The Fog of EMS
The term "Fog of War" is ascribed to a Prussian military advisor of the 18th century, Carl von Clausewitz. The term is meant to describe the uncertainties that a general faces when battling the enemy. Information that the general receives may be incomplete, exaggerated, or just plain wrong. Nevertheless, a commander must often act, even without a complete picture.
The analogy with EMS is crystal clear, and so I propose that we create a new phrase, called the "Fog of EMS." This phrase refers to the initial confusion that we face both in the field and in the ER when we are confronted with a new patient. We gather clues and information from a variety of sources, and make our best educated guess as to what is going on and how to proceed. What information is accurate, and what is plain wrong? Later, with time and more information, the picture may come into sharper focus, but not at first.
Let me go over a recent case that was flown from the mountains down to my trauma center. It's fire season in the foothills of California, and firefighters from around the country are converging onto California to help us from turning into a cinder and battle some of our horrific forest fires. One of those firefighters is named Kurt.
Kurt is a healthy 18-year-old from a neighboring state, and is stationed at a forward base for fighting a recent outbreak of fires in the Sierra Nevada mountain range. The day before he arrived in the ER, he had been on the line, but there was nothing unusual — just a typical hot/exhausting/grimy day on the fire line.
Today started uneventfully for Kurt, but in mid-morning, he was struck on the back of his leg with a log — nothing awful, but he went to a local ER to be checked out, and got a clean bill of health.
Later, back at the camp, he stood around, just chatting. Suddenly, Kurt developed severe right sided chest pain, with severe difficulty breathing. His level of consciousness quickly deteriorated, and BLS measures were instituted. An air ambulance was dispatched due the remoteness of the camp.
The flight paramedic and nurse rapidly assessed the patient. A brief summary of their chart showed the following:
Unconscious, unresponsive. Pupils are equal, round, and reactive to light. No movement of extremities, but gag is still present. Skin is warm and dry, but has a pale appearance. Capillary refill is less than two seconds.
Normocephalic. Ears: No drainage noted, Normal. Nose: Normal nares. Throat has intact gag.
No trauma. Trachea mid-line; and no JVD noted. No trauma noted.
No external evidence of trauma or abnormality.
Shallow breathing with decreasing rate, but clear to auscultation.
Regular rate and rhythm, with weak pulses and rate decreasing.
ABD soft, flat no evidence of trauma; pelvis is stable.
The patient was correctly determined to have a crash airway, and was given a neuromuscular blocking agent and intubated. Once on the monitor, a sinus rhythm of 60 was found, and oxygen saturations went up to 100 percent.
Forty minutes later, the patient arrived in the ER, and now it became my problem. The "Fog of EMS" enveloped me. I reviewed what I knew about the patient — or what I thought I knew — which was not very much: healthy male, sudden onset of chest pain, major decrease in LOC accompanied by poor breathing (so much so it required a crash intubation).
My initial thoughts as I entered the "Fog of EMS" included asking myself what caused the chest pain. Maybe a pneumothorax or pulmonary embolism? The leg injury might be important, and could produce a blood clot to the lungs. Did he have an MI? Was it an arrhythmia? Perhaps it wasn't cardiac in origin at all, but a toxic exposure (although doubtful, since he had no known exposure and no one else was sick). Maybe it's hyperthermia, but not likely because he wasn’t engaged in any physical activity at the time and wasn't on the fire line.
Navigating the unknown
As I met the flight team, nothing looked too weird. Kurt's exam was unremarkable (that is, for a chemically paralyzed, intubated young male). You may recall in a previous article on ALOC, I advised:
When you first approach the patient, look at the big picture. Using your eyes alone, you can sometimes get a wealth of information.
Now that the patient had arrived in the ER and I could see him, more information became available to me. The patient was being easily ventilated, had good vitals and sinus rhythm on the monitor. His rectal temperature was normal, so that shot down one of my ideas — hyperthermia. The easy ventilation made tension pneumothorax unlikely.
Chest X-ray and electrolytes were unremarkable. The EKG was slightly weird, showing a right bundle branch block, but no MI or ectopy was evident.
I sent him for a CT head, looking for brain bleed or stroke, but no signs of those were present, either. He had a normal scan. CT chest was next, where I would look for aortic dissection or pulmonary embolism. It also turned up negative. There went my blood clot theory.
I was now at a loss as to what happened. I was lost in the "Fog of EMS." In Scouts, you are taught to "stay where you are" when you are lost. So that's what I did with Kurt.
I kept the vitals stable, and waited for the Fog to lift. I got help from the hospitalists and cardiologists. We started to circle around the EKG, because the EKG and the chest pain gave our only "positive clues."
Surprisingly, after an hour or so, Kurt started to awaken! He moved his arms and legs. Hallelujah! He was then taken upstairs to the ICU.
Arriving at an answer
Over the next few days, additional information came my way. More history was obtained now that Kurt was awake. Apparently, he had a syncopal episode during football in high school!
Given the EKG, chest pain, and history of syncopal episodes, plus negative results on all the other tests, it was decided that he most likely had an arrhythmia problem. Brugada's (a newly described arrhythmia that can cause sudden cardiac death) was considered but ruled out with further testing.
Fortunately, this story has a happy ending. The great news is that Kurt is alive, healthy, and back home. He now has an automatic defibrillator/pacer inside his chest, which will prevent any future episodes.
What's my take-home lesson? In the pre-hospital environment as well as the ER, we live and thrive in the "Fog of EMS." Most people can't handle the Fog, but if you are reading this, you belong to the group than can. Like generals, you enjoy the challenges of "not knowing" but still having to act.