Posted by: medicblog999 | March 29, 2010

The Truth, The Whole Truth and Nothing But The Truth??

truth-serumNow, I know with great certainty, that all of you in EMS will identify with this little tale. Maybe not to this exact example of this phenomenon, but to many other similar episodes to a greater or lesser degree..

Called to a 61 yr old female lady who has fallen and hurt her hip. The time is 02.30 and on this night, I was working on the ambulance with my crew mate, Sandie.

We arrived on scene and on entering the house, were met by a mobile warden who had been sent by the council, after the patient had pulled her alert cord in her home when she fell.

The patient, Joan, was sitting next to her bed and stated that she was about to get up and go to the toilet when she rolled out of bed and landed heavily on her left side, on the floor. This caused immediate pain to her left hip and she was unable to get back up.

The warden informed me that the family had been called and they were on their way.

I immediately noticed that Joan looked to be in considerable discomfort. She was conscious, alert and orientated. She didn’t appear to be unduly short of breath and remained chatty during the whole time I was assessing her. All of her observations were within normal parameters, other than being slightly tachycardic at 105 beats per minute.

She also had a shortened and externally rotated left leg.

So, as Sandie went about getting the chair from the ambulance, I started to work on gaining IV access with the intention of giving some Morphine prior to moving her off the floor and onto the chair. It was also at this time that her son arrived.

I went through my usual questions…

“Do you have any allergies?”

“Do you have any problems with your kidneys, specifically Phaeochromocytoma? (A special contraindication for us)”

“Do you take any major anti-depressants?”

“Have you ever had Morphine before?”

As I got to this question the son jumped in to inform me that

“she had morphine earlier in the year but she was worried about having it due to problems in the past with other drugs  so the Doctor had to give it to her very slowly to see if it was going to give her any trouble”

Me: “Ok, so did it give her any trouble or was she alright with it”

Son: “Oh no, it worked fine, but they only gave her a small dose, just in case”

Ok then. Cautiously onwards it is. I gained access and made up my 10mg/10ml Morphine and gave 2.5 mg very slowly over the next 4-5 minutes whilst carefully watching her. She seemed to be getting relaxed and the pain appeared to be easing from her face, then she nodded off to sleep.

Me: “Joan? How’s the pain now”

Joan woke immediately and said that the pain was much better, and then she quickly rested back against the bed and shut her eyes again.

Son: “Yeah she was like this that last time….After they gave her the dose she virtually slept for 2 days. It really knocked her out for a while”

Me (in my head) : Ahhhhhhhh !

Me: “Oh? You said that she was fine with the Morphine that the doctors gave her”

Son: “Oh yes, she was fine, they just had to keep an eye on her for a couple of days because she was so sleepy, and her oxygen levels kept dropping”

Me (in my head) : Bloody Hell!! That doesn’t sound like she was ok to me!!!

Me: “Ok then. I think its best that I don’t give her any more then. She seems to be very comfortable there now. Is that right Joan? Do you feel a little better now?”

Joan: “Yes thank you. I think I may be able to have a little sleep now”

Me: “Champion!”

Sandie and I strapped her legs together and lifted her onto the chair, then carried her downstairs and to the ambulance. She remained very easily rousable throughout the journey to hospital and remained fairly comfortable considering the injury to her hip. She never dropped her respiratory rate or oxygen saturations whilst she was in my care and I watched her like a hawk for the whole time!

I followed her up on the ward a couple of days later after she had her surgery where she appeared well and was starting to mobilise around the ward. I had a chat with the Charge Nurse and told him about what had happened and enquired into her analgesia needs on the ward.

He laughed and said that they had the same experience, but this time the son had told them that the paramedic had seemed `a little concerned` with what he had told me, so they had been very cautious in their management of her pain post op, but seemed to be able to stay on top of it.

So there it is folks…..

What the answer is, I don’t know, but I have lost count of the amount of times that I have asked a patient one thing only to be told something completely different 10 minutes later.

I bet most of us have had the experience of handing a patient over to the hospital, informing them that they don’t have any chest pain, only to have the patient state

“Yes I do”

So why not share your own stories with me.

Have you ever had a patient or relative hold back an absolutely essential piece of pertinent information which you absolutely needed to know?

