Six Patient Statements That Should Concern You

As we develop our experience in EMS, we encounter certain statements that make us sit up and take notice. Sometimes we take notice because we remember a call where things started going down hill right after we heard that phrase. Other times, we’ve simply learned from the experiences of others to sit up and take notice. Often our best lessons come from our moments of regret.

Any time we can get the lesson without the regret is a plus. In the spirit of learning from the regret of others, I offer up seven phrases that immediately make me sit up and take notice. Hopefully you will too. Start paying close attention any time you hear your patient say:

“This is the worst headache of my life.”

Headaches come and go. People who typically get headaches know their symptoms and become accustomed to the severity and length of their migraines. People who don’t normally get headaches still know what a good throbbing headache feels like. When someone says this statement, it means one of two things. Either they normally suffer from headaches and today what they are experiencing far surpasses what has occured in the past or someone who doesn’t typically get headaches has something brand new going on today.

Either way, this is cause for concern. There is a long, long list of thing that can cause headaches. A whole bunch of them are actually pretty scary. Regardless of how we might feel about people accessing 911 with a complaint of headache, when someone says that the pain in their head is worse than any headache in the past, pay attention. Do a thorough assessment and transport them appropriately.

“I feel like I’m going to die.”

Feeling like you are sick, or feeling frightened about what might be happening to you is different than a feeling of impending doom. Sometimes, folks who are about to decompensate rapidly get a sense or feeling that they are about to decompensate. Don’t take that statement for granted. It’s easy to write off, “I’m going to die.” remarks as overly dramatic Hollywood antics, until you have the experience of someone telling you they think they are about to die right before they die. Then it becomes a red flag.

When someone make this type of a remark, step back and reassess the situation. Take a close look at their vital signs. Reassure them that you are paying attention and you are going to do everything you can to prevent that possibility. Them make sure all your treatment ducks are in a row.

“My shoulder hurts.”

A whole host of chest and abdominal problems can present as referred pain to the shoulder. The shoulders are the most common area of the body to find referred pain. (A complaint of pain in a region of the body that is removed from and unrelated to actual location of the problem.) Heart conditions, respiratory ailments like pneumonia and pleurisy and injury or illness in the liver, spleen and gallbladder can all cause pain to radiate up into the shoulder.

When a patient doesn’t have specific trauma to the shoulder region or another specific reason to have pain in their shoulder, we should examine the chest and abdomen with a heightened awareness that there may be an unrecognized injury or illness that is causing the shoulder pain. If the patient was seat belted in an auto accident, don’t assume the pain is directly caused by the seat belt against the shoulder. A lacerated liver or spleen may be the true culprit of the pain.

Referred pain is a subtle physical sign. When a patient localizes their pain we tend to ficus on that region of the body. When your patient complains of pain in their shoulder with no obvious mechanism, consider referred pain and assess accordingly.

“I don’t want to go to (Insert specific hospital here).”

When a patient refuses to be attended to by their local hospital ER, there is often some sort of history behind the bias. At some point in the conversation, after we’ve decided where we are going, I like to come back and explore this bias. I ask, “So why is it that you don’t want to be transported to (insert obvious hospital choice here)?”

Sometimes, the patients bias is related to insurance, specialization of care or history with another facility. But, often times, there has been some sort of conflict with that facility in the past. It could be related to a perceived missed diagnosis or dissatisfaction with previous care. Often, people will avoid a particular hospital because that facility is familiar with the patient and may have knowledge of some aspect of the patients medical history that they are hiding from you.

If the patient has a particular reason to steer clear of a specific medical facility, I always want to know why.

“I’m just going to walk home from here.”

Patient disposition is an often overlooked aspect of medical refusal. When patients refuse medical care, we need to take the time to ensure that they are being left in a safe place. Preferably in the presence of another, responsible person and with access to 911 if they change their mind about needing our care.

I always get nervous when a patient tells me that they are planning on walking somewhere immediately after refusing care. If they don’t arrive at their destination safely, I know the scrutiny will be on me (as it should be). Any time a patient is planning on refusing care, before you have them sign your form, ask what they are planning on doing next. Then make every effort to create the safest environment possible for them prior to your departure.

If they need to go somewhere, help arrange safe transport. Check on the possibility of taking them there yourself or arranging a ride with local law enforcement or public transport. Be nervous any time someone decides to walk away from your scene.

“This is probably just indigestion.”

When people start explaining how their chest discomfort is probably related to some benign cause, I immediately take notice. Denial is such a common finding in our cardiac patient population that it’s actually one of the hallmark symptoms of a heart attack.

Statements like this one are often based in fear. The patient is looking for reassurance that their symptoms are not serious. If the patient is searching for reassurance, ask yourself why. When we feel indigestion, we don’t normally summon 911. We take a Tums and go back to watching the next episode of Mad Men. If people summon 911 and then look to you for reassurance that they are being foolish, don’t rush to agree. Take a closer look. There’s probably more there than they are admitting.

“I was just sitting here and the next thing I remember…”

Syncope in the sitting position is always cause for concern. (And cardiac in origin until proven otherwise.) We so so many instances of dizziness and syncope for fairly benign causes that we can sometimes fail to recognize the subtle but critical detail that falling unconscious while seated in a resting state is highly unusual. Our first consideration needs to be cardiac and, if the patient proves themselves hemodynamically stable, then neurological.

One problem we often encounter with our syncope patient population is their embarrassment over the episode and their desire to refuse care and move on to something that takes the spotlight off of them. In cases of sitting syncope we need to be insistent about transport. Don’t let patients who experience syncope while sitting refuse care without a strongly worded advisement, solid orthostatic vital signs and a detailed physician consult.

So there are my seven patient phrases that always trigger my concern. What about you. What things can a patient say that always make you sit up and take notice. Share them in the comments section below and add to the list.

Comments

  1. I would add one more response to the above List: “Oh, my spouse will take me to the hospital”.
    Among the elderly, there are concerns that first, an ambulaance ride will cost them money which they may not have. Since most EMS calls now result in an insurance charge for such services nationwide, the elderly may not understand the local policy. Therefore some will resist any idea of an ambulance ride, not because it is the neccessary to preserve life, but because they don’t want to have to “pay”. On most calls, the elderly may not understand that an EMS response is the critical first step in assessing and taking lifesaving actions
    for their benefit.

  2. Bang on. Especially ‘I think I’m going to die’.

  3. This is exactly the type of information that needs to be reviewed by experienced medic’s and passed on to new ones. Info like this will save a patient’s life, and save a medic’s ass. Well written, concise, great job!

  4. Ditto on “I think I’m going to die”.

Speak Your Mind