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Watch out for zebras

A red-flag approach to identifying true emergencies and treating patients with compassion

NEW ORLEANS — In 2009, in the height of the H1N1 scare, Jeff Jarvis, MD, MS, EMT-P, saw 57 patients in 12 hours. All of them had the flu – except for the 23-year-old who had leukemia. “I let him down because I missed that,” Jarvis told attendees at EMS World Expo.

Jarvis, chief medical officer and system medical director for Metropolitan Area EMS Authority/MedStar Mobile Healthcare in Fort Worth, Texas, shared this experience to open his discussion on differential diagnosis and keeping an open mind about rare conditions.

Memorable quotes on diagnostic red flags

Following are memorable quotes from Jarvis:

“Yes, common things are common, but in emergency medicine, we have to think worst first.”

“Does high blood pressure cause headaches? No. High blood pressure is associated with headaches. You know what causes high blood pressure? Headaches.”

“I challenge you to find a disorder for which droperidol is not the solution.”

“If you are under 3 months, I’m going to pay attention to you. Neonates are never allowed to have fever.”

“Please think about including red flags in your differential diagnosis.”

top Takeaways

Common things being common, when you hear hoof beats, don’t waste time looking for a zebra; or so the saying goes. However, in EMS, we aren’t worried about the common complaints; we’re worried about the complaints that can kill, Jarvis stressed.

He present a ‘red flag’ approach to several frequently encountered presentations that help us isolate the lethal zebras from the rest of the heard.

1. Red flags for back pain

Jarvis gave two pointers on back pain: remember everybody’s nerves are just a little bit different, and back pain in an older person is very different from back pain in a younger person.

Watch out for these red flags that could indicate a serious illnesss, like IVDA, cancer or diabetes in patients with back pain:

  • Trauma, fever
  • Urinary retention
  • Saddle anesthesia
  • Bowel/bladder incontinence

2. Red flags for headaches

Watch out for these red flags in patients with a headache that could indicate a true emergency:

  • Sudden onset at maximal intensity
  • Onset during exertion
  • Onset with syncope
  • Radiation of pain to neck/neck stiffness
  • Focal neuro deficit
  • Temporal tenderness

3. Tips for treating migraines

Jarvis offered tips for assessing and treating patients with severe headaches, and noted a non-traumatic headache protocol is beneficial to providers and patients.

Do not ask the patient if it’s the worst headache of their life. They already feel guilty for calling you and they’re going to say yes, Jarvis noted. Instead, ask, “When was the last time you had a headache like this?” Consider follow up questions like, “How long did it take to get to where it is right now?”
“Did it come on gradually and get worse and worse?” “Did you pass out?”

Jarvis also advised the audience to avoid administering narcotics to patients with headaches. While narcotics may fix the headache, they are associated with longer stays, higher rates of readmission, decreased headache-free days, as well as risk for addiction. Instead, treat patients with a more appropriate drug, like droperidol, and importantly, with compassion.

Additional resources

Kerri Hatt is editor-in-chief, EMS1, responsible for defining original editorial content, tracking industry trends, managing expert contributors and leading execution of special coverage efforts. Prior to joining Lexipol, she served as an editor for medical allied health B2B publications and communities.

Kerri has a bachelor’s degree in English from Saint Joseph’s University, in Philadelphia. She is based out of Charleston, SC. Share your personal and agency successes, strategies and stories with Kerri at