NEW ORLEANS 鈥 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 鈥 except for the 23-year-old who had leukemia. 鈥淚 let him down because I missed that,鈥 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:
鈥淵es, common things are common, but in emergency medicine, we have to think worst first.鈥
鈥淒oes high blood pressure cause headaches? No. High blood pressure is associated with headaches. You know what causes high blood pressure? Headaches.鈥
鈥淚 challenge you to find a disorder for which droperidol is not the solution.鈥
鈥淚f you are under 3 months, I鈥檓 going to pay attention to you. Neonates are never allowed to have fever.鈥
鈥淧lease think about including red flags in your differential diagnosis.鈥
top Takeaways
Common things being common, when you hear hoof beats, don鈥檛 waste time looking for a zebra; or so the saying goes. However, in EMS, we aren鈥檛 worried about the common complaints; we鈥檙e worried about the complaints that can kill, Jarvis stressed.
He present a 鈥榬ed flag鈥 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鈥檚 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鈥檚 the worst headache of their life. They already feel guilty for calling you and they鈥檙e going to say yes, Jarvis noted. Instead, ask, 鈥淲hen was the last time you had a headache like this?鈥 Consider follow up questions like, 鈥淗ow long did it take to get to where it is right now?鈥
鈥淒id it come on gradually and get worse and worse?鈥 鈥淒id you pass out?鈥
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
- Serial killers: Trauma 鈥 Assessing for the 5 things that can kill people emergently when they suffer major trauma
- Serial killers: Altered mental status 鈥 In this episode learn the 5 diagnoses for altered mental status that can kill your patient emergently
- Serial killers: Shortness of breath 鈥 In this episode, learn the 5 emergent conditions that will kill patients experiencing shortness of breath
- Serial killers: Abdominal pain 鈥 Identifying the conditions that can kill people emergently when they call 911 with abdominal pain
- Serial killers: Acute chest pain 鈥 Targeting the most common chief complaints and deadly diagnoses to consider in prehospital medicine