Although I occasionally have trouble deciding which of the voices in my head are worth listening to, I'm a firm believer in paying attention when one of them is obviously making sense. You know about "The Gut Feeling," that paramedical spidey sense we often rely on to keep us out of trouble or decide how to care for a patient.

I'm not ashamed to say that many, if not the majority, of my patient care decisions are based on the general impressions I form as soon as I encounter my patients. As far as I'm concerned this "instinct" is one of the most valuable tools we have, in part because it is based mostly on hard-earned experience. But it's important not to let ESP take over when EMT should still be running the show. Four calls I have run recently are perfect examples of how gut feelings influenced my patient care. Three times my trained eyes deceived me, once certainly affecting the patient negatively, but the fourth time my instinct was dead-on (pun sort of intended) and hopefully resulted in better care for my patient down the line.

In the past few months I have transported two seemingly-stable patients who turned out to be in ventricular tachycardia (v-tach). The first was a female, around 50, with a history of kidney failure and non-compliance with dialysis treatments who I have taken care of several times. Any time I get dispatched to a familiar address of course my guard immediately drops, and as expected when we arrived she didn't look particularly sick. We leisurely loaded her and started toward the hospital. The pulse oximeter wasn't working well on her right hand, which I attributed to her thick nail polish, and I came very close to simply removing it and putting it away, but I decided to try it on her other hand. Immediately the heart rate began reading in the 150s reliably (her radial pulse had felt normal, as was her blood pressure), and I thought it had to be wrong so I put her on the cardiac monitor and sure enough, classic v-tach.

The second was a man in his 80s with a history of dementia. His family had called 911 because they thought they noticed a change in his mental status. Again, other than having soiled himself he seemed fine. He didn't complain of anything, although he did admit to being slightly short of breath when I asked specifically, and initially he didn't want to go to the hospital. Since he couldn't correctly answer my basic orientation questions, though, I knew he would have to be transported and with a little persistence he agreed. We took our time cleaning him up and changing his clothes and strolled to the truck. I did a big double take when my partner attached the cardiac monitor, though, because he was in supraventricular tachycardia above 200 bpm, occasionally morphing into prolonged runs of v-tach. This alternated with periods of sinus arrhythmia, atrial fibrillation, and all kinds of I-don't-know-what with maybe 5 unique complexes.

Luckily I did catch the problems with those two patients, but a third one slipped by me and everyone else completely. I picked up a man, maybe in his 40s or 50s, complaining of bilateral leg pain. He told us he had peripheral neuropathy and that it wasn't unusual for him to hurt like that although this particular pain seemed more severe than usual. He looked fine, his vitals were fine, and I don't even remember the ride to the hospital. We dropped him off in triage at the ER where he proceeded to suffer a sudden cardiac arrest. He died after a short hospital course. In talking with the ER physician who took care of him afterward, I was told that the cause of death was likely overwhelming sepsis and that there was no apparent cause for anyone involved to have anticipated such a devastating outcome.

Ending on a positive note, a couple of shifts ago I transported a gentleman in his 70s with a history of cardiac problems who had passed out at home and did not respond for about 3 minutes according to his wife. When we got there he was conscious and alert, again no complaints other than a little shortness of breath when he exerted himself. During my interview I found out he had suffered a similar loss of consciousness the day before and had fallen, but did not go to the hospital, and that in the days prior to our encounter he had been having problems with his blood pressure being too low. So at this point I was thinking maybe his blood pressure medication needed to be adjusted or maybe he had some kind of chemical imbalance, nothing life-threatening.

But I was feeling something quite different. I couldn't get over how pale and sweaty he looked, and he had that strange look on his face that seems to say, "I'm holding it together for the crowd but something is very wrong with me." Even after we got him loaded and obtained vitals and a 12-lead there still were really no other red flags. The EKG showed atrial fibrillation with a bundle branch block; obviously not normal but not unexpected for somebody with an extensive cardiac history.

Goodness knows I have skidded breathlessly into the ER on two wheels, lights blazing and siren screaming, with patients who turned out to be completely fine, or outright faking, enough times that I am leery of transporting a patient echo 3 without a solid reason. In fact, I recall twice freaking out over patients who presented identically to this man and ended up only being anemic. So I hesitated, having no other justification than a little pallor and an uneasy feeling inside, as well as multiple experiences that told me this was probably nothing to worry about. I decided to err on the side of caution again, though, so we ran echo 3 to the hospital. I transmitted my EKG to the ER and gave a concerned report to a physician on the radio. Later we learned the man was indeed having a heart attack, and hopefully our caution and speed resulted in a better outcome for him.

There is no question that our own individual experiences give us a certain sixth sense that cannot be taught in EMT school. I can see how my patient care has become much more calm and reasonable over the years as I have learned to more accurately tell who is sick and who isn't. But as we all know, patients don't read textbooks and things aren't always what they appear to be.

When I was in medical school my professors would say things like, "If you hear hoof beats you should be looking for horses, not zebras," and, "Common things are common." I believe it is true that part of our job as EMTs is to calmly assess the situations we face, even when everybody involved is excited beyond logic, and make informed decisions about what level of care the patient really needs. However, we must be careful not to become so complacent and cynical that we forget to be responsible caregivers. We may only run real calls once in a while, but we still have to be ready to step up and deliver the best possible care to those few patients who really need it....even if it means admitting that we don't always recognize who those patients are.

Jody Marks began with a volunteer ambulance service & fire department about 10 years ago, and has now been a paramedic for 7 years. He is currently a full-time paramedic with Huntsville Emergency Medical Services, Inc. ("HEMSI") in Huntsville, Alabama.