Dear Sirenhead: I recently screwed up an assessment and learned a few lessons as a result. The experience changed me both personally and professionally, so I wanted to share it.

My partner and I responded to a call for a 19-year-old male reported down at a local basketball court. During my initial assessment, I found the patient conscious, but confused. His pulse was 100, respirations 20, BP 128/86. His skin was hot and diaphoretic.

His friends reported he had completed a lay-up while playing basketball in the hot sun, mumbled a few words, took a few steps and then collapsed to the ground. They said he was unconscious for about two minutes.

He denied having any pertinent medical history and told me he felt weak and just wanted to go home. He seemed embarrassed lying on the ground, so I told him I'd finish the assessment in the cool of our ambulance.

I thought the guy had a syncopal episode due to the heat. We helped him to his feet and walked him to our unit. I told our comm center we'd be transporting a post-syncope patient to a nearby hospital.

The patient climbed into our unit and sat on the side of the stretcher without incident. Then, without any warning, he fell backward and seized. We secured him to the litter so he wouldn't hurt himself and requested backup.

We administered oxygen, established an IV and administered diazepam (Valium) to stop his seizure. While treating the patient, I asked one of his friends if the patient had exhibited any seizure activity when he initially fell. His friend said the victim appeared to get rigid, but the episode quickly subsided. He sheepishly told me he hadn't thought it was important or he would've told us earlier. When we arrived at the hospital, I transferred care of the patient to the ED staff without incident.

I knew I had messed up the assessment, mistaking the call for syncope instead of a seizure-but I thought it would be kept between my partner and me. I forgot I had reported it over the radio as a syncopal episode before the patient began to seize. My supervisor heard my report and called me when I got back to the station to ask why I felt it was syncope and not a seizure. My explanation wasn't acceptable to him, so he asked me to make an appointment with our medical director to discuss the case. I did so and met with him the next day.

I feared I might be taken off the street because of my error, but I wasn't. Realizing my confusion between syncope and seizure, my medical director assigned me to research each condition and prepare a lecture to deliver at our next continuing education (CE) session.

It was the most effective punishment I've ever received for making an error in the field. I worked my butt off and soon felt comfortable differentiating between syncope and seizures. After delivering my presentation, my coworkers told the medical director it was one of the most informative CE classes they'd ever attended. I felt I'd been treated like an adult and given the opportunity to improve myself without the usual guilt and shame that goes with a street suspension.

-Rick S., via Internet

You're lucky. In my system the medical director would smash your knuckles with a meat tenderizer. He's lazy and doles out punishments that don't make sense. Example: In June, my partner made a medication error on an anaphylaxis call and our medical dictator (oops) made him sign up for an anaphylactic shock lecture scheduled for Oct. 24. He could have made 20 more medication errors during that four-month period. So I sat him down myself and reviewed the drug dosages so he wouldn't kill one of my relatives. We can all learn a couple of lessons from your experience: Don't jump to conclusions on any call, and don't zero in on the first condition that fits the history or vital signs you initially receive. When a patient is confused, their denial of a pertinent medical history should make you suspicious. You have to ask bystanders to tell you everything they saw and heard before, during and after the patient collapsed. I make the do-gooders ramble on while I perform my physical assessment. Most of what they say is garbage, but I listen for key words that'll help me identify the real problem. Syncope is usually preceded by a warning period in which the patient complains of feeling lightheaded. Seizures strike with little or no warning. You can usually take it to the bank that a syncope patient will regain consciousness as soon as they hit the floor and go supine. Seizure patients can be unconscious for a while (minutes to hours). Syncope patients tend to lose any associated headache within 15 minutes, while seizure patients' headaches last longer than 15 minutes. While many of us street saviors are subjected to chart reviews and punishment from medical directors who don't even know our names, your medical director seems to be a cool guy who cares about you more than his golf game. He probably taught you the most important lesson of all-that punishment doesn't always have to be punitive to be effective.

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