My old partner Arthur once said I was too nice -- that I believed everything my patients told me. I didn't really agree with him. I was actually sort of torqued he said it because he told it to a newspaper reporter who was riding along with us that day to do a story. I didn't like the implication that I might be naive or gullible.
True, he made that comment ten years ago, but I think I am as good as anyone at sorting out the bullshit. I've done enough calls over the years to be have been able to build up a pretty good "Yeah, right" meter. I can spot a fake seizure the moment I walk in the door. I need a little more proximity to a patient to tell when they are feigning unresponsiveness, but I am rarely fooled. These of course involve a degree of physical assessment and observation. Any medic who has spent his time in the street can pick this up. After awhile, you run out of ways to get burned. You've learned every trick in the book, and you don't fall for the shit anymore.
I remember quite a number of years ago I was called to help another medic on a seizure call. This was when we only carried Valium and could only give it IV. A patient was seizing, you had to get a line and this medic was having trouble getting one. I opened up the back door and saw right away that the patient was arching their back and moving their limbs asynchronously. I climbed into the back leaned over the man and said "Knock it off!" he immediately stopped. I nodded to the other medic, who was dumbfounded. Then I exited, clearing the assist without another word.
I have found that phrase and the authoritative tone behind it to be quite effective on other similar occasions.
I don't mean to imply that I am never fooled. I am. But if I am fooled, it is because I have come to start taking the patient at their word, and I pass their word on with the phrase, "patient states..."
When I was a younger medic it was a badge of honor to never be fooled. For some reason it came to deal with your manhood. A stud medic was never fooled. It wasn't just a patient deliberately fooling you with their story, but fooling you with their presentation. That, for some (never for me), meant not treating a patient with pleuritic chest pain, not working up a drunk, not c-spining an elderly person with a low fall because you were sure they didn't have a fracture. And giving pain-meds to anyone, forget about it. You couldn't let a drug-seeker fool you.
Drug seekers do fool me. Not all of them, but I have been burned by a few just because I would rather give drugs to a drug-seeker than deny someone in legitimate pain.
I guess my basic attitude these days is, who am I to judge? I have to go with what people tell me. You look fine, but you tell me you are sick, okay, what hospital do you want to go to? I'll just relay what the patient (or bystanders) tell me, and then I relay what I have seen. Just the facts.
Still I am hurt when I find out someone has lied to me. Here's what happened the other day:
We get called for chest pain. Attractive 45-year-old woman at work having ten out of ten chest pain. Pain goes into her neck and down her arms. She's been having the pain for an hour, but she still drove to work. She is under a lot of stress. She's going through a divorce. There have been layoffs at work. Nice woman. She's been seeing a psychiatrist for anxiety. This she says feels like an anxiety attack, but much worse. Those have never lasted longer than five minutes. She's a little hypertensive (BP 170/100), a little tachycardic (104-112) skin warm and dry, has some congestion in her lungs, she says she's getting over bronchitis. She's all concerned she needs to call her mother and she doesn't want to worry her mother.
I put her on oxygen by cannula. The nurse at her job has already given her aspirin and one nitro with only temporary relief. I pop her on the monitor and the initial leads look good. NO ST elevations. I tell the nurse, we'll do the full workup out in the ambulance. The nurse notes a PVC. Maybe, I think or maybe it is just a wire being jostled.
I ask the patient for some more history. Anything different today or recently? Anything out of the ordinary? Any reason you could be feeling like this?
No. Just the stress. Lots of stress.
The patient is having an anxiety attack in my opinion, but I fully plan to treat it as cardiac. I explain this to her. I don't think it is your heart, I say, but I'm going to treat you like it is.
The full 12-lead is normal, except for a PVC or two. I ask her if she has ever had any heart trouble or the feeling of an irregular rate. She says no. I am seeing an occasional PVC -- unifocal, but fairly regular. So I guess it is more than an occasional PVC. That is a concern. I give her a full three nitros that don't seem to help, but do bring her pressure down a little. She is bouncing off the walls now with her anxiety, and I am seriously thinking about giving her some ativan. And, while I rarely give morphine to patients with chest pain (due to some recent literature that raises the possibility that it may do more harm than good), I go ahead and give her 2 mgs and then another 2 mgs just to calm her down.
It gets her pain down to a 6. Throughout all of this, she is complimenting me, telling me what a nice guy I am, how compassionate I must be to do this work. She keeps her arm on my knee. She calls me by my first name. Asks me if I am married? When I show her the pictures of my daughter, she tells me what a beautiful girl she is. I feel we are bonding. Not just paramedic to patient, but person to person.
We, of course, are well on our way in to the hospital. Not going lights or siren, but proceeding directly. I call in my patch that goes something like this:
"We're five minutes out with a 45 year old female with substernal chest pressure X 1 hour that goes into arms and neck. No prior cardiac history. Patient does have a history of anxiety and recent bronchitis. The 12 lead is normal, but the patient is having occasional PCS. She says she has had similar episodes in the past none lasting more than 5 minutes that her doctor's attribute to anxiety. She's gotten ASA, NTG X 3 and 4 of morphine with the pain initially a 10 of 10 now down to a 6..."
Pretty impartial patch. I'm basically saying she's having chest pain, but there is a good possibility it is anxiety. She'll need a room in the main with a cardiac workup, but there is no need to activate the cath lab yet or haul an ED doctor out of a procedure to prepare for our arrival. Just a room with a nurse and an ECG machine to start.
We get her registered, get her to the room. She is much calmer now. I get her to sign my run form. She thanks me again for being so nice. I go and find a nurse, who is very busy with another patient so I sit near the nurse's desk, typing up my run form until I can give her the report. She's finally ready and I bring her into the room and give her the run down while a paramedic student looks for an ECG machine. The nurse has some general questions for the patient and I excuse myself to head out for the ambulance. The patient calls after me, thanking me again. I say you are in good hands.
I come back later with another patient and when I see the nurse I ask how the woman made out. Was it anxiety or truly a cardiac issue?
Sky high cardiac enzymes, the nurse says. She's upstairs waiting for the cath lab.
Really?
Then the nurse says the patient finally admitted that she did some cocaine with her boyfriend late last night.
Cocaine.
I have to admit, I felt hurt. Betrayed. She shouldn't have hidden that from me. I thought we were friends.
