Not as Simple as It Looks

Prehospital emergency medicine has come a long way in the past few decades. Even so, it remains an imperfect science. No matter how much technology we bring to the scene, it's not always possible to make an accurate diagnosis, or even to determine just how sick the patient really is.

Early this evening we responded to a clinic in a homeless shelter, where a man was said to be having a heart attack. The patient was rocking back and forth in a chair, moaning and holding his belly. His color was good, and he wasn't sweating at all. His blood pressure and EKG looked normal. He appeared to be suffering from nothing more serious than an upset stomach.

The man had a disconcerting history, though. High blood pressure. A previous heart attack. Surgery to insert stents to keep his coronary arteries open. No matter how healthy a patient might look, it's hard to ignore medical problems as serious as these.

To complicate matters further, the patient seemed to have left out a crucial detail. He continued to hold his abdomen, but when I asked whether he had chest pain, he pointed to his heart and said it hurt there, too. It would have been nice to mention this at the outset, of course, since we were treating him for a suspected heart attack.

It's not always easy to take homeless patients seriously, because they often have ulterior motives. Some enjoy the attention they receive in the hospital. Others use illness as an excuse to sleep in a clean, quite treatment room for a night, instead of on a dormitory cot, surrounded by smelly, snoring bodies. Whatever the reason, homeless people regularly claim to have chest pain and other heart-related symptoms when they really aren't sick at all.

We had to take the guy seriously, though. Given his previous cardiac problems, we couldn't rule out the possibility of a cardiac problem, regardless of his awkward presentation. Reluctantly, we started an IV, gave him some aspirin and nitroglycerine, and took him to the hospital. There, too, he was treated as a genuine cardiac patient--although I did hear the physician telling a nurse, "I don't think this guy is real."

From the hospital we were sent to a South Boston housing project for another suspected heart attack. This time, the patient was a thirty-nine-year-old woman. She appeared nervous, jumping around on her couch while clutching her chest. When I asked what had happened, she launched into a long, complicated tale about her doctor, a prescription, and a dispute over the amount of medication she should take for her blood pressure.

After a great deal of interrogation, we learned that the woman didn't like the inconvenience of taking three blood pressure pills each day. She'd demanded something more powerful, something she could take once each morning. Her doctor saw no reason to change a prescription that had worked well. Having reached an impasse, the woman went without any blood pressure medication at all for more than a week.

She shouldn't have been surprised to learn that her blood pressure was high. But she was. When the EMT reported it to be 190/108, she went into full panic mode, flopping onto her side, flailing her arms, shouting that she couldn't breathe. She demanded that we give her something for her chest pain.

Again we found ourselves in a difficult situation. The woman did not look sick. Her EKG was normal. Her behavior suggested an anxiety attack, not a heart attack. But with the high blood pressure and chest pain, we couldn't be certain. Just like the homeless man, she would get a full cardiac workup, no matter how unnecessary it was likely to be.

I explained the situation to her. It was the usual lecture, one we've given thousands of times before. She didn't appear to be having a heart attack, I said, but because we couldn't be sure what had caused the pain, she would need to be examined in the hospital.

It was a waste of time. "So, you mean I don't have to go to the hospital?" she asked hopefully, no longer acting as if she was dying. She hadn't listened to a word I'd said.

I tried again. I explained that chest pain has many different causes--some serious, others not so serious. In the hospital, she could get a chest x-ray and other tests that would tell the doctors what was wrong with her--tests we couldn't perform in her apartment.

"No, I don't think so," she said. "I think I'll stay here. Good thing I'm okay."

She still didn't get it. I began to explain--for the third time--that we really didn't know whether she was okay or not, when the situation suddenly became much more complicated.

One of the EMTs had been in the bedroom, talking to the woman's brother. He emerged and handed me a card that read, "She's been nervous since her boyfriend died of a heart attack two months ago. And her 16-year-old son has been giving her problems." This was relevant information because it helped to explain her anxiety. We still didn't know whether she was experiencing a cardiac event, or a panic attack, or was simply a nut, but at least we had a clearer picture of the events leading up to the ambulance call.

Seeing the note in my hand, the woman demanded to know what it said. Without waiting for an answer, she went on the offensive, accusing us of conspiring against her. "I know what that note says!" she shouted. "And if you don't want to take me to the hospital, then fine! I'm a recovering drug addict! So what? And you can tell the welfare people to go to hell! I don't care! They have no right to cut off my benefits! Go on! Get out of here! If you're not going to bring me to the hospital, then I don't need you!"

