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A Complete Secondary Assessment

That’s what our policies require and it makes perfect sense.  A complete secondary assessment to rule out all known causes of illness or injury to allow providers to make a good faith report of condition to the patient to inform their decision.  We have tools and education to perform this task and it really isn’t hard to put it all together.


Or so I thought.


On a call for the syncopal.  This is our bread and butter.  We find the patient pale, a bit moist with his shirt clearly previously soaked through (symptoms for 25 minutes now) but he is alert and oriented and refusing all care.  Being caring human beings we impressed upon him the need for an assessment.  After all, “what if we find something we can treat?  Wouldn’t it feel nice for that dizziness to go away and your head to stop sweating?”

Strong radial, irregular, wife says he’s got a history.  No chief complaint verbalized but his body is clearly telling me otherwise.  Meds and history paint the picture of an old a-fib but the ECG is showing PACs in II about 7:1.  Clearly something has changed.  The beats that should be irregular are regular…except that one little bugger.  He is calm and normotensive as we begin the chat that will convince him he should be seen by a physician sooner rather than later.  This conversation usually ends with them telling me they are going to hospital and there is nothing I can do to stop them.  Iceboxes to Eskimos.

The transport crew arrives and I ask them to set up the cot while we run a 12 lead and give a brief report.

“But he isn’t having chest pain.  We don’t need to run a 12 lead.”

I was told later that the glare I shot him was visible from the space station.

“We need to get a better picture of what’s going on as we have sudden onset syncope with an abrupt change in baseline ECG.  He is clearly no longer able to maintain homeostasis and we owe it to him to look for anything and everything we can to paint a clearer picture for his continuing care.”

I didn’t say that to the medic, I said it to the patient’s wife who was standing nearby.  She seemed suddenly concerned and I was able to put her at ease.


Later, down at the ambulance I had a chance to speak to the transport medic.

“We don’t run 12 leads on non chest pain patients, it isn’t in the protocol.  Besides, he said before we got there he didn’t even want to go.”


I followed them to the hospital and assisted with the hand over, then helped the EMT reload the cot.  As the medic came out we discussed the importance of a complete secondary assessment when we can’t reliably determine the cause of the chief complaint.

“He didn’t have a chief complaint.”

“His body sure as hell did.  Quit trying to pretend you’re just here to push Epi and instead use your tools and education to find the cause of your patient’s illnesses.  Assess, diagnose, intervene and reassess.  Just keep that wheel turning.  OK?”

“We don’t diagnose.”

Lost cause.

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One Comment

  1. Christopher November 13, 2016 10:53 am

    *smh* Yes, we do diagnosis. That’s what a protocol is, treatment for a field diagnosis. The medical director of a “small” county in the East Bay once told me, “[you] diagnose every patient you come across. You just can’t bill for it. End of discussion.”

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