"The eye altering, alters all." - William Black, The Mental Traveler

While driving home recently, I noticed the warning inscribed on my right-side rearview mirror. It warns, "Objects in mirror are closer than they appear." I find it amazing that a simple change in perception can distort things so dramatically. Seeing hazards in the correct perspective can obviously make all the difference in the world when we perform important tasks like driving an ambulance or flying an airplane. It's also important when we assess our patients. For an example, let's examine this month's case.

Scenario

You're getting the day's first cup of coffee when the dispatcher tones you out. "Elderly male, unknown condition, at the Saldin Institute, 324 Brian Road, at the corner of Kelly Ave. Time out is 0650." You know Saldin is a large facility that provides care for geriatric patients and houses a psychiatric wing as well.

On arrival, you're directed to the bedside of a 78-year-old male. The staff tells you he's suffering new-onset tremors, continuing drowsiness and has had a fever of 102° for the past 24 hours. They also tell you he's been irritable lately. His only worrisome history is high blood pressure and the fever. His vital signs: blood pressure 134/84, pulse 80, respirations 18. A staff nurse tells you he takes a beta-blocker for the blood pressure and has received an antibiotic for the fever.

As your partner administers oxygen, you connect the ECG. It shows a heart rate of 80 with no ectopy. The 12-lead reveals no abnormality. You mentally start to pigeonhole the patient into a non-critical category.

Not to miss anything, you assess him for neck stiffness to rule out meningitis. He can move his head freely. You listen to his chest and hear rhonchi and other low-pitched rumbles on his right side. The staff now informs you the in-house physician, who treated the patient earlier that morning, had expressed concern about right-side pneumonia. You note the patient also has a non-productive cough, reinforcing your belief in the doctor's pneumonia suspicion. While working on the patient, you again notice how warm he is. You start an IV of normal saline.

The staff tells you his doctor is waiting for him at North Area Hospital. It's 15 minutes away, but your patient seems stable, so you decide to transport him to where his doctor awaits.

During transport, the patient becomes less responsive and seems intoxicated. His current vitals: blood pressure 126/78, pulse 90, respirations 20. Solid, stable vitals-nothing requiring advanced therapies, you believe.

On arrival at the emergency department (ED), you present the patient to the triage nurse, who sends the patient directly to a bed. The patient's physician begins her evaluation while you complete your paperwork and get a signature. You get back on the road and notify dispatch you're back in service.

Discussion

Several days later your medical director calls you in to explain your thoughts and actions on the Saldin call. You recount the dispatch and patient condition when you arrived. It seemed as if the patient had an infection, probably pneumonia, and you hydrated him via IV and transported him to the hospital. Your medical director agrees the diagnosis was pneumonia.

The problem: Your patient's doctor called. The ED checked the patient's blood glucose because he was minimally responsive on arrival and found the patient had a blood glucose level of 18-clearly a medical emergency. You failed to conduct a complete assessment, and-because of it-the patient suffered severe brain damage due to hypoglycemia. He probably won't survive.

You should've remembered from your training that a fever increases metabolic rate and can cause profound hypoglycemia. The patient was on a beta-blocker, putting him at further risk. The beta-blocker masked the tachycardia that accompanies hypoglycemia. Your director asks why you didn't obtain a blood glucose reading in a less-than-alert patient. You can offer no answer.

Conclusion

In this case, the providers bought into the doctor's presumptive diagnosis of pneumonia. They concentrated solely on treating that problem, ignoring changes in the patient's condition that warranted more immediate care. You know your protocols call for a blood glucose check on patients who aren't alert. The object in the mirror (the hypoglycemic condition) was closer to you than it appeared. You should have recognized the indications for checking the patient's blood glucose reading. The pneumonia posed the more distant threat. We need to keep our minds open to all possibilities, no matter how remote they may seem.

Paul Werfel, NREMT-P, paramedic program director for the University Medical Center at State University of New York, Stony Brook, may be reached via e-mail at pwerfel@epo.hsc.sunysb.edu.

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