was clearly the pain he felt form his kidney area. 

We packaged this patient for C-Spine precautions, took further history, and transported to the hospital. When we arrived, I offered my theory to my partner: this patient had been having extra-marital sex. Probably with the second woman in the house. He probably picked up a sexually transmitted disease that went untreated for a good while and eventually became a urinary tract infection. 

I made some assumptions about the education level of this patient and his family. I made some assumptions about the behavior patterns based on the relationship between the man and the two women, the patient's desire to keep his condition quiet, the patient's age and the abundance of children. Stepping into this man's home was like reading a page from the book of this man's life. As it turned out, our guesses proved correct. 

Obviously, reading the environment and paying attention to clues is not the most definitive method for determining what's going on with a patient. Patients still need the tests and the scientific process that medical providers in a hospital setting can provide. But paying attention to the context DOES give you useful clues as to what might be going on with your patients. Passing this information on to the medical team in the hospital can save valuable time.

In the case above, we alerted the hospital medical team to what we thought was going on. This information lead to a more rapid focused assessment and treatment. The patient was treated for the UTI and the STD and I assume was ultimately released (we don't often get to find out what ultimately happens to a patient once we leave the hospital). X-rays showed there was no spinal injury at all. Pain in his legs resolved during transport. It was probably caused by hanging them over the end of the bed for too long. 

Other examples of useful context include:

  • mechanism of injury
  • bystander testimony
  • weather conditions
  • condition of the environment
  • hygiene of the patient
  • time of day or night
  • time for response / extrication / transport
  • nearby facilities and activity
  • ejection from a vehicle (or not)
  • skid marks (from braking cars) or not
  • airbag deployment
  • seatbelt use
  • stuff found in a patient's pockets
  • position the patient was found
  • hair on the patient (no hair on the extremities can often be a sign of diabetes)
  • condition of the nail beds
  • ascites
  • medications found / taken
  • etc

As a medic on the streets, you have a tremendous about of useful information available to you. All you have to do is pay attention to it. With practice, you can help the medical teams further down the line to fit together the whole picture and improve the patient experience with the entire medical system.

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