At 0200 hrs, dispatch requests that Medic 99 "respond to an asthma attack." On arrival, the crew finds a 65-year-old female having difficulty breathing. Their initial assessment reveals bilateral expiratory wheezing. The patient's vital signs: HR 120, RR 24, BP 180/110.
The crew begins oxygen administration and completes their assessment. The ECG confirms sinus tachycardia with no ectopy. A paramedic establishes an IV and gathers information from the patient's family. At 0220 hrs the senior medic calls into the hospital base station and reports a 65-year-old female in respiratory distress due to an asthma attack. They tell the physician the patient exhibits bilateral expiratory wheezing. They provide the patient's vital signs, advise the physician that she has no known allergies and takes digoxin, Lasix and potassium. The senior paramedic then requests approval to administer epinephrine 0.3 mg SQ.
The physician asks if the patient has a history of asthma. The paramedic replies that the family says she's having an asthma attack. He again requests to give 0.3 mg of epi SQ. The physician tells the medics to give the patient 1/150 sublingual nitroglycerin and one-half inch of nitro paste, continue monitoring and transport immediately. When the paramedic again pushes for epi because of the patient's wheezing, the physician directs the paramedic to just continue oxygen therapy and transport.
Hospital treatment
On arrival at the emergency department (ED), the patient is still in moderate respiratory distress. The physician asks the crew to stay with him and observe his initial assessment and treatment of the patient.
The doctor administers the 1/150 sublingual nitroglycerin and one-half inch of nitro paste. Within three minutes, the patient's respiratory distress begins to subside. The physician points out that the crew should have suspected congestive heart failure (CHF) over asthma because she was on Lasix and potassium. The crew tells him they assumed the patient had an asthma history based on the dispatch report.
The physician tells them they incorporated an erroneous "dispatch diagnosis" into their decision-making process. On scene, they found a wheezing patient and put the erroneous diagnosis (asthma) together with their physical exam finding (wheezing) and concluded the patient's problem was as dispatched. They then locked themselves into a protocol-driven treatment plan for "asthma."
Discussion
This case illustrates what can happen when dispatch personnel deviate from EMS/EMD protocols. The dispatcher received a call for a patient in respiratory distress, and the family said they thought the patient was having an asthma attack. Thus, when the call was dispatched, it went out as "respond to an asthma attack."
The dispatcher transmitted a presumed diagnosis based on limited information. By protocol, the call should have been dispatched, "Respond to a patient in respiratory distress." By leaving the working diagnosis, or chief complaint, as a broad category (e.g., respiratory distress) rather than a specific diagnosis (e.g., asthma) the EMS crew would have begun their diagnostic process by exploring possible causes of respiratory distress in a 65-year-old female. They would have noted the expiratory wheezing and taken into account the patient's medications.
They would have concluded that this was probably CHF, not asthma, because they would have conducted their own assessment and come to their own differential diagnosis.
Remember, wheezing does not always equal asthma. Wheezing also occurs in CHF, pulmonary embolism, pneumothorax, pneumonia, foreign body aspiration, chronic obstructive pulmonary disease, bronchitis and other disease processes that restrict airflow through the bronchial tree.
It's imperative, especially considering the widespread use of EMD, that a breakdown in the diagnostic process does not begin during call taking or dispatching. If crews receive erroneous information at dispatch, it's more likely that an accurate diagnosis will be delayed or missed completely. Armed with a broad general chief complaint category during response allows EMS providers to review possible conditions they might find on arrival. I refer to this as "chief complaint preplanning." Just as fire crews have pre-plans for individual buildings, EMS crews should have a pre-plan for individual chief complaints and discuss possibilities while en route.
Make sure your dispatch personnel don't lead you down the wrong assessment path. Evaluate each patient in a standard manner and work to validate information provided by dispatch, not make advance decisions because of it.
Paul A. Matera, MD, EMT-P, is a fire surgeon in Anne Arundel County (Md.) Fire Department. He's also medical director for Maryland Natural Resources Police Department and a clinical associate professor of Medicine and Health Care Sciences at George Washington University.
Due to a busy schedule, Paul Werfel has decided to contribute only four cases annually. Look for his next column in September. This dynamic column will continue to appear monthly, however, with contributions from EMS physicians, clinical experts and educators.
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