Have you ever been made out to be a bare faced liar in front of the nursing staff?

Let me know in the comments…..

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Responses

  1. When I take histories to report back to a consultant, patients regularly neglect to tell me that they have had operations, or been on medications before coming to hospital, and even give me complete red herrings with what they came into hospital with. You look really stupid when you give a history that isn't at all correct because the patient has told you something completely different from the truth!

  2. Female patient at a music festival, who, like many of the patients we saw that day, presented with reduced levels of consciousness – most patients seen had syncope'd due to insufficient food and water in hot venues. However, something told me it wasn't the same as the other cases, despite having a similar presentation.I asked all the standard questions (allergies, meds, history) and got nothing; obs within normal ranges (slightly increased resp rate, temp = 35.5C), but no improvement in LoC after 5 mins which I would expect from a faint, so I got a nurse involved. Nurse goes through the process, nothing. After another five minutes I'm still not happy and an ECP happens to walk through, and I asked him to have a try. She mentions to him (ie: on the third time of asking) that's she's on citalopram, at which point I put it all together, recognise she's having an anxiety attack (probably late, because she definitely wasn't hyperventilating) treat her and discharge her 20 minutes later into the care of her family.But it took three of us to find out a really key piece of information (and I'll never distrust the readings from a piece of kit until I've personally tested it again – the lowered core temp should have alerted me to the possibility of SSRIs).

  3. We get a call for lower back pain. Arrive at the address to find 2 females. One about 17, and one about 40. Our patient is the 17 year old kind of large young girl. They where waiting for us in the alley. Patient gets in the back of the medic, mom gets upfront. I go my run down, normal vitals, denies any medical history, any falls or other trauma. I ask her to describe her pain, she says she has lower abdominal pain going all the way through her back. Says she feels like she has to have a BM. I ask her if she was pregnant. She said no, I ask her is she sure. “I am sure I am not pregnant.” I ask her if she is sexually active, she says no. I ask her if she has been having normal and regular periods. She says yes. She denied increased pain with palpation. I asked her again, quietly as to make sure mom who was upfront didn't hear, “Are you sure there is no way you can be pregnant?” She says “There is no way I can be pregnant.” I ask her if she has been having normal BMs. She says yes. I ask is she sure she didn't fall or have any trauma to her back, or abdomen. She says she is sure. We get to the ER and I turn over to the RN, then she tells the RN she got hurt yesterday playing dodgeball. The ball hit her back. I knew something else was up and was at this point really mad, she had told me over and over again she didn't have any trauma and couldn't be pregnant. 10 minutes after we left the ER she delivered a baby. Thanks for lying to me and making me look like an idiot!!!

  4. It happens all the time to me. I am a medic on a fire engine so I am almost always there before the ambulance. Every couple of weeks someone will tell me one thing, I'll relay the information to ambulance medic, and then have the patient contradict every word I just said. Luckily the ambulance crews know me well enough to know that I did do a complete assessment and that the patient just isn't being consistent. At least I think they know that!

  5. At about 21:30 called to a patient who was unconcious on the bathroom floor. When we arrived sure enough there he was. He would respond to verbal commands. When asked about current meds, his wife said he hasn't had his meds today. We packaged and transported. After the handoff the wife told the nurse he had taken his prescribed sleeping pills as directed about 20:00. The next day he was released. He just needed to “sleep” it off.

  6. You know what they say, “History repeats itself, but patient history changes every time.”That's why I no longer get offended when a triage nurse asks the patient questions I've already given the nurse the answers to. I've seen the answers change too many times.

  7. That's funny, I once responded to a bad part of town for a mother and daughter claiming to both be in labor at the same time. Both were heavy set and had food stains all down the front of thier filthy shirts and black feet with no shoes, oh and thier power was out at thier house(probably a good thing for me). The women did NOT look pregnant to me just big and they insisted on transport, so being in the USA, I had to take them. I couldn't get a word out of the daughter and the mom kept interupting me to say they were both having contractions on a regular basis. And of course the recieving doctor happened to be the medical program director of our county(guy that writes our protocols that tells us how to respond to given situations). He told me he had my card in his pocket and anymore “Of these” and I may need to find somewhere else to work, jokingly of course. As I was leaving the ER I could hear him nearly yelling, “Look lady, if you're not sexually active there is NO WAY you can be pregnant!” And the caveat was that it was 3 in the morning and they insisted on getting the OB doc(no one like him) out of bed, apparently he new them and had this trouble with them before. While they didn't tell the Docs something different they were lying and making me look like an idiot.

  8. This happens from the first day you get your “card” (whichever level it might be:You: Do you have any issues or history of high blood pressure?Pt.: NopeYou: I see in your list of meds that you are taking medication to control your blood pressure.Pt. Yup, thats why I have no problems. I realize patients lie, mostly by accident, somtimes not. But what burns me every time is why the admitting Nurse ASSUMES we got it wrong and never believes that our turn over report was accurate to what the patient TOLD us. There is always more to know, thats why we ask the same questions in different forms over and over through the trip. Someimtes, if I'm really dubious, I fain bad memory and apooigize for forgetting, but ask the question one last time. Capt. Tom

  9. Yes! Any medical problems? No. Usual questions repeated – are you diabetic, any allergies, any heart problems, any chest problems, ever been in hospital. Not being happy, we asked further. No medical problems, no medication. We were still not happy, asked doctor to pop by (on duty with St John Ambulance). He asked the same questions – patient pipes up, “oh yes, I was told in the hospital I am diabetic but I don't believe them – we have no diabetics in our family so they must be wrong”. Duh

  10. Just a quick question from the US–what's a mobile warden?

  11. Hi Matt,Some of our residents have a 'call button' around their necks which they press when in need which connects them to a call centre who can either contact a family member or us. Routinely, they will also send one of their own 'mobile wardens' who is someone who is not medically trained but just goes to see if they need any help etc.

  12. just the usual. any medical history…no. upon arrival at the hospital same question by the nurse and out comes the list. Or the lady being FAST positive if she has had a previous stroke or TIA….No. but when we show up at the ED she tells the nurse she has……cheers lady thanks for making me look incompetent. Oh well

  13. I have a theory about this sort of thing. Alien Abduction. What happens is that you turn you head for a second, or blink, or do something that makes you take your eyes off the patient and *poof* the aliens beam up your patient and replace him or her with an exact duplicate only they have a totally different complaint, history, and med list. I've even had this happen a couple of times with the same patient! Turn your head at triage and your belly pain with no allergies becomes back pain who is allergic to all no narcotic pain relievers. I just don't know why the aliens do this. Or the patient who answers “No.” when you ask if they have any medical problems. Then they go on to list a dozen meds that they take every day. When asked, they tell me that as long as they take their meds, they don't have a problem. Maybe it's me. On a more serious note, what is the standard for splinting an injury like this in Britain? I've always placed my hip Fx patients on either a scoop stretcher (that's one of the things it was designed for) or long board. I'd never consider sitting one in a chair unless there was absolutely no other way to move them.

  14. I've finally realized why the nurse in the ER asks the patient the same questions I just gave her the answers to. And it seems as though every time the patient says something different! Glad to know its not just me. 🙂

  15. I have a theory about this sort of thing. Alien Abduction. What happens is that you turn you head for a second, or blink, or do something that makes you take your eyes off the patient and *poof* the aliens beam up your patient and replace him or her with an exact duplicate only they have a totally different complaint, history, and med list. I've even had this happen a couple of times with the same patient! Turn your head at triage and your belly pain with no allergies becomes back pain who is allergic to all no narcotic pain relievers. I just don't know why the aliens do this. Or the patient who answers “No.” when you ask if they have any medical problems. Then they go on to list a dozen meds that they take every day. When asked, they tell me that as long as they take their meds, they don't have a problem. Maybe it's me. On a more serious note, what is the standard for splinting an injury like this in Britain? I've always placed my hip Fx patients on either a scoop stretcher (that's one of the things it was designed for) or long board. I'd never consider sitting one in a chair unless there was absolutely no other way to move them.

  16. I've finally realized why the nurse in the ER asks the patient the same questions I just gave her the answers to. And it seems as though every time the patient says something different! Glad to know its not just me. 🙂


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