There was a huge flaw in her reasoning, of course, one I immediately pointed out. "Think about it," I said quietly. "All this time, we're the ones who have been telling you to go to the hospital. You're the one who hasn't wanted to go. Don't turn it around and make it sound like we're refusing to take you, because we're not. We don't care whether you use drugs. We don't care whether you're on welfare. If you're having chest pain, you should come with us to the hospital. But we're not going to stay here all night, and we're not going to drag you out of here. So, what's it going to be? Are you coming with us to the hospital or not?"

She shot a suspicious glance at her brother. Then she looked back at me. "What did my brother tell you? He told you about my welfare benefits, didn't he?"

"No, he told us about the stress you've been under. We needed to know about that, so we can treat you properly."

"Let me see the note." I handed it to her. She read it slowly.

"See?" I said. "Just like I told you. It's got nothing to do with drugs or welfare. It's about your stress."

"Let me be brutally honest," my partner said. "Your son is sixteen, right? How are you supposed to be a good parent to him if you stay here and die of a heart attack?"

"Why are you being so mean to me?" the woman snapped back.

"He's being mean because he wants you to get help," I said.

The woman went silent for a moment. Suddenly her demeanor changed. She looked at my partner. "Yeah, you're right," she said. "I'm sorry. I'll go to the hospital."

She cooperated as we started an IV and gave her aspirin and nitroglycerine. She came with us to the hospital. For the second time in two hours, we treated someone who did not appear to need it.

In the emergency department, we got a surprise. The homeless man from the shelter had gone to the coronary care unit. His EKG remained normal, but a blood test revealed elevated cardiac enzymes. He was having a heart attack.

What a strange sequence of events. First we treated someone who appeared to be faking, but wasn't. Then we practically forced someone to go to the hospital, even though we couldn't find anything wrong with her. We did these things because, at its core, prehospital emergency medicine still consists largely of guesswork. As paramedics and EMTs, we have access to all sorts of diagnostic tools not available to EMS personnel in the past. We perform 12-lead EKGs, and pulse oximetry, and capnography. But these things are not enough. At some point on every call, we have to decide what we think is wrong with the patient. We do this not by looking at an x-ray, or checking laboratory results, or performing exploratory surgery--as many physicians have the liberty of doing--but by looking at the patient, inquiring about his history, and taking our best guess.

When I first became a paramedic, my preceptor said, "The most difficult part of this job is the thinking. It's not about starting IVs, or putting endotracheal tubes in the right place, because anybody can be taught to do that. Looking at a patient, and figuring out what's wrong with him, and knowing what to do about it--that's the challenging part."

At the time, I lacked the experience to know what he was talking about. But I understand now, and I agree. EMTs and paramedics on television shows have it easy. Invariably, they load the patient into their ambulance, strap an oxygen mask to his face, and race off to the hospital, without giving any thought to diagnosis or treatment. In real life, prehospital medicine isn't nearly that simple. The problem isn't always obvious.

A patient has chest pain. You're worried that it might be a heart attack. So you take a cardiogram. The cardiogram is normal, but that doesn't eliminate heart attack as a cause of the pain. So you question the patient. Does the pain get worse when you take a deep breath? It does? That sounds more like an injury than a heart problem. Have you fallen recently? Have you had a cough? You have? Maybe it's bronchitis. Persistent coughing can lead to chest pain. But you're still not sure. His skin doesn't feel warm, and he doesn't seem to have a fever.

So, what do you do? It looks more like bronchitis than anything else. That's not something that can be fixed in an ambulance. What he needs is a chest x-ray and some antibiotics. And with just five paramedic units covering the entire city, you really don't want to tie one up treating a guy who can be transported safely in one of the city's fifteen EMT-staffed ambulances.

But what if you do send the man to the hospital with the EMTs? And what if a blood test reveals that the guy with the cough and the chest pain was having a heart attack? Now you're in trouble. The doctor wants to know why you missed the diagnosis. The nurses want to know why the guy arrived at the emergency department without an IV. And the EMTs think you're lazy for making them bring the patient to the hospital.

We receive a lot of training. The city gives us all the latest equipment. But in the end, it all comes down to guesswork. You look at the patient, ask a bunch of questions, decide on the most likely diagnosis, and hope that you're